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Acute pharyngitis may lead to immediate complications including abscess purchase 25 mg clomiphene overnight delivery women's health big book of 15 minute workouts review, cellulitis buy 50mg clomiphene menstrual napkins, epiglottitis buy 25mg clomiphene amex menstrual jars. Untreated pharyngitis may lead to a later complication of rheumatic fever discount clomiphene 50 mg fast delivery womens health 15 minute workout book, which is a leading cause of structural heart disease later in life. Examine patient for trismus (inability to open mouth), drooling, meningismus, stridor or other signs of severe disease or airway compromise. Severe disease may also present with inability to swallow or lie supine, muffled voice or respiratory distress (use of accessory muscles) o Patients with retropharyngeal abscess may hold the head stiff and complain of neck pain. In adults, often extends into mediastinum o Patients with peritonsillar abscess may lean to one side o Patients with simple pharyngitis will be well appearing, have a clear voice, no difficulty with respirations. May also see absence of a deep, well-defined vallecular air space running parallel to the pharyngotracheal air column that approaches the level of the hypoid bone (vallecula sign) in epiglottitis. Management: • The goal of management is to recognize simple throat infections and treat with appropriate antibiotics. Therefore, patients should be told that if they continue to have severe pain or fever after two days, they should return for further examination. Complications include puncture of the carotid artery, which could lead to massive hemorrhage. Insertion of the needle more than lcm runs the risk of puncturing the internal carotid artery. Internal carotid artery runs laterally and posterior to the posterior edge of the tonsil. Often present in a "tri-pod" position-sitting up and forward with obvious difficulty breathing or stridor. About 90% of bleeds come from a blood vessel in the anterior part of the nose and can be visualized. Ask patient to blow nose and clear clots in order to visualize bleeding vessel better. Attempt anterior nasal packing: Apply tetracycline ointment to tip of gauze before packing. Recommendations • Most cases of epistaxis are benign and resolve with good pressure to the nasal bridge. They can complain of pain in the jaw or have persistent pain on swallowing without fever. Ear, Nose Throat Foreign Body Definition: It is a foreign object inserted into the nose, ear, or throat. Causes • Typically self-inflicted by children putting foreign body into their nose or ear or swallowing foreign body. If a good light, otoscope/microscope, and tools like alligator forceps are available, it may be possible to try to remove a foreign body from the nose or the ear. Attempt to suction smooth objects like a bean or bead, but insects require alligator forceps under direct visualization • Foreign body in nose o If object can be visualized with light, can attempt the "Kissing Technique. It can be acute (occurring within the past few hours or days) or gradual (occurring within the past weeks or months). Drowsiness or lethargy is a minor change with slightly decreased wakefulness, but patient is aroused with verbal stimuli or light. Differential diagnosis: Several mnemonics can help to remember extensive differential diagnosis list. Acute Stroke Definition: A stroke is the acute loss of neurological function due to interruption of blood supply to the brain. Most strokes will present with a new focal neurologic deficit, such as unilateral weakness. However, both more severe presentations such as coma and more subtle presentations such as dizziness can be caused by a stroke. General management: Then general goal in management of all strokes includes consideration for airway protection, aspiration risk, blood pressure control, and immediate physiotherapy. However, the long- term prognosis in a patient in coma from severe stroke, whether ischemic or hemorrhagic, is quite low. Specific management • Ischemic stroke o Thrombolytics are not currently recommended in our setting for ischemic stroke for the following reasons: ■ In order to cause more good than harm, these drugs must be used early, generally within 3-5 hours of stroke onset, which