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Your presentations to the attendings and the residents are probably where you will be graded the most purchase viagra amex erectile dysfunction drugs natural. Presentations should incorporate relevant past medical history and be focused on the presenting complaint 50 mg viagra overnight delivery erectile dysfunction treatment food. Different people want to hear different presentations purchase viagra without a prescription erectile dysfunction young adults, either short and to the point or complete H&P’s—when in doubt, go for completeness. While an attending is interested in your detailed physical exam findings, in the back of his/her mind he/she is thinking about what needs to be done for the patient and is focused on things that could be life-threatening. Depending on your site, your shifts will vary but students generally work approximately 110 hours over the course of the rotation in addition to didactics. To qualify for honors students need to receive at least an 85% on the test and have an average of at least 6/7 on their evaluations. Anesthesiology The week-long pass/fail clinical rotation in anesthesiology is a great experience for 200 level students. Over the course of the week, you will help with all aspects of pre-operative, intra- operative and post-operative patient management. Your experience will depend greatly on the residents you work with, the types of cases involved, and your interest level and motivation. In general, all of the residents are very excited about teaching medical students and clearly love their field. You can expect to learn a good deal about the induction of anesthesia, general anesthesia, local anesthesia, and the monitoring of physiologic functioning and how to respond to changes in those functions. Clinical experience is supplemented by a highly regarded lecture series covering important topics including local anesthetics, anesthesia risks, pain management and conscious sedation. They come in all formats, and they will all try to convince you that they will give you the best preparation for the shelf exam. All of us learn differently from each other and from you, so you will see quite a bit of variation among recommendations. In general, you will want to spend a good deal of time reading and reviewing, and will also want to do at least one book of practice questions. First, a general overview of the major series of review books: • First Aid o This series generally provides a good overview, covering the basics of the important topics related to the clerkship. The books are dense and full of detailed information; however, they are much more complete than Blueprints. Questions are arranged via topic and 63 explanations to questions are generally fairly complete, so doing the questions and analyzing the answers helps you learn the material. The book contains a couple of 50 question tests for each discipline and more for core rotations like medicine and surgery, and you would be wise to purchase this book and do the relevant questions for each rotation. Questions tend to be difficult, and several people noted that they could be damaging to confidence if done too close to the shelf. Probably unnecessary, but if you’re nervous before starting clerkship year this might be a good thing to flip through at Barnes and Noble. Particularly if you are on an inpatient medicine service in the 8 weeks prior to the test, it’s hard to find time to study. Keep in mind that it is nearly impossible to read the entirety of any of the three general medicine books because they are very long and you simply won’t have enough time. You are better off being selective about which topics require more coverage and using the textbook or online references only for these topics. Harrison’s Internal Medicine is available online through the Biomedical Library website at no cost, and is a fantastic reference when you need more information than you find in your review books. Doing at least one entire book and reading explanations thoroughly will take a good amount of time but is crucial for the medicine shelf. The questions are very similar to the shelf style, you can time yourself, and the explanations are very thorough. You can skim topics for the main points just before you know you’re going to be asked a question, and there is space for your own notes. Focus on medical problems requiring surgical intervention, anatomy, post-operative management/ complications in your reading. It is much more valuable to use your time making it through a review book than looking through a text book, but if you’re going into surgery you might eventually want one of these. Consider doing the medicine questions as well as the surgery questions as the content overlap between the two exams is quite high (60-80%). A few of the answers in the book are incorrect, so if you find a different answer elsewhere, don’t get stressed about it. Nelson’s is a huge book that is available online (from the biomed library page) and is useful for reading about specific patients/ topics. Baby Nelson is more readable; some people found it useful, most noted that it was not an efficient use of time. Whatever book you choose for