X
|
STUDENT DIGITAL NEWSLETTER ALAGAPPA INSTITUTIONS |
|
Kathleen Elizabeth Batley, MD
https://medicine.duke.edu/faculty/kathleen-elizabeth-batley-md
Outline erectile physiology including role of blood flow and nitric oxide impotence natural buy cheap vimax 30 caps on line, neural influences erectile dysfunction at age 17 order 30 caps vimax with amex, hormonal influences erectile dysfunction new drug generic vimax 30 caps amex, and psychogenic factors herbal remedies erectile dysfunction causes vimax 30 caps with visa. Although usually the evaluation of a patient is not urgent, in a few situations it is a medical emergency. Acquired glucuronosyltransferase deficiency (breast milk, hepatocellular disease) 2. Compression of biliary ducts (malignancy) Key Objectives 2 Determine which patients have significant liver dysfunction and its cause. Order and interpret a blood smear in patients with unconjugated hyperbilirubinemia. Select patients in need of specialized care and/or in need of urgent hospitalization. Patients with liver disease may lack the capacity to give consent to investigate or treat. The physician should maintain a non-judgmental attitude toward such patients and care for their condition in a fashion that does not differ from that of any other type of patient. Outline 4 stages of bilirubin metabolism by the liver: uptake from the circulation, intracellular storage, conjugation with glucuronic acid, and biliary excretion. Although some causes are ominous, the majority are transient and without consequences. Gastrointestinal,в##absorption (pyloric stenosis, meconium ileus, sequestered blood) 2. Decreased bilirubin excretion/Obstructive (biliary atresia, obstruction, choledochal cyst) Key Objectives 2 Determine if jaundice presented in the first 24 hours, since it is more likely to be pathologic. In the relatively immature central nervous system of the neonate, especially in the premature, unconjugated bilirubin may be deposited and can result in severe brain damage. Objectives 2 Through efficient, focused, data gathering: Elicit a history regarding family history of hematological disorders, previously affected children, maternal blood type, and antibody status, delivery history, how coloration was noticed, vital signs, and any medications. Perform examination of scleral and mucous membranes, skin, liver and spleen, ascites, shock, urine, and stool. Select investigations that will differentiate pathologic hyperbilirubinemia from exaggerated physiologic jaundice. State that conjugated hyperbilirubinemia is never physiologic and select tests for immediate investigation. Explain advantages and disadvantages of phototherapy, exchange blood transfusions, and pharmacologic therapy. In addition, pain caused by a problem within the joint needs to be distinguished from pain arising from surrounding soft tissues. Objectives 2 Through efficient, focused, data gathering: Differentiate articular from non-articular disorders (arthritis is more likely when movement causes pain and there is loss of motion accompanied by swelling or erythema). List the indications, contraindications, and adverse effects of drugs commonly used in the treatment of arthritis. Post-infectious (reactive) - rheumatic fever, Reiter Syndrome, enteric infections iii. Non-inflammatory (osteoarthritis) Key Objectives 2 Determine whether the patient has a musculo-skeletal/neurologic emergency. Objectives 2 Through efficient, focused, data gathering: Differentiate between inflammatory and non-inflammatory arthritis (pain worse with immobility, lasts>1 hour, or relieved by rest and worse with motion). Determine whether the arthritis is migratory or not, if fever is present or absent, symmetric or not. Describe articular and extra-articular manifestations and complications (rash, adenopathy, alopecia, oral/nasal ulcers, pleuritic chest pain, Raynaud phenomenon, dry eyes, fever, etc. Examine joints for soft tissue swelling, warmth, joint effusion, range of motion (active and passive); examine lymph nodes, parotid, heart, lungs, skin, eyes, spine. Outline a management plan for patients with inflammatory and non-inflammatory arthritis including drug therapy, physiotherapy, occupational therapy, and treatment of joint deformities. Identify the origin and evaluate the utility of measurement of rheumatoid factors. Bone pain (leukemia, cancer, osteoporosis, sickle-cell