in almost all cases will be impossible to achieve. Even within this accepted time window, the value of thrombolysis for acute stroke continues to be debated. Good agents that have been studied for this indication include hydrochlorothiazide and long acting Nifedipine. Recommendations • Stroke in Rwanda appears to have a different risk factor profile and likely a different pathophysiology from those in more industrialized countries. Stroke guidelines from these settings may therefore not be as appropriate for application in Rwanda. Therapeutics such as aspirin, statins, or thrombolytics (for ischemic strokes) or neurosurgery (for hemorrhagic strokes) are not likely to be very effective in these cases. Rather, focus on good early stroke care with prevention of aspiration, fever control and early physiotherapy. Young patients or those with an unclear presentations or history should be referred to referral center for advanced imaging and further workup. Non-traumatic Headache Definition: Pain in the head that can be classified as acute and singular (first headache), acute recurrent, or chronic in nature. If symptoms change or worsen, tell the patient to return to the hospital for evaluation. Seizure Definition: Uncontrolled shaking in the body from excessive and disorderly neuronal discharge in the cerebral cortex. Status epilepticus is defined as a seizure that lasts 5-10 minutes or two seizures without full recovery between them. If a seizure lasts more than 30 minutes, the body can no longer regulate homeostasis- blood pressure drops and acidosis builds, sometimes resulting in neuronal damage. Management: General goal is to stop the seizures as soon as possible to prevent permanent brain damage and aspiration. Once seizures are under control, patient should return to normal mental baseline between 1-8 hours. Once seizures are controlled for 24hr, wean off thiopental by decreasing the dose by lmg/kg every 12hr. The most common reaction, simple febrile reaction, is not life-threatening, but needs to be recognized early. Other reactions are more rare, but have a very high mortality rate (acute hemolysis and transfusion-related acute lung injury), and must be recognized and treated immediately. Ensure the patient really needs the transfusion and that the benefits outweigh the risks. Generally speaking, you can transfuse a unit of blood over 2hr (faster if it is a trauma patient or someone who is severely ill). If there is a transfer sheet from another facility, find out what antibiotic was given and how many doses • Exam o Obtain full set of vital signs, including saturation and temperature. If patient with fever on arrival and signs of sepsis, start antibiotics immediately.

Antihypertensive treatment in patients with type–2 diabetes mellitus: what guid- ance from recent controlled randomized trials? Health outcomes associated with various antihypertensive therapies used as first-line agents: a network meta-analysis discount clomiphene 25 mg fast delivery menstruation yoga practice. Effects of different blood-pressure-lowering regimens on major cardiovascular events: results of prospectively-designed overviews of randomised trials clomiphene 50 mg visa womens health raspberry ketones. A comparison of outcomes with angiotensin-converting enzyme inhibitors and diuretics for hypertension in the elderly generic 50mg clomiphene free shipping breast cancer 1a. How strong is the evidence for use of beta-blockers as first-line therapy for hypertension? Re-examining the efficacy of beta-blockers for the treatment of hypertension: a meta- analysis buy generic clomiphene 50 mg online menstrual period blood clots. Regional and racial differences in response to antihypertensive medication use in a randomized controlled trial of men with hypertension in the United States. Department of Veterans Affairs Cooperative Study Group on Antihypertensive Agents. Antihypertensive effect of low-dose hydrochlorothiazide alone or in combination with quinapril in black patients with mild to moderate hypertension. Executive summary of the guidelines on the diagnosis and treatment of acute heart failure: the Task Force on Acute Heart Failure of the European Society of Cardiology. Angiotensin-converting enzyme inhibitors and progression of nondiabetic renal disease. Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. Renoprotective effect of the angiotensin-receptor antagonist Irbesartan in patients with nephropathy due to type 2 diabetes. The effect of spironolactone on morbidity and mortality in patients with severe heart failure. Randomised double-blind comparison of placebo and active treatment for older patients with isolated systolic hypertension. Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension. Effects of prophylactic antiarrhythmic drug therapy in acute myocardial infarction. Beta blockade during and after myocardial infarction: an overview of the randomized trials. Cost-effectiveness analysis with defined budget: how to distribute resources for the pre- vention of cardiovscular disease? Prevention of coronary heart disease with pravastatin in men with hypercholesterolemia. Effect of fluvastatin on cardiac outcomes in renal transplant recipients: a multicentre, randomised, placebo-controlled trial. Use of lipid lowering drugs for primary prevention of coronary heart disease: meta-analysis of randomised trials. Helsinki heart study: primary-prevention trial with gemfibrozil in middle-aged men with dyslipidemia. Safety of treatment, changes in risk factors, and incidence of coronary heart disease. Cholesterol lowering with statin drugs, risk of stroke, and total mortality: An overview of randomized trials. Use of statins in primary and secondary prevention of coronary heart disease and ischemic stroke. Efficacy and safety of cholesterol- lowering treatment: prospective meta-analysis of data from 90,056 participants in 14 randomised trials of statins. Quantifying effect of statins on low density lipoprotein cholesterol, isch- aemic heart disease, and stroke: systematic review and meta-analysis. Efficacy of lipid lowering drug treatment for diabetic and non-diabetic patients: meta-analysis of randomised controlled trials. Effect of different antilipidemic agents and diets on mortality: a systematic review. Drugs: atorvastatin, cerivastatin, fluvastatin, lovastatin, pravastatin and simvastatin. Safety and tolerability of cholesterol lowering with simvastatin during 5 years in the Scan- dinavian Simvastatin Survival Study. The effect of pravastatin on coronary events after myocardial infarction in patients with average cholesterol levels. Effect of very high-intensity statin therapy on regression of coronary atherosclerosis. Gemfibrozil for the secondary prevention of coronary heart disease in men with low levels of high density lipoprotein cholesterol. Veterans Affairs High-Density Lipoprotein Cholesterol Intervention Trial Study Group. Fifteen years mortality in Coronary Drug Project patients: longterm benefit with niacin. Efficacy and safety of high density lipoprotein cholesterol increasing compounds a meta analysis of randomized controlled trials. Third Joint Task Force of European and other Societies on Cardiovascular Disease Prevention in Clinical Practice. A cost minimization analysis of diuretic-based antihypertensive therapy reducing cardiovas- cular events in older adults with isolated systolic hypertension. Impact of incident diabetes and incident nonfatal cardiovascular disease on 18-year mortality: the multiple risk factor intervention trial experience. Mortality from heart disease in a cohort of 23,000 patients with insulin-treated diabetes. A prospective study of maturity-onset diabetes mellitus and risk of coronary heart disease and stroke in women. Impact of diabetes on long-term prognosis in patients with unstable angina and non-Q wave myocardial infarction. The relative contributions of insulin resistance and beta-cell dysfunction to the pathophysiology of type 2 diabetes. Metabolic characteristics of individuals with impaired fasting glucose and/or impaired glucose tolerance. Is the current defini- tion for diabetes relevant to mortality risk from all causes and cardiovascular and noncardiovascular disease? The metabolic syndrome and total and cardiovascular disease mortality in middle-aged men. Metabolic syndrome with and without C-reactive protein as a predictor of coronary heart disease and diabetes in the West of Scotland Coronary Prevention Study. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. Multifatorial intervention and cardiovascular disaese in patients with type 2 diabetes.