review, make sure to supplement it with question books and/or Case Files. Ob-Gyn • Most of us recommended using one book for an overview in this course: o Blueprints: The Ob/Gyn part of this series is more detailed than most of the other Blueprints books are. The majority of people felt that this was sufficient for the shelf exam, with the addition of Case Files and a question book. Their relevance varies from test to test, but they are generally reflective of the exam and often extremely helpful. It is especially helpful for the shelf exam, since you only have three weeks to study, and it covers many of the basic topics that will be on the exam. Pruitt’s review questions (“yellow pages”) that she hands out in the beginning of the course, as well as her review session on high-yield topics. For the most part, knowing the class notes well is sufficient, but the exam does test the notes in detail. You are expected to do the online cases as practice for the exam, and review your notes from the lectures. Additionally, you will sometimes encounter situations where residents or attendings are not following universal precautions (e. Penn Med policy regarding potential exposures is as follows: Any medical student who sustains a needlestick or other wound resulting in exposure to blood or body fluids should follow the following protocol. Please keep in mind, that drug prophylaxis following a high-risk exposure is time sensitive, therefore you must immediately seek help from the appropriate hospital department. Immediately wash the affected area with soap and water and cover the area with a dressing if possible. If you are seen in the Emergency Room, an occupational medicine doctor is on-call 24 hours a day to provide immediate consultation on post-exposure drug treatment and counseling. Do not hesitate to ask the physician treating you to page the Occupational Medicine doctor carrying the needlestick pager. Students should bring their records to Student Health Service so that appropriate follow-up testing can be scheduled. Children’s Hospital of Philadelphia - Report to Occupational Health Service during weekdays or to the Nursing Supervisor on weekends and evenings. Pennsylvania Hospital - Report to Employee Health (Wood Clinic) or to the Emergency Room if they are closed.

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Irregular Bones An irregular bone is one that does not have any easily characterized shape and therefore does not fit any other classification buy viagra 50mg low price impotence prostate. These bones tend to have more complex shapes buy viagra 100mg on line erectile dysfunction causes divorce, like the vertebrae that support the spinal cord and protect it from compressive forces purchase viagra 50 mg with mastercard creatine causes erectile dysfunction. Sesamoid Bones A sesamoid bone is a small, round bone that, as the name suggests, is shaped like a sesame seed. These bones form in tendons (the sheaths of tissue that connect bones to muscles) where a great deal of pressure is generated in a joint. Sesamoid bones vary in number and placement from person to person but are typically found in tendons associated with the feet, hands, and knees. Bone Classifications Bone Features Function(s) Examples classification Femur, tibia, fibula, metatarsals, Cylinder-like shape, longer Long Leverage humerus, ulna, radius, than it is wide metacarpals, phalanges Cube-like shape, Provide stability, support, Short approximately equal in while allowing for some Carpals, tarsals length, width, and thickness motion Points of attachment for Sternum, ribs, scapulae, cranial Flat Thin and curved muscles; protectors of bones internal organs Irregular Complex shape Protect internal organs Vertebrae, facial bones Small and round; embedded Protect tendons from Sesamoid Patellae in tendons compressive forces Table 6. Bone is hard and many of its functions depend on This OpenStax book is available for free at http://cnx. Later discussions in this chapter will show that bone is also dynamic in that its shape adjusts to accommodate stresses. Gross Anatomy of Bone The structure of a long bone allows for the best visualization of all of the parts of a bone (Figure 6. The hollow region in the diaphysis is called the medullary cavity, which is filled with yellow marrow. The wider section at each end of the bone is called the epiphysis (plural = epiphyses), which is filled with spongy bone. Each epiphysis meets the diaphysis at the metaphysis, the narrow area that contains the epiphyseal plate (growth plate), a layer of hyaline (transparent) cartilage in a growing bone. When the bone stops growing in early adulthood (approximately 18–21 years), the cartilage is replaced by osseous tissue and the epiphyseal plate becomes an epiphyseal line. The medullary cavity has a delicate membranous lining called the endosteum (end- = “inside”; oste- = “bone”), where bone growth, repair, and remodeling occur. The outer surface of the bone is covered with a fibrous membrane called the periosteum (peri- = “around” or “surrounding”). The periosteum covers the entire outer surface except where the epiphyses meet other bones to form joints (Figure 6. In this region, the epiphyses