disease, multiple myeloma, osteomalacia) Key Objectives 2 Differentiate from articular pain by clinical criteria. After excluding infection, diagnose other causes of soft tissue rheumatic disorders. Drugs (estrogen replacement, tamoxifen, Я -blockers, glucocorticoids, cyclosporine) v. Objectives 2 Through efficient, focused, data gathering: Identify patients with secondary causes for their lipid abnormalities. Describe dietary fat and cholesterol absorption, transport, and metabolism; list major circulating lipoproteins. The clinical manifestations of atherosclerosis include coronary heart disease, stroke, and peripheral artery disease. Outline the basic aspects of the pathogenesis of atherosclerosis including factors such as endothelial dysfunction, dyslipidemia, inflammation, tissue factor, etc. Describe the mechanism of action of drugs that have been shown to lower cholesterol levels. Extrahepatic (cholestasis from stone or neoplasm, stricture, congenital atresia) Key Objectives 2 Discuss abnormal liver function tests in the context of the clinical presentation, and select patients requiring medical management. Objectives 2 Through efficient, focused, data gathering: Differentiate between the causal conditions for abnormal liver function tests. Counsel and educate patients about primary and secondary prevention strategies for viral hepatitis (include public health measures). Some patients with chronic hepatitis C virus infection (about 4% per year) decompensate with cirrhosis and may become edematous. As a consequence, the decision whether to inform contacts regarding this potential for infection rests with the physician and patient. Ensuring that patients have all relevant information available eases the path to appropriate decision-making for each individual patient. Compare the biochemical difference in injury to hepatocytes to that of cholangiocytes (bile duct cells). Musculoskeletal lumps or masses are not common, but they represent an important cause of morbidity and mortality, especially among young people. Vascular/Other (deep vein thrombosis) Key Objectives 2 Identify patients at greatest risk for infectious lesions. Objectives 2 Through efficient, focused, data gathering: Discriminate between muscle contusion, hematoma, deep vein thrombosis, osteomyelitis/septic arthritis, pyomyositis, or neoplasm. Obtain history about crampy, local muscle pain, swelling, fever, or painless lump, or symptoms secondary to pressure effect on nerves. In a study of patients with lymphadenopathy, 84% were diagnosed with benign lymphadenopathy and the majority of these were due to a nonspecific (reactive) etiology. Cervical (bacterial/myco infections, head/neck malignancies, metastatic cancer) ii. Acute or chronic lymphocytic leukemia Key Objectives 2 Differentiate the cause of lymphadenopathy based on its location, distribution, and size (abnormal nodes are often>1-cm in diameter). Objectives 2 Through efficient, focused, data gathering: Obtain history of constitutional symptoms (fever, night sweats, weight loss), medications, exposure. Outline the organization and function of the immune system (migration of lymphocytes, lymphocyte populations, antigen specific receptors, immunoglobulins, T cell receptors, initiation of immune responses, humoral immunity, T-cell mediated immunity, etc. Evaluation of such masses is aided by envisaging the nature of the mass from its location in the mediastinum. Objectives 2 Through efficient, focused, data gathering: Obtain history of aching pain or cough in adults, respiratory difficulty, and recurring infections in children. Objectives 2 Through efficient, focused, data gathering: Examine for tetany, Chvostek, and Trousseau signs. If no cause is clinically apparent differentiate between gastrointestinal and renal causes by measuring urinary magnesium excretion/fractional excretion. Conduct an effective plan of management for a hypomagnesemic patient: 2 State that cellular uptake of magnesium is slow, and repletion requires sustained correction. Select potassium-sparing diuretics as an adjunct to management in patients with diuretic-induced hypomagnesemia if diuretic therapy cannot be stopped. Between these ages, absence of menstruation is a cause for investigation and appropriate management. Premature ovarian failure (infection, radiation/chemotherapy, autoimmune disease) ii.