Mental health issues ranging from mild distress to severe and • Take seriously a colleague who shows signs of disabling psychiatric syndromes are among the leading causes depression proven 25 mg clomiphene pregnancy jokes. For example order 100mg clomiphene free shipping breast cancer 60 mile walk san diego, the point • Suicide is a real problem buy clomiphene 25mg low cost breast cancer latest studies, and doctors who have prevalence of major depressive disorder in the general popula- suicidal ideation need care urgently order 50 mg clomiphene with visa women's health clinic york region. Studies suggest that rates • Education and behavioural adjustments are of mood and anxiety disorders are slightly lower among work- necessary to improve the ability to cope with the ing physicians, but research also shows that serious emotional stresses of a medical career and to enhance distress is not rare in the physician population. Such fear can present as apprehensions about losing one’s livelihood, being rejected by colleagues and patients, the Among the factors known to contribute to physician stress possibility of regulatory sanctions, and generally diminished are their high-pressure training and practice environments, career options. Serious, recurrent mental health problems can the challenging decisions they must make every day, long change one’s professional life and affect work performance and irregular work hours, and constantly witnessing sickness and patient safety. In addition, some personality traits such as performing in complex clinical environments might eventually, perfectionism, a tendency to assume responsibility for events, for some doctors with disabling mood disorders, become a a strong work ethic and a robust desire to help others can thing of the past. By extension, physicians who do reach out for nizes a mental health assessment by a psychologist. However, resident discloses a longstanding history of anxiety that corridor consultations and collegial interventions, even with has typically been ignored or minimized. The resident the best intentions, can result in inaccurate diagnoses and sub- realizes that they are vulnerable to panic and anxiety when optimal treatment. It is essential that appropriate boundaries sleep-deprived, not eating well, socially isolated or under between the physician provider and the physician patient be signifcant academic pressure. Slowly, the symptoms wane and the Approximately 70 to 90 per cent of suicides are associated with resident enjoys much better health, self-awareness and mental illness. It is important not to downgrade the clini- depressed and burnt out residents: prospective cohort study. Arlington: Improving personal resiliency can help physicians cope with American Psychiatric Publishing. Suicide rates among regularly and taking time for friends and family are essential. Early detection, education and treatment of mental health dis- orders are crucial in this safety sensitive profession. Appropriate follow-up and monitoring of these conditions, particularly those that recur, is essential for physicians with mental illness not only as individuals but also as professionals who wish to safely and competently practise their chosen vocation. Expert assessment, including clinical history, physical • discuss the nature and prevalence of substance use disorders examination, lab and toxicology studies and collateral history, as they affect physicians, is often needed to formulate an accurate diagnosis. Physicians probably experience substance use disorders at much the same rate as the general population. Although they don’t have risks associated with low socio-economic status, there are Case other risks especially associated with being a physician. It has A resident is completing a fellowship and is in their fnal been postulated that many physicians have personality traits year. The resident has struggled academically during the that contribute both to their professional success and to their fellowship because of marital problems, fnancial diffcul- personal vulnerability. Over the past year, the cated in the extreme to the well-being of their patients, even at resident has noticed that they have taken to drinking daily the expense of their own basic health needs. In the past two months, this alcohol use has perfectionistic and obsessive personality traits. They are often increased and the resident has begun to keep a fask in rigidly self-controlled. One of the resident’s close colleagues coping strategies, some fnd ease and comfort in the use of begins to suspect alcohol abuse when she notices the resi- drugs or alcohol. Access to drugs and the pharmacological optimism that comes with expert experience in prescribing for patients opens the Introduction door to drug self-administration. Anesthesiologists who inject Medical students, residents and physicians are as human as themselves with potent opioids such as fentanyl, which are their patients. They experience substance use disorders just particularly prone to cause dependency, are a special case that as others do. An important Physicians who are experiencing substance abuse problems sel- facet of addressing the issue is learning how to recognize dom receive assistance early in the course of their illness. They substance use problems in medical colleagues, intervening deny the magnitude of the problem, just as others—in their on their behalf, and directing them to the excellent treatment discomfort and uncertainty about how to help—deny what resources that do exist. They fear that reaching out for help might follow-up and monitoring is more constructive than a punitive, result in a report to their