are covered 222 Chapter 6 | Bone Tissue and the Skeletal System with articular cartilage, a thin layer of cartilage that reduces friction and acts as a shock absorber. Flat bones, like those of the cranium, consist of a layer of diploë (spongy bone), lined on either side by a layer of compact bone (Figure 6. The two layers of compact bone and the interior spongy bone work together to protect the internal organs. If the outer layer of a cranial bone fractures, the brain is still protected by the intact inner layer. Bone Markings The surface features of bones vary considerably, depending on the function and location in the body. These surfaces tend to conform to one another, such as one being rounded and the other cupped, to facilitate the function of the articulation. In general, their size and shape is an indication of the forces exerted through the attachment to the bone. As with the other markings, their size and shape reflect the size of the vessels and nerves that penetrate the bone at these points. Bone Cells and Tissue Bone contains a relatively small number of cells entrenched in a matrix of collagen fibers that provide a surface for inorganic salt crystals to adhere. These salt crystals form when calcium phosphate and calcium carbonate combine to create hydroxyapatite, which incorporates other inorganic salts like magnesium hydroxide, fluoride, and sulfate as it crystallizes, or calcifies, on the collagen fibers. The hydroxyapatite crystals give bones their hardness and strength, while the collagen fibers give them flexibility so that they are not brittle. Although bone cells compose a small amount of the bone volume, they are crucial to the function of bones. Four types of cells are found within bone tissue: osteoblasts, osteocytes, osteogenic cells, and osteoclasts (Figure 6. When osteoblasts get trapped within the calcified matrix, their structure and function changes, and they become osteocytes. The osteoblast is the bone cell responsible for forming new bone and is found in the growing portions of bone, including the periosteum and endosteum. As the secreted matrix surrounding the osteoblast calcifies, the osteoblast become trapped within it; as a result, it changes in structure and becomes an osteocyte, the primary cell of mature bone and the most common type of bone cell. They can communicate with each other and receive nutrients via long cytoplasmic processes that extend through canaliculi (singular = canaliculus), channels within the bone matrix. If osteoblasts and osteocytes are incapable of mitosis, then how are they replenished when old ones die? These osteogenic cells are undifferentiated with high mitotic activity and they are the only bone cells that divide. The dynamic nature of bone means that new tissue is constantly formed, and old, injured, or unnecessary bone is dissolved for repair or for calcium release. They are found on bone surfaces, are multinucleated, and originate from monocytes and macrophages, two types of white blood cells, not from osteogenic cells. Osteoclasts are continually breaking down old bone while osteoblasts are continually forming new bone. The ongoing balance between osteoblasts and osteoclasts is responsible for the constant but subtle reshaping of bone. Bone Cells Cell type Function Location Osteogenic Develop into osteoblasts Deep layers of the periosteum and the marrow cells Growing portions of bone, including periosteum and Osteoblasts Bone formation endosteum Maintain mineral concentration of Osteocytes Entrapped in matrix matrix Table 6. Most bones contain compact and spongy osseous tissue, but their distribution and concentration vary based on the bone’s overall function. Compact bone is dense so that it can withstand compressive forces, while spongy (cancellous) bone has open spaces and supports shifts in weight distribution. It can be found under the periosteum and in the diaphyses of long bones, where it provides support and protection. Running down the center of each osteon is the central canal, or Haversian canal, which contains blood vessels, nerves, and lymphatic vessels. These vessels and nerves branch off at right angles through a perforating canal, also known as Volkmann’s canals, to extend to the periosteum and endosteum. The osteocytes are located inside spaces called lacunae (singular = lacuna), found at the borders of adjacent lamellae. As described earlier, canaliculi connect with the canaliculi of other lacunae and eventually with the central canal. Spongy (Cancellous) Bone Like compact bone, spongy bone, also known as cancellous bone, contains osteocytes housed in lacunae, but they are not arranged in concentric circles. Instead, the lacunae and osteocytes are found in a lattice-like network of matrix spikes called trabeculae (singular = trabecula) (Figure 6. The trabeculae may appear to be a random network, but each trabecula forms along lines of stress to provide strength to the bone. The spaces of the trabeculated network provide balance to the dense and heavy compact bone by making bones lighter so that muscles can move them more easily. In addition, the spaces in some spongy bones contain red marrow, protected by the trabeculae, where hematopoiesis occurs.