After making the diagnosis of carcinomatosis in a patient with chronic abdominal pain where to buy erectile dysfunction pump 30 caps vimax mastercard, the physician may be asked by the patient to refrain from informing the immediate family erectile dysfunction doctor cape town 30caps vimax free shipping, despite the fact that optimal care and quality of life requires family involvement erectile dysfunction pills nz cheap vimax 30 caps with mastercard. Bacterial erectile dysfunction gnc proven vimax 30 caps, fungal, parasitic Key Objectives 2 Perform visual inspection, palpation, and rectal examination in all patients presenting with anal pain. Objectives 2 Through efficient, focused, data gathering: Differentiate between the causes of anal pain. Counsel patients with hemorrhoids and anal fissure in the conservative treatment options including sitz baths, stool softeners, and secondary preventative measure such as strict avoidance of constipation. The rationale for considering them together is that in some patients with a single response. Moreover, 50% of patients with atopic dermatitis report a family history of respiratory atopy. Celiac Key Objectives 2 Elicit clinical data in order to differentiate allergic responses from those caused by other agents. Objectives 2 Through efficient, focused, data gathering: Elicit a history to identify the possible causes of an anaphylactic reaction. Interpret results so as to differentiate the allergic from the non-allergic child. Outline the immediate and long-term management of the child with allergies including education and counselling for the child, parents, school, and the community. Outline the interaction of different immune mediators involved in allergic reactions including leukotrienes, cytokines and other mediators. Lengthy waiting lists for specialists together with the urgent plight of patients often force primary-care physicians to care for these children. Hyperactivity/Inattention secondary to other (learning/developmental) disorders a. Objectives 2 Through efficient, focused, data gathering: Determine whether there is family history for attention deficit or any of the co-morbid conditions. Determine whether there is evidence of development delay, genetic syndromes, encephalopathies, poisoning. Obtain (with consent) an education history (from teachers); physical examination should focus on ruling out underlying medical disorders (hearing, vision, mental status, neurologic disease). Select patients who require further medical investigation or psychological testing. The management of patients with hyperactivity/attention deficit disorder is resource intensive. The physician requires special knowledge and skill in how to access the needed resources. The management of patients with hyperactivity/attention deficit disorder may on occasion involve the use of medications that are considered controlled substances. Provincial licensing authorities may be involved in the regulation of such medications and may require the co-operation of the physician in regulating their use. The management of patients with hyperactivity/attention deficit disorder may involve a team structure that includes other health care workers, educators etc. Lower intestinal bleeding usually manifests itself as hematochezia (bright red blood or dark red blood or clots per rectum). Melena may be seen in 5 - 10% of patients with colorectal/small bowel bleeding and hematochezia may be seen with massive upper gastrointestinal bleeding. Objectives 2 Through efficient, focused, data gathering: Outline the diagnostic value/limitations of contrasting hematochezia and melena. The urgency of treatment and the nature of resuscitation depend on the amount of blood loss, the likely cause of the bleeding, and the underlying health of the patient. Objectives 2 Through efficient, focused, data gathering: Determine whether a bleeding diathesis may contribute to the bleeding. Early identification of colorectal cancer is important in preventing cancer-related morbidity and mortality (colorectal cancer is second only to lung cancer as a cause of cancer-related death). Rectal injuries and sexual abuse Key Objectives 2 List the key steps in the management of lower gastrointestinal bleeding in high-risk patients as resuscitation and assessment, localization, and diagnosis and treatment (early involvement of a gastroenterologist and surgeon is essential). Objectives 2 Through efficient, focused, data gathering: List indications for nasogastric tube aspiration and diagnose the most likely cause of hematochezia. List and diagnose the presence of associated drugs or medical conditions predisposing to the development of diverticulosis or colorectal cancer. List and interpret critical clinical and laboratory findings which are key in the processes of exclusion, differentiation, 2 and diagnosis: Select colonoscopy as the initial examination for diagnosis and treatment. Bleeding usually starts and stops unpredictably, but under certain circumstances may require immediate establishment of an airway and control of the bleeding. With massive hemoptysis/respiratory difficulty, once the patient is stabilized, refer promptly for bronchoscopy. Objectives 2 Through efficient, focused, data gathering: Differentiate between the causes of hemoptysis; determine the presence of prior lung, renal, or cardiac involvement. Identify presence of smoking, prior hemoptysis or family history of hemoptysis, infectious symptoms, upper airway or gastrointestinal symptoms; determine exposure to chemicals/asbestos, travel history, anticoagulants/platelet drugs; examine for skin rash, murmurs, deep venous thrombi. Conduct an effective initial plan of management for a patient with hemoptysis: 2 In the presence of massive hemoptysis (>200 ml/day), ensure adequacy of ventilation and hemodynamic stability first and consult a specialist. Outline the management of causes of hemoptysis which are not life threatening and do not require immediate referral to a specialist. Contrast the disproportionate amount of blood flow in the pulmonary arteries, almost the