training program or to regulatory or disciplinary approach. They are needlessly trapped in their fear and Substance use disorders in physicians shame. Meanwhile, the bystanders who do nothing become Neither epidemic nor inconsequential, the prevalence of seri- part of the problem. This means that, over Recognition the course of a lifetime in practice, nearly one doctor in 10 will There is rarely a single observation that will clearly identify a experience a problem with drug or alcohol abuse or depen- substance-abusing colleague, at least not early in the progres- dence that will have a signifcant and potentially serious impact sion of their illness. Physicians are skilled at presenting an upon their lives and the lives of others around them. Alcohol appearance of calm and self-control even when they are suffer- is the most common drug of choice for doctors, followed by ing. Sensitive to the shame and stigma that are often attached opioids and other substances. But some mary disorder that, without treatment, can be progressive and clues can be readily apparent to a caring colleague, especially even fatal. It is if they are familiar with the doctor’s baseline behaviour and characterized by a pattern of maladaptive use of substance(s) personality (see textbox). The desire to return to training or physicians work can in itself motivate a physician to seek the necessary • mood swings and/or irritability, treatment. Finally, the consequences of not complying with • loss of effciency and reliability, the intervention conditions—such as the termination of • a decline in standards of dress and grooming, training or a report to regulatory authorities—must be clearly • increased somatic complaints, illness and fatigue, understood. Successfully treated • alcohol on the breath at work, physicians not only remain abstinent, but learn about living in • nodding off at work, a more balanced way. Recovery from substance use disorders • being caught drinking or self-administering drugs means improved physical, psychological, social, familial, oc- at work, cupational and even spiritual health. It falls to each physician to protect the well-being of their col- leagues, to be watchful for signs of drug and alcohol problems, Intervention and to be prepared to respond. Waiting until a physician with a substance use problem asks for help, if that time ever comes, can have tragic results. We must pay attention to signs of distress in our colleagues, respecting Case resolution our own visceral empathy and formulating an intervention plan The resident’s colleague alerts the chief resident and as soon as possible. At the least, one or two friendly colleagues program director of her concerns discreetly. They can mediately meet with the resident and request that they make time to talk, offer helpful suggestions and resources, and proceed to the emergency room for an assessment. They can do this without needing to know resident complies, and it becomes clear that the resident with certainty just what the problem might be. The physician health program is notifed, and arrangements are made for an urgent assessment. The If this intervention is rejected or proves to be unhelpful, the resident is placed on medical leave. Two or of treatment, the resident is able to return to work, more individuals, respected by the physician and in a position participate in treatment services and health monitoring, of authority, must intervene in a timely, planned and rehearsed and enjoy a full recovery.

Any appeal must be submitted in writing to the University Secretary as soon as possible (usually less than 6 weeks) generic 50mg clomiphene overnight delivery menstrual girls. Representation and informal feedback from any student is welcome by this group at any time purchase 50mg clomiphene free shipping 36 menstrual cycle. Appendix I: It is the duty of all students to observe those parts of the University Health and Safety Policy relevant to their own work: see www discount 50mg clomiphene with mastercard menstruation through history. Please note: This programme handbook in no way supersedes University regulations 25 mg clomiphene fast delivery menstruation migraine, but seeks to interpret and apply these and to provide further information relating to this particular programme. Those entering Year 3 (dissertation) of the programme will also be expected to follow the University’s Code of Good Practice in Research, available from www. The Curriculum and Assessment Committee are responsible for all decisions about programme outcomes, content, assessment and evaluation, and make recommendations for the constitution of the Board of Examiners and appointment of External Examiners. Student feedback and course evaluation Student feedback provides invaluable input to the review and development of curriculum and course organisation. At the beginning of the session students will be asked to elect programme representatives, the representatives can raise issues of general concern on behalf of their class. However all students should feel free to approach staff at any time throughout a session. The overall aim is to identify, at both local and national level, areas where improvements could be made and efforts targeted to further enhance the provision of taught degree programmes. A high response rate is necessary to obtain robust results, so participation is very important and would be greatly appreciated. They are able to raise concerns and issues which they may feel may be relevant to this Committee. Representatives are also welcome to participate in the Edinburgh University Students’ Association. Graduation All students intending to graduate must register