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No patient Set breath delivered within an interval based on the interaction discount viagra 50 mg fast delivery erectile dysfunction in diabetes ppt, pressure or volume modes buy 75mg viagra with amex free sample erectile dysfunction pills. Ventilator waits for a spontaneous breath by the patient as a trigger to Uses: Commonly for neonates buy viagra 75 mg free shipping erectile dysfunction recreational drugs. If this is not sensed it Contraindications: uncomfortable automatically gives a breath at the end of the Advantages: Regular breaths guaranteed. Any other breaths during the cycle Disadvantages: Patient is not allowed to breathe are not supplemented with the ventilator, i. Disadvantages: Can be uncomfortable for small Ventilators: All but the Sechrist patients, need to have appropriate sensing. Breath is controlled by the either on the patient’s initiative or at the set interval Pmax, not the set tidal volume. Allows synchrony with the Contraindications: Not a friendly mode in the patient with maximal support. Especially in patients with high Contraindications: Any patient w/o spontaneous airway pressures. Advantages: Delivers a guaranteed tidal volume Disadvantages: Provides no supportive ventilation. Where to Start: Initial Ventilator Settings Obviously, the individual patient and clinical setting will determine the mechanical ventilation needs, but the following is a good place to start, realizing that the settings will most likely require adjusting to achieve the desired effect. Preemie Infant/Toddler Child Adolescent/Ad ult Rate 40 30 20 12 - 48 - Inspiration 0. Obtain first gas 15-20 minutes after initially starting ventilation or after major changes. The trend is more important than any specific blood gas, oxygen saturation, or chest film. Surgical patients are excellent examples of organisms under stress, and a great deal of acute physiology can be learned by caring for them--airway and pulmonary issues, fluid/electrolyte issues, neuroendocrine response to stress, pain and sedation, etc. In general, pediatricians know about infants and children, and “medical” issues, and surgical attendings/residents know about “surgical/technical” issues. If a collaborative relationship is formed, the patients will receive the best of both sets of knowledge. Finally, because of the potential for miscommunication to lead to mis-understandings and problems with care, these patients present excellent opportunities to practice the art of communication and finesse. Post-operative care must be approached in an organized, timely manner, with attention to the acute nature of the patient’s changing physiology. Before the patient arrives, you should familiarize yourself with the patient’s past medical/surgical history and the planned surgical procedure. Only when you know what they planned to do, and what they did it on, will you be prepared to evaluate your patient when he/she arrives, and anticipate potential problems that you must watch for. When the patient arrives--the initial evaluation The patient has just undergone general anesthesia, been intubated +/- extubated, and had some fairly invasive procedure performed. The anesthetic record can be viewed as the “history of present illness” for the surgical patients--it contains information related to maintaining physiologic stability during the course of the operation. Each hospital’s record is somewhat different, but all will contain the following information: 1. Maintenance of anesthesia--potent inhalational agents (halothane/isoflurane/sevoflurane), nitrous oxide, narcotics, propofol. Lines and tubes Fluids in the Operative and Post-operative patient Pediatrician: “Why do they always get so much fluid? Major abdominal procedures can lead to losses of 15 cc/kg/hr in “third space” losses which must be replaced. Effect of Anesthesia on Fluid Balance: General anesthesia produces vasodilatation and some degree of myocardial contractility (usually overcome by sympathetic drive induced by the surgical stimulus), and thus a volume bolus may be needed. There is much discussion about which is better, what the cost/benefit ratio is, etc. You should at least be aware of which is which, and of the implications of choosing one over the other. Water flows along its concentration gradient, hence, water will leave the vascular space with the sodium, and less so with albumin. There is controversy (in the literature and with respect to individual patients) regarding when one needs to transfuse the patient. Remember that the function of red cells is to carry hemoglobin, carried by cardiac output. O2 transport capacity will thus be a factor of Hg level and the ability of the Hg to get to cells--which will