entire cardiac output but at low pressure, to the much smaller blood flow at high pressure through the bronchial arteries, usually one or two branches off the aorta for each lung. Despite this disproportion,>90% of the time, hemoptysis originates from the bronchial arteries. Identify the pulmonary arteries as supplying nutritive blood supply for the airways, hilar lymph nodes, visceral pleura, and some of the mediastinum. Persistent hematuria implies the presence of conditions ranging from benign to malignant. Anticoagulants (note that the incidence of hematuria in patients on anticoagulants is similar to that in patients not receiving anticoagulants) 2. Objectives 2 Through efficient, focused, data gathering: Determine whether the patient has true hematuria. Differentiate between glomerular and extraglomerular hematuria by examination of urine sediment. Formulate a management plan (non-pharmacological) for prevention of recurrent nephrolithiasis. Discuss possible strategies for the detection and prevention of urinary tract tumors. Once the presence of hematuria has been established and urinary tract infection has been excluded, it is critical to the further investigation of the patient to determine whether the hematuria is glomerular in origin or extra-glomerular. An experienced physician examining the urine sediment best accomplishes this differentiation. This information should be discussed with the patient before recommending more invasive and/or expensive investigations. Because persistent hematuria implies the presence of conditions ranging from benign to malignant, it cannot be ignored or assumed to be benign. List and explain various clinical findings that predispose to nephrolithiasis such as hypercalciuria, hyperuricosuria, hyperoxaluria, hypocitraturia, dehydration, and pH changes. Outline the role of humoral immunity and cellular immunity in glomerulonephritis and the target antigen predominantly localized in the glomerulus. Outline the structural and functional consequences of immune deposit formation in glomeruli. Explain the mechanisms of glomerular damage by immune events involving the complement system, polymorphonuclear cells, platelets, macrophages, oxidants and proteases. Describe the manner in which macromolecules are prevented from entering Bowman space and the permeability changes that make entry possible. Under such circumstances, the diagnosis of hypertension is made only after three separate properly measured blood pressures. Appropriate investigation and management of hypertension is expected to improve health outcomes. Determine whether hypertension is refractory/severe, prior treatment and response, sudden dyspnea, known renal problems, headaches, palpitations, sweating, muscle weakness, polyuria.
A feature function defines its value to be 0 in most cases fda approved erectile dysfunction drugs order vimax 30caps with mastercard, and to be 1 in some designated cases erectile dysfunction non organic discount vimax 30 caps free shipping. For instance impotence 2 generic vimax 30 caps overnight delivery, the forward variable t(si) defines the probability that state at time t being si at time t given the observation sequence o impotence marijuana facts order vimax 30caps with amex. Assumed that we know the probabilities of each possible value si for the beginning state 0(si), then we have t +1 (si) = t (s) exp(k f k (s, si, o, t) (2) s k In similar ways, we can obtain the backward variables and Baum-Welch algorithm. Once all token feature (Maybe including context features) values are determined, an observation sequence is feed into the model. Each token state is a combination of the type of the named entity it belongs to and the boundary type it locates within. To extract the list feature, we simply search each text string among the list items in maximum length forward way. The tagging operation iterates on the remaining part until all characters are tagged. The results are shown in Table 4 and Table 5: 4 Feature Extraction for Close Tracks In close tracks, only character and word list features which are extracted from training data are applied for word segmentation. Because lack of constraint checking on distant entity mentions, the system fails to catch the interaction among similar text fragments cross sentences. The system often fails to judge the right boundaries and the reasonable type classification. This file may be an incomplete output when the organizer transfers from another encoding scheme. Among them, a significant part of abbreviations are mentioned before their corresponding full names. Although it provides a unified framework to integrate multiple flexible features, and to achieve global optimization on input text sequence, the popular linear chained Conditional Random Fields model often fails to catch semantic relations among reoccurred mentions and adjoining entities in a catenation structure. The situations containing exact reoccurrence and shortened occurrence enlighten us to take more effort on feature engineering or post processing on abbreviations / recurrence recognition. Another effort may be poured on the common patterns, such as paraphrase, counting, and constraints on Chinese person name lengths. Acknowledgment this work is supported by the National Science Fund of China under contract 60203007. Conditional Random Fields: Probabilistic Models for Segmenting and Labeling Sequence Data. This system was entered into the Third International Chinese Language Processing Bakeoff and evaluated on all four corpora in their respective open tracks. Later testing with the gold-standard data revealed that while the additions we made to Low et al. Cn t0 (n = -1, 0, 1) In the above feature templates, Ci refers to the character i positions away from the character under consideration, where negative values indicate characters to the left of the present position. The punctuation feature P u(C0) is added only if the current character is a punctuation mark, and the function T maps characters to various numbers representing classes of characters. L is defined to be the length