by completing an online graduation registration form. The form should be submitted as soon as possible, but no later than 3 weeks before your ceremony. Any form submitted after this deadline will not be processed and graduation will be deferred until the next appropriate set of ceremonies. A registration fee of £40 is payable on first graduation from The University of Edinburgh in respect of life membership of the General Council, the statutory body comprising all of the University’s graduates. Students who, for any reason, do not wish to attend a ceremony (graduate in absentia) may do so but must still complete an online graduation registration form in order to receive their award certificate. Please be aware that if it is your intention to graduate at the above ceremony, any outstanding debts to the University must be paid to the Finance Office 21 days prior to the Graduation Ceremony. The Disability Office can assess your requirements and request adjustments and support you may need or negotiate specific assessment and exam arrangements. Assessment will be through an online journal review and basic statistics multiple choice questions. Online assessment (participation in interactive modules, discussion boards and group work) will constitute the other 10% of the overall course grade and is taken to represent a formative assessment of learning throughout the programme. The discursive paper will cover unusual clinical scenarios, difficult patient consultations and aspects of good and bad communication, possibly involving video clips. Online assessment through discussion boards and group work (wikis) will constitute the other 10% of the overall course grade and is taken to represent an assessment of learning throughout the programme. Online assessment through discussion boards and group work (wikis) will constitute the other 30% of the overall course grade and is taken to represent a formative assessment of learning throughout the programme (more details in programme proposal document). This is a written assignment critically reviewing a specific current global health problem. Online assessment in the form of discussion boards/ tutorials and group work and participation will constitute the other 50% of the overall course grade. This is taken to represent a formative assessment of learning throughout the programme. The written assignment should review aspects of palliative care management and should be considered in a specific clinical scenario. Summative works will be approximately 3,000 words in total and will be approved by the Health Informatics Programme Committee, on the recommendation of the Course Convener. This will be a reflective piece of around 2,000-2,500 words entitled, for example: "Take a learning outcome from your own clinical area and discuss how you would teach, assess and evaluate it; explaining and justifying the reason for your choices". This will be a written case assignment based on a particular patient- focused ethical situation and submitted online. Discussion boards and tutorial contributions will constitute the other 30% of the overall course grade which is also taken to represent a formative assessment of learning throughout the programme. Online assessment through participation in discussion boards, group work (wikis) and interactive materials will constitute the other 10% of the overall course grade and is taken to represent a formative assessment of learning throughout the programme. Within each specialty module students will be assessed by means of:  Critical appraisal of recent journal articles (50%) through a combination of online journal clubs and written online journal article appraisal forms. Students will be encouraged to produce either a short PowerPoint presentation, podcast or audio lecture that can be put online for peer and tutor assessment. This piece should be written in a style appropriate for a general medical (non-specialist) audience. The formatting should be suitable for formal publication and should contain an appropriate review of the literature. Tutors and fellow students will grade presentations with marks allocated in a 60% (tutor) to 40% (student) ratio. Writing skills, awareness of issues relating to plagiarism and referencing will be introduced. Students will be expected to actively use these tools throughout the course to create pieces of solo and group work, for example making presentations, reviewing journal articles and writing short review articles. The tools and resources available to perform thorough and accurate literature researching both within the University library services and on the internet will be introduced. How to conduct literature appraisal and the concept of evidence- based medicine will also be discussed. Students will receive some initial information on statistics that will be developed in later modules. The University’s librarians and a team for transferable skills will be working to tailor this module to students’ needs. Intended learning outcomes At the end of this course candidates should be able to conduct a literature search and critically review research and statistics used in clinical research. Online assessment (participation in interactive modules, discussion boards and group work) will constitute the other 10% of their overall course grade and is taken to represent a formative assessment of learning throughout the programme. Course description This programme aims to ensure that practitioners have a sound understanding of basic pharmacology principles and practices. Pharmacodynamic and pharmacokinetics principles will be taught using clinical examples.

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