be adversely affected by hyper viscosity. This does not, however address the issue of “tolerable” hematocrit--healthy patients will tolerate much lower hematocrits, and there is a risk involved in any transfusion. Component Therapy During a massive transfusion, coagulation factors and platelets will be reduced due to dilution, as they are not present in packed cells. If not replaced, bleeding will be greater, necessitating greater packed cell transfusion, etc. Extubation Criteria for extubation in the operating room are the same as those elsewhere--the patient must have an adequate airway, maintain oxygenation and ventilation (adequate strength as well as lung function), and have a neurologic status able to protect the airway and maintain adequate drive. Did the operation affect the airway (trachea, cords, pharynx) Breathing--Are the lungs normal or abnormal. Has there been enough fluid administered that there is concern about pulmonary edema? Did the operation involve the chest or abdomen in a way that will adversely affect the patient’s ability to breathe deeply? Neuro--Has anesthesia worn off to a degree that the patient can protect his airway and have adequate drive. Stridor--causes include trauma to trachea or cords, laryngeal edema, recurrent nerve damage, arytenoid dislocation. Treatment is as for viral croup--racemic epi, decadron, and re-intubation if necessary. If patient’s airway is compromised due to decreased mental status, a jaw thrust and nasal airway may temporize the problem. Generally patients will require some oxygen due to atelectasis, narcotics, and splinting. Remember that the In/Outs will not necessarily reflect the patient’s intravascular volume status (due to blood loss replacement, third space losses, evaporative losses). Of note, hypercarbia will lead to sympathetic nervous system activation, with impressive hypertension and tachycardia. Titration of drugs in the infant or ventilated/sedated/paralyzed patient requires assessment of vital signs. Common Procedures and Common Problems Spinal Fusion--Respiratory, Pain, Fluid Balance The post-operative course will be affected by the patient’s general medical history, degree of curvature, extent of the repair, and intraoperative course (fluid balance, blood loss, narcotics given). The most dreaded complication is paralysis, and patients who are cognitively able to follow commands will be submitted to a “wake-up test” intra-operatively, before closure of the wound. Potential post op problems include respiratory depression (excess analgesia), respiratory difficulty due to splinting (inadequate analgesia), pain control (difficult), and fluid balance. There is typically a fair bit of blood loss and there can be significant swelling of the involved tissues.

Microscopic pathology: Reactive microglial cells are present throughout the gray and white matter buy viagra without prescription impotence at 55. Occasionally 100mg viagra with mastercard erectile dysfunction treatment aids, they aggregate into cellular clusters with reactive astrocytes to form microglial nodules best order viagra age for erectile dysfunction. These cells can be found in microglial nodules, perivascularly, or scattered through the brain parenchyma. Nonspecific white matter changes include foci of demyelination and vacuolar change. The calcification often involves the basal ganglia, but may spill into the centrum semiovale. In addition, they also may be found in the lower layers of the cortex and in the basal ganglia. These disorders are quite unusual and have been classified in the past as ‘infectious’, but more appropriately ‘transmissible’ disorders. This group of disorders is also widely classified as neurodegenerative disorders because the clinical and pathological features are more characteristic of neurodegenerative disorders rather than infectious disorders. The putative transmissible agent has been called a Prion (proteinaceous infectious particle). This agent differs radically from conventional infectious agents in that it appears to 41 be composed of protein only. It is insensitive to physical or chemical treatments that inactivate all known viruses. Formalin fixation does not destroy infectivity, but exposure to Clorox, formic acid or stringent autoclaving does. Two isoforms of the Prion protein (PrP) have been hypothesized: a normal, cellular form (PrP-C) and a modified infectious form (PrP-Sc). The incidence of Kuru has dropped precipitously since the suppression of ritual cannibalism. All three diseases are transmissible by intracerebral injection of infected nervous tissue into experimental animals. By six months dementia is profound and myoclonic jerking is evident as the individual becomes vegetative, mute and bedfast. Accidental