of the longest word W in the dictionary that matches some sequence of characters around C0 185 1 Segmenter Our Chinese word segmenter is a modification of the system described by Low et al. The dictionary features are derived from the use of the same online dictionary from Peking University that was used by Low et al. If C is assigned a tag t by the model with probability p, t is equivalent to the tag assigned by the actual training corpus D, and p is less than 0. Train a new model using all of the original training data along with the new data derived from the other corpora as described in the previous step. At each stage the likelihood of the current path is estimated by multiplying the likelihood of the path which it extends with the probability given by the model of the assumed tag occurring given the surrounding context and the current path. To keep the problem tractable, only the 30 most likely paths are kept at each stage. Such an algorithm is likely to run into situations where choosing the most likely tag for one character forces the choice of a very sub-optimal tag for a later character by making impossible the choice of the best tag. In contrast, the Viterbi algorithm entertains multiple possibilities for the tagging of each character, allowing it to choose a less likely tag now as a trade-off for a much more likely tag later. The surname feature is set if the current character is in our list of common surname characters, as derived from the Peking University dictionary. These features were designed to give the system hints in cases where we saw it make frequent errors in the 2005 data. This is accomplished 186 In addition to the features previously discussed, we added a number of features to our system that are outcome-dependent in the sense that their realization for a given character depends upon how the previous characters were segmented. If the current character is one of the place characters such as Q or G which commonly occur at the end of a three-character word and the length of the current word (as determined by previous tagging decisions on the current path) including the current character is equal to three, then the feature place-char-and-len-3 is set. If the situation is as described above except the next character in the current context is the place character, then the feature next-place-char-and-len-2 is set. If the current character is I and the word before the previous word is an enumerating comma (), then the feature deng-list is set. If the current character is I and the third word back is an enumerating comma, then the feature double-word-deng-list is set. If the length of the previous word is at least 2 and is equal to the length of the current word, then the feature symmetry is set. If the length of the previous word is at least 2 and is one more than the length of the current word, then the feature almost-symmetry is set. Similar features are added if the length of the current word is equal to (or one less than) the length of the word before the last and the last word is a comma. These features were largely designed to help alleviate problems the model had with situations in which it would otherwise be difficult to discern the correct segmentation. For example, in one development data set the model incorrectly grouped I at the end of a list (which should be a word on its own) with the following character to form I, a word found in the dictionary. This is intended to improve the utility of additional data from the traditional Chinese corpora when training models for the simplified corpora, and vice versa. The columns show F scores, recall rates, precision rates, and recall rates on out-of-vocabulary and in-vocabulary words. Moreover, its proportion of words over 5 characters in length was five times that of the other corpora. Another comparatively high proportion involved very long words, especially names with internal syntactic structure. Much of this can be attributed to the value of using an external dictionary and additional training data, as illustrated by the experiments run by Low et al. In particular, the maximum entropy toolkit utilized along with the training algorithms chosen seem likely candidates for sources of the disparity. We stripped out all of the additions and then added them back in one by one, segmenting and scoring the test data each time. What we found is that our system actually performed best with the implementation of the Viterbi algorithm (which raised F scores by an average of about 0. Besides these small differences, the model was best off without any of the features enumerated in Sections 1. It should be noted that in our testing during development, even when we strove to create a system which matched as closely as possible the one described by Low et al. It is possible that at least 188 4 Conclusions Using a maximum entropy approach based on a modification of the system described by Low, Ng, and Guo (2005), our system was able to achieve a respectable level of accuracy when evaluated on the corpora of the word segmentation task of the Third International Chinese Language Processing Bakeoff. However, it should be investigated whether the rest of the added features, especially the outcome-dependent ones, are useful in general or if they were only beneficial for the 2005 test data due to some pattern in that data, after which they were modeled. Error bounds for convolutional codes and an asymptotically optimum decoding algorithm. A Pragmatic Chinese Word Segmentation System Wei Jiang, Yi Guan, Xiao-Long Wang School of Computer Science and Technology, Harbin Institute of Technology, Heilongjiang Province, 150001, P. Sentence Input Sequence Abstract this paper presents our work for participation in the Third International Chinese Word Segmentation Bakeoff. We apply several processing approaches according to the corresponding sub-tasks, which are exhibited in real natural language. In our system, Trigram model with smoothing algorithm is the core module in word segmentation, and Maximum Entropy model is the basic model in Named Entity Recognition task.
