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F. Lee. New England College.

In doubtful cases it is wise to compare the staining of the suspect film with that of a normal film stained at the same time cheap malegra dxt 130 mg on line. This can be distinguished from a true one in that the change in the central pale area is sudden while in true hypochromia it is gradual cheap malegra dxt 130mg otc. Usually deep staining of red cells is seen in macrocytosis when the red cell thickness is increased and the mean cell volume also increased and in spherocytes in which the red cell thickness is greater than normal and the mean cell hemoglobin concentration is slightly increased generic malegra dxt 130 mg amex. An increase in reticulocytes in the peripheral blood will be seen as a polychromatic red cell population which is also macrocytic buy generic malegra dxt 130mg on line. It is a finding in treated iron deficiency anemia where there is the new normochromic red cell population and the original hypochromic population and inpatients with hypochromic anemia who have been transfused cheap malegra dxt 130 mg on-line. Red cell inclusions • Basophilic stippling/Punctate basophilia The red cells contain small irregularly shaped granules which stain blue in Wright stain and which are found distributed throughout the cell surface. What parameters of the red cell morphology are appraised in red cell morphology study on a stained blood film? Describe the standard grading system used to evaluate changes in erythrocyte morphology on a stained blood film? A physiologic definition stresses the inability of an anemic individual to maintain normal tissue oxygenation. Alterations in total circulating plasma volume as well as of total circulating hemoglobin mass determine the hemoglobin concentration. Reduction in plasma volume 236 Hematology (as in dehydration) may mask anemia or even cause polycythemia; conversely, an increase in plasma volume (as with splenomegaly or pregnancy) may cause anemia even with a normal total circulating red cell and hemoglobin mass. After acute major blood loss, anemia is not immediately apparent since the total blood volume is reduced. It takes up to a day for the plasma volume to be replaced and so for the degree of anemia to become apparent. The initial clinical features of major blood loss are, therefore, due to reduction in blood volume rather than to anemia. Clinical features If the patient does have symptoms, these are usually shortness of breath (particularly on exercise), weakness, lethargy, palpitation and headaches. In older subjects symptoms of cardiac failure, angina pectoris or intermittent claudication or confusion may be present. Visual disturbances due to retinal hemorrhages may complicate very severe anemia, particularly of rapid onset. General signs include pallor of mucous membrane 237 Hematology which occurs if the hemoglobin level is less than 9-10g/ dl. Skin color, on the other hand, is not a reliable sign of anemia; the state of the skin circulation rather than the hemoglobin content of the blood largely determined skin color. The association of features of anemia with excess infections or spontaneous bruising suggests that neutropenia or thrombocytopenia may also be present. Used together, these offer a rational pathophysiologic approach to the laboratory diagnosis of anemia. Physiologic Hypoproliferation Excessive M a t u r a t i o n destruction or loss abnormality of red cell Aplastic anemia Hemolytic anemia Megaloblastic anemias Myelophthisic anemia Blood loss M y e l o d y s p l a s i a , including sideroblastic anemia Renal insufficiency Thalassemia Chronic disease Iron deficiency Endocrine deficiency Stratus 17. Microcytic anemias An important mechanism of anemia is defective hemoglobin synthesis, which results in small, poorly hemoglobinized erythrocytes. After Wright staining, instead of red cells with pink hemoglobin filling the cytoplasm, the cells are pale with only a rim of 239 Hematology hemoglobin. Since hemoglobin is made up of two components, either of two pathophysiologic mechanisms can lead to decrease hemoglobin synthesis-defective heme or decreased globin production. Deficiency of iron store, failure to utilize iron properly, and defective heme or porphyrin synthesis are characteristic of iron deficiency anemia, anemia of chronic disease, and the sideroblastic anemias, respectively. In thalassemia syndromes, globin production is decreased, thereby hindering hemoglobin synthesis and producing a microcytic anemia. Iron deficiency anemia Iron deficiency is the commonest cause of anemia in every country of the world. This is because the body has a limited ability to absorb iron and excess loss of iron due to hemorrhage is frequent.