transmission of the disease with corneal graft and with intracerebral electrode implantation has been reported. It is also important to remember that the tissues remain ‘infective’ after formalin fixation for a year or two. The x-ray source rotates around the patient’s head and divides the x-ray attenuation into compartments called pixels. From about 800,000 measurements, the computer assigns a number to each pixel and, by using a gray scale, reconstructs an image. Scan times can be shortened to less than 1 second to minimize motion artifact when the patient is restless. Iodinated water-soluble contrast agents can be given intravenously to enhance differences in tissue density. Following the pulse, the relaxation of these protons back to their original energy state is accompanied by emission of radiowaves that are characteristic of the particular tissue. Two tissue-specific relaxation constants, known as T1 and T2, as well as proton density can be measured. These different weightings are produced by varying 1) the imaging techniques (spin-echo, fast spin-echo, gradient-echo, inversion-recovery or echo- planar), 2) the repetition time (interval between repetitions of the pulse sequence), and 3) the echo time (the interval between radiofrequency excitation and measurement of the radiowave emission or signal). The time required for obtaining conventional spin-echo images ranges from 4 to 7 minutes for T1-weighted images to 8 to 12 minutes for both proton density and T2-weighted images. Fast spin-echo images allow similar images to be obtained in as little as 2 to 3 minutes. An even newer technique known as echo-planar imaging allows images to be obtained in a matter of seconds; these include “fast T2-weighted images” and diffusion-weighted images. Other advantages include better visualization of the posterior fossa and spinal cord, and the lack of ionizing radiation. The accumulation of Gd-media within a specific region of the brain shortens both T1 and T2 relaxation times, and appears as an area of increased signal intensity on T1-weighted images, even when precontrast images show no evidence of abnormal signal. The earliest changes of cerebral infarction may be seen within the first three hours after the onset of stroke on diffusion-weighted images; this is related to the visualization of cytotoxic edema within affected cells in the zone of acute infarction. During the first 5 days after stroke onset, Gd-enhancement may be seen within the small arteries of the ischemic cerebral territory, with gyral enhancement present 5 days to several months after onset. Additional lesions within the optic nerves, brainstem, and spinal cord may also be detected. If multiple small enhancing nodules were found, the diagnosis of cerebral toxoplasmosis or other granulomatous infection would be favored. These include patients with complex partial seizures, headache, dementia, head trauma, psychosis and congenital craniospinal anomalies. A gradient-echo pulse sequence enables visualization of flowing blood as areas of increased signal intensity. After obtaining a series of contiguous thin sections with gradient-echo techniques, a map of the blood vessels is reconstructed as a set of projection angiograms that can be viewed in any orientation. The relative regional selective vulnerability within the brain causes atrophy, which can be detected intra vitam using neuroimaging techniques (radiologic evaluation). The selective vulnerability of one or more systems may cause specific symptoms such as dementia or movement disorder or both (clinical evaluation). The neuropathological examination determines the type, distribution and extent of the abnormal changes involving the brain (biopsy or postmortem evaluation). The integration of the neuroimaging, clinical, and pathologic findings leads to a definitive diagnosis of neurodegenerative diseases. Neurodegenerative diseases encompass a group of chronic, progressive disorders usually involving the elderly. Neurodegenerative disorders of childhood are generally considered in separate categories. The common link uniting these entities is a slowly progressive loss of neurons, the symptoms of which are dependent on the region of the brain affected. The psychological and financial burdens of neurodegenerative diseases increasingly strain the familial and social framework of our societies. This trend is linked to the gradual lengthening of life expectancy and is therefore worsening. The pathogenesis of neurodegeneration is only partially understood and there are no cures currently available. They are sporadic except in about 10 percent of instances in which they are either autosomal dominant or recessive.

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