Cheap 30caps vimax overnight delivery. Erectile Dysfunction Education - 3D Medical Animation.
Elicit history about mechanism of injury and examine structures in the spine which have been damaged experimental erectile dysfunction treatment buy vimax 30 caps on-line. Perform examination of spine erectile dysfunction gnc vimax 30caps otc, motor power in arms and legs erectile dysfunction family doctor generic vimax 30caps, sensation erectile dysfunction massage trusted 30 caps vimax, superficial and deep tendon reflexes. Conduct an effective initial plan of management for a patient with spinal injury: 2 Conduct education of people at risk for prevention of spinal injuries (diving into shallow water, skiing out of control, cross checking from behind in hockey, drinking and driving, etc. Initiate and maintain "spinal precautions# and log rolling of patients; outline methods available for stabilizing the spine. Counsel and support patient and family including access to rehabilitation programs. Define spinal cord injuries as either complete or incomplete (complete injury occurs when functional motor output and sensory feedback are absent below the spinal cord injury level, while some neurological activity persists below the site of injury in the case of an incomplete injury. Ventilatory muscles innervated below the level of a complete spinal cord injury are completely nonfunctional, while the degree of ventilatory muscle compromise is variable in patients with incomplete injuries). Explain that the extent of ventilatory muscle impairment depends upon the degree and location of the spinal cord injury. Explain that spinal cord injury affects ventilatory control in that individuals with tetraplegia have blunted perceptions of dyspnea and an abnormally small increase in ventilatory drive in response to hypercapnia (ventilatory response to hypercapnia among quadriplegics was approximately one-fourth that of normal controls). Objectives 2 Through efficient, focused, data gathering: Elicit history about the nature of the injury, difficulty voiding, and blood in urine or at meatus; differentiate straddle injury from sexual abuse (straddle injuries typically are unilateral and superficial and involve the anterior portion of the genitalia in both boys and girls). Conduct an effective initial plan of management for a patient with urinary tract injury: 2 Outline initial management of anterior urethral injury. Laceration Contusion/Spasm Compression Foreign body Key Objectives 2 Provide initial management and obtain consultation when indicated. Objectives 2 Through efficient, focused, data gathering: Elicit and interpret information from the history and physical examination to diagnose an arterial injury. Elicit and interpret information from the history and physical examination to diagnose compartment syndromes. Examine for vital signs, hematoma, and pulse deficit, distal ischemia; differentiate occlusive from hemorrhagic injury. List and interpret critical clinical and laboratory findings which were key in the processes of exclusion, 2 differentiation, and diagnosis: List the most appropriate investigations used in the diagnosis of vascular injury. Conduct an effective initial plan of management for a patient with vascular injury: 2 List risks in the use of tourniquets and clamps. Pain usually implies infection whereas difficulty is usually related to distal mechanical obstruction. Urinary frequency (normal or decreased volume) associated with dysuria and/or pyuria a. Irritable bladder (bladder dissynergia) Key Objectives 2 Differentiate between urinary tract infections and conditions outside the urinary tract with similar presentation; determine which infections require treatment, and select the appropriate treatment. Objectives 2 Through efficient, focused, data gathering: Interpret urinalysis and clinical findings in order to diagnose problems external to urinary tract. Evaluate examination findings so that problems involving the urethra or prostate are identified. Describe the collection of samples to be sent for culture and sensitivity; interpret results. Determine which patients should be on prophylactic treatment and the type of treatment. Diabetes mellitus is a common disorder with morbidity and mortality that can be reduced by preventive measures. Urinary frequency (normal/decreased volume) associated with dysuria and/or pyuria Key Objectives 2 Evaluate diabetic patients and determine whether diabetic ketoacidosis or hypoglycemia is present; formulate a management plan for diabetic emergencies. Objectives 2 Through efficient, focused, data gathering: Determine whether the obstruction is acute or chronic, duration, complete or partial, and unilateral or bilateral, and site. Select and interpret tests of