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Other heart disease 21 130mg malegra dxt otc,004 Cerebrovascular disease 15 discount malegra dxt 130mg line,922 The negative long-term health consequences for Aortic Aneurysm 8 order malegra dxt 130 mg online,419 children exposed to prenatal smoking include Atherosclerosis 1 cheap 130mg malegra dxt with amex,893 increased risk for substance-related problems discount malegra dxt 130 mg on-line, 129 Other arterial disease 1,254 depression, attention deficit/hyperactivity Respiratory Diseases: 392,683 disorder, conduct disorders and childhood Chronic airway obstruction 78,988 130 obesity. The nicotine in tobacco products can Bronchitis, emphysema 13,927 produce structural and chemical changes in the Pneumonia, influenza 10,423 developing adolescent brain and make young * These data do not reflect all tobacco-attributable deaths. Tobacco use contributes to approximately 30 percent of cancer and heart disease-related 118 * deaths and numerous other health conditions 1964 to 2004. Alcoholic liver disease 12,219 Stroke, hemorrhagic 8,725 Recently, the term “third-hand smoke” has been Liver cirrhosis, unspecified 7,055 developed to describe the invisible but toxic Esophageal cancer 4,225 gases and particles--including heavy metals, Alcohol dependence syndrome 3,857 Liver cancer 3,431 carcinogens and radioactive materials--that form Breast cancer (females only) 1,835 a residue on smokers’ hair, clothing and Oropharyngeal cancer 1,528 household items and remain for weeks or Laryngeal cancer 1,460 months after the second-hand smoke has 136 Hypertension 1,480 cleared. Acute Causes: Motor-vehicle traffic crashes 13,819 Alcohol Homicide 7,787 Suicide 7,235 Alcohol use is the third leading cause of death in Fall injuries 5,532 the United States (after tobacco use and poor Poisoning (not alcohol) 5,416 diet/physical inactivity) and is responsible for Fire injuries 1,158 138 Drowning 868 approximately 3. Of the 13,555 substance-related traffic fatalities in 2009, 10,185 involved drivers who were In 2009, alcohol was reported in at least one- 140 quarter (24. These victim of an alcohol-related traffic fatality reports, however, significantly underestimate the 141 prevalence of alcohol-related emergency compared to older people. Other associated conditions producing seizures or strokes or inhalants include increased risk of cancer of the liver, producing cardiac arrhythmias that can lead to 149 breast, mouth, throat, esophagus and colon, sudden cardiac deaths), but also the infections and recent research suggests that risky alcohol transmitted via drug self-administration (e. Heavy alcohol use during pregnancy is Marijuana use is associated with sexually associated with miscarriage and stillbirth and is transmitted disease due to unsafe sexual one of the primary causes of severe mental and behaviors engaged in while under the influence 151 developmental delays in infants. Marijuana use is associated with the 154 onset of psychotic disorders, particularly in in combination with alcohol (2,792 deaths). Methamphetamine, cocaine and other stimulant Enough prescription painkillers were prescribed use (including the use of amphetamine-related in 2010 to medicate every American adult 174 and other “designer drugs”) are associated with around-the-clock for a month. The risky use of controlled prescription drugs was involved in Approximately 160,000 pregnancies in 2004 166 an estimated 1,079,683 emergency department were associated with illicit drug use. Marijuana and cocaine exposure The risky use of prescription opioids can result have been linked to impaired attention, language in a range of consequences from drowsiness and and learning skills, as well as to behavioral 169 constipation to depressed breathing, at high problems. Infants exposed to prenatal illicit drug use are at 170 One study found that individuals with addiction increased risk of low birth weight, involving opioids had significantly higher rates developmental and educational problems and 171 of comorbid health conditions, including future substance use and addiction. Controlled Prescription Drugs ‡ At high doses, risky use of prescription In 2008, there were an estimated 20,044 § stimulants can produce anxiety, paranoia, overdose deaths attributable to risky use of 179 seizures and serious cardiovascular controlled prescription drugs. Overdose deaths from controlled §§ interactions with other drugs and sudden prescription drugs have increased significantly 181 death. Likewise, risky use of barbiturates, such as butalbital and phenobarbital, can lead to changes in alertness, 183 irritability and memory loss. If combined with certain medications or alcohol, tranquilizers and sedatives can slow both heart rate and 184 respiration, which can be fatal. Taking certain controlled prescription drugs during pregnancy, such as alprazolam (Xanax) or phenobarbital, may harm the developing 185 fetus. Few of these individuals, however, are routinely screened for risky use of addictive substances or receive any services designed to reduce such use such as 2 brief interventions. Of those who do receive some form of screening, in most cases it involves only one type of substance use-- tobacco or alcohol--which fails to identify risky use of other substances or recognize that 30. In order to reduce risky use and its far-reaching health and social consequences, which may include the development of addiction, health 4 care practitioners must: *  Understand the risk factors, how these risks vary across the lifespan and how risky use-- whether or not it progresses to addiction-- can have devastating outcomes for individuals, families and communities;  Educate patients, and their families if relevant, about these risks and the adverse consequences of risky use;  Screen for risky use of addictive substances and related problems using tools that have been proven to be effective; and  Provide brief intervention when appropriate. To assure that † oppositional defiant disorder and conduct these health care services are provided, a range ‡ 10 § 11 disorder, those who engage in bullying of barriers must be addressed, including ** 12 and those who have sleep problems; and insufficient training of health care and other professionals and a lack of trained specialty  Children who are maltreated, abused or have providers to which patients with addiction can 13 suffered other trauma. Hormonal changes that occur adolescence with the initiation of risky use of 6 during adolescence also pose a biological risk addictive substances, but the onset of risky use for substance use in this age group. The surge in and addiction can occur at any point in the the female hormone estrogen and the male lifespan. Common * 7 behavioral symptoms include defiance, spitefulness, of substance