renal function; outline indications for prostate cancer screening. Contrast mechanism of hypertension in unilateral obstruction (vasoconstriction secondary to elevated rennin-angiotensin) to bilateral obstruction (volume expansion). Contrast the lack of hydronephrosis with obstruction within the first 1 - 3 days (the collecting system is relatively uncompliant) to that in more chronic obstruction (collecting system encased by retroperitoneal tumor or fibrosis). Amount or pattern is considered outside normal when it is associated with iron deficiency anemia, it lasts>7days, flow is>80ml/clots, or interval is<24 days. Neoplasms, malignant/benign (endometrial cancer, uterine sarcoma, fibroids, adenomyosis) B. Age related (immature hypothalamic-pituitary-ovarian axis, menopausal ovarian decline) ii. Drugs (hormone replacement, contraception, anticoagulants, chemotherapy, steroids) Key Objectives 2 Determine whether the patient is hemodynamically stable prior to any other task. Objectives 2 Through efficient, focused, data gathering: Differentiate between bleeding related to or unrelated to pregnancy first. If age or clinical information makes pregnancy unlikely, differentiate between causes of gynecologic bleeding: ask about precipitating factors, temporal pattern duration, quantity, associated symptoms, bleeding disorder, medical and drug history, and any weight change. Perform pelvic and rectal exam; exclude gastrointestinal and urinary tract bleeding. List indications for cytologic/biopsy studies, hysteroscopy, and select patients to be referred for investigation. Outline follow-up of patient after treatment of ectopic pregnancy; gestational trophoblastic disease. Where sexual abuse is suspected, outline legal implications and requirement for support. In a patient with vaginal bleeding, where sexual abuse is suspected, legal definitions may be needed. Victims should be asked to sign consent forms prior to collection of any samples for evidence. Such samples, if consent is given, should be collected at the time of the initial evaluation and stored securely even if the patient eventually decides against reporting the abuse. Contrast ovarian function during menstruation to peri-menopause/menopause (intermittent anovulation as ovarian function declines to chronic anovulatory cycles and progesterone deficiency with unopposed estrogen exposure). Desquamative inflammatory vaginitis/Focal vulvitis Key Objectives 2 Determine the appearance of the discharge, but state that appearance may be misleading, and up to 20% of patients may have two coexistent infections. Elicit information about precipitating or aggravating factors (oral contraceptives, antibiotics, pregnancy, sexual activity, diabetes, genital hygiene, chemical irritants, etc. Perform genital and pelvic examination; determine whether pelvic inflammatory disease is present. List types of vulvo-vaginitis associated with sexual activity and discuss risk reduction. Outline a management plan for moniliasis, trichomoniasis, and for vaginitis due to gonorrhea and/or chlamydia including role of local hygiene in prevention. Domestic violence is one of them, since it has both direct and indirect effects on the health of populations. Intentional controlling or violent behavior (physical, sexual, or emotional abuse, economic control, or social isolation of the victim) by a person who is/was in an intimate relationship with the victim is domestic violence. The victim lives in a state of constant fear, terrified about when the next episode of abuse will occur. Despite this, abuse frequently remains hidden and undiagnosed because patients often conceal that they are in abusive relationships. It is important for clinicians to seek the diagnosis in certain groups of patients. Other (former victim of abuse, intellectual functioning, family and cultural influences, impulsivity) 2. Cognitive disorders (delirium, dementia) Key Objectives 2 Diagnose family violence if one partner (usually male) is excessively controlling, (will not allow the other to speak); specious excuses for bruises or rumors of many falls or injuries are suggestive of family violence. Objectives 2 Through efficient, focused, data gathering: Elicit a history of frequent emergency room visits, previous violence, violence against animals, recent violence, current violent thoughts, legal history, insight into (or absence of) ability to maintain control (most deny premeditation, claim impulse). Determine whether explanation of injuries is inconsistent, there is delay in seeking treatment, late for prenatal care, chronic pelvic pain, abdominal pain, headaches, fatigue, or eating disorder. Determine whether there are support systems, recent stresses, substance abuse, depression, and anxiety.
References