use and its consequences, but signs of risk sometimes can be observed much negativity, hostility and verbal aggression. In addition to the overall risks enormous difficulty following rules and behaving in a associated with substance use, children and socially-acceptable manner. These children may adolescents with heightened risk of engaging in bully others, start fights, show aggression toward substance use, of experiencing the adverse animals, steal or engage in sexually inappropriate consequences of risky use and of developing behavior. The lack of fully developed decision-  Coping with the stresses of child rearing, making and impulse-control skills combined balancing a career with family and 23 with the hormonal changes of puberty managing a household; compromise an adolescent’s ability to assess risks and make them uniquely vulnerable to  Facing divorce, caring for an adult family 16 substance use. In recent years, researchers have begun to recognize the developmental stage of young Middle aged and older adults who engage in adulthood--often referred to as emerging risky use may be even more vulnerable to the adulthood--as a period of life that is strongly health consequences of such use since physical 18 associated with risky use. Young adults facing tolerance for alcohol and other drugs declines heightened risk include: with age: the ways in which addictive substances are absorbed, distributed, *  College students-- --while approximately metabolized and eliminated in the body change two-thirds of college students who engage in 27 as people get older.

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You are expected to carry a maximum of 4 patients (and will often carry fewer in the first week or two of the rotation) – if you are carrying too few or too many buy malegra dxt 130mg otc, discuss it with your senior resident 130mg malegra dxt overnight delivery. When you see a patient in the morning discount 130mg malegra dxt fast delivery, you should find the chart and look for documentation of any acute events overnight malegra dxt 130mg low cost, check in with the patient’s nurse to be sure you’re not missing anything order malegra dxt 130 mg mastercard, check labs and radiologic studies, and check for notes left by any consultants you may have called. Check with your intern when you start the rotation to see how they want to deal with morning signouts; it’s often helpful if you and the intern can touch base before rounds to go over new information. When you see the patient, document his or her vital signs from the night (these will be documented in a chart at the door of the room or bedside), get a subjective response from the patient on his or her condition, and do a physical exam. You should write the majority of your notes before rounds, but your assessment and plan may change after discussion with your attending, so leave some space for this. Make sure you find out if your attending expects your note to be in the chart before a certain time in the morning—if he/she does, it’s a good idea to photocopy the note so that you can use it as a guide when presenting the patient at rounds. Patients may also need to follow-up with consultants seen in the hospital, and you will help arrange this. Decide with your resident what medicines the patient will go home on, and make sure there are scripts written (you can write these if your resident feels comfortable with it, but they need to be cosigned). Write discharge orders when given permission by your senior resident and a discharge note when appropriate. Call: Note: At the time this book was written, changes were not solidified for the 2011 students, so we are giving you call info for 2010. Students at Pennsylvania Hospital have a short, medium and long call system, which will be reviewed the first day of the rotation. Unless you are on the hospitalist service doing shifts, you should leave the hospital by 10pm on call. Once you have 2 patients, you are expected to prepare your presentations for the next day and read up on your patients so that you are ready to talk about them in rounds. The day after your call (your post-call day), you and your team will leave the hospital around noon unless you have scheduled didactics (although if you were able to 32 get some sleep during your call night, there may be times you want to stay for the afternoon if there are interesting things happening with your patients). Ask your resident about the weekend schedule before your first weekend call day, as this will vary by team. Plan to leave weekends open during your medicine and surgery rotations, as you will not learn your schedule until your first day on service; however, if you know of a special occasion that you must attend, there are ways to manipulate your call schedule by contacting the course administrator (not course director) far in advance of team assignments. Post-call attending rounds often occur earlier (7:30 or 8 am start); however, this varies significantly by team. Before you meet your team, you need to have seen your patients, collected information, and written your notes. They might send you home, but if they do give you a job to do, you’ll help the whole team get out earlier. Some days, you will have classes at the medical school during the day, and you should let your resident know when you’re leaving for these (and remind them because sometimes they forget with all the patient issues they are taking care of). If you are not on call, most residents do not expect you to come back after class; however, this may take some hinting on your part. If you don’t stay in the hospital, you are technically not supposed to wear scrubs on your post- call day; however, you can discuss this with your resident, and most medical students do wear scrubs on call and post-call days. Grading/Assignments: Note: At the time this book was written, changes were not yet solidified for the 2011 students. Your final grade will be a combination of your shelf score and evaluations from all of your residents and attendings. If you do an outstanding job with your clinical responsibilities, and this is reflected in your evaluations, you will most likely do well in the course. You will also have a series of assignments over the course of the rotation, including three formal, typed patient write-ups. Tips for Studying for the Shelf: Your first shelf exam will be the hardest, as you will gain shelf-taking skills throughout the year. Try to use your patients’ cases as learning examples for large blocks of information and use downtime in the hospital to study. Make sure to plan a reading schedule starting the first week—it is really hard to cover all the material if you don’t stick to a schedule. You will need to study on most of your days off, so make sure to leave some time on those days to do work.

Before you walk in to the room cheap 130mg malegra dxt with mastercard, either you or the junior resident/intern will present the overnight numbers order malegra dxt 130 mg otc. By the middle of the rotation you will likely be writing notes on the patients on whom you are pre-rounding purchase 130mg malegra dxt free shipping. You will also 55 frequently write post-op check notes and/or pre-op notes for some patients—see Maxwell’s or pages 20-21 of this packet for more details on these order malegra dxt 130mg online. A word about the “Scut Bucket”: The “scut bucket” is a pail full of supplies that some teams use when on rounds buy 130 mg malegra dxt overnight delivery. Typically, the embarrassing job of toting the bucket is reserved for the person lowest on the surgical totem pole (i. As such, you will likely be responsible for stocking the bucket before rounds and carrying the bucket on rounds. Every evening, make sure to stock the “bucket” and put it in a place (typically a call room) for safe keeping. For example, if a patient is bleeding briskly and the team appears concerned, perhaps it is best to hold your question until the bleeding has been managed. Call: Beginning this year, all students will be required to take one night of overnight call with a consult resident. In general, students are not expected to round during the weekends, but all schedules are team specific, so be sure to check with your chief resident! Schedule: The schedule varies greatly from service to service and from hospital to hospital (and the med student schedules have changed in the past year or two as part of a general re-working of the Surgery clerkship). This information is detailed in the orientation packet you will receive on your first day of the Surgery Clerkship. In general, and as of this printing, 200 medical students on the Surgery Clerkship are expected to work 12-hour days, from 6am – 6pm. The attendings, residents and interns are aware of this recent change, however, they will usually not be watching the clock. If your team typically rounds at 6am but has to round at 5:45am one day to make it to a morning conference, use your judgment about when you should show up. These evening rounds are usually abbreviated and to- the-point but can be prime time when it comes to teaching. This is a great opportunity to interact with attending surgeons and to ask questions regarding disease management (i. What to Put in Your White Coat: - Stethoscope - Penlight/Reflex Hammer - Epocrates/ Pharmacopaeia - Surgical Recall (or at least have it somewhere close at hand—can be kind of bulky in your pocket! In these session, you will typically go over problem sets and may have to do a presentation at the conclusion of the rotation. Additionally, each student will need to follow a patient for the duration of the clerkship in accordance with the National Surgical Quality Improvement Program. Examples of 58 different write-ups include one acute consult, new patient visit, one post-op visit etc. You may not know much, but if you are always eager to scrub on cases, regardless of how late they go, you will be revered by your team. On the other hand, surgeons are extremely busy and are sometimes difficult to track down to complete your evaluations. You may be asked to do one or two topic presentations during each month, depending on the team/location—see the “Sample Documents” packet for an example of a surgery presentation. Tips for Studying for the Shelf: Part of the reason the 200 medical student is slated to only work from 6am-6pm is to allow him/her more time to study for the surgery shelf. It is impossible to learn all of the subspecialty information covered on the exam, so don’t worry if you can’t remember all of the LeFort fractures in the face…nobody can. Tips for Success: • Always be friendly and have some enthusiasm even for the little jobs that you do (like getting numbers for pre-rounding). Chances are, 90% of the questions that will be thrown your way will be covered in the few page review of the operation in which you are about to scrub. Lots of students never think they will enter surgical fields and end up choosing surgical residencies. Regardless if you love or hate it, it is a really unique experience that only lasts 8 weeks, so try to enjoy it! First day/week suggestions: • Ask your intern/junior/whoever is around when they have a moment to go over what is expected of you for this rotation. In the middle of the second week: • Tell your senior that you’d really like some feedback, constructive criticism, etc. If they feel they haven’t seen you work for a long enough period of time, ask them if they wouldn’t mind giving you some suggestions to “improve your learning experience/be a more efficient student/etc.

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