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By: Rasheed Adebayo Gbadegesin, MBBS

• Professor of Pediatrics
• Professor in Medicine
• Affiliate of Duke Molecular Physiology Institute

https://medicine.duke.edu/faculty/rasheed-adebayo-gbadegesin-mbbs

Sources of lead poisoning include leaded gasoline symptoms joint pain order 1 mg finax with amex, lead smelters treatment lichen sclerosis order 1mg finax with visa, paint chips from houses with lead-based paint medicine in the civil war purchase generic finax canada, old batteries symptoms diagnosis purchase finax 1 mg line, magazine color pages medications not to take during pregnancy order finax amex, and lead-glazed pottery symptoms food poisoning order finax online pills. Decreased hemoglobin levels from lead toxicity are a product of inhibition of heme synthesis, resulting in accumulation of heme precursors and causing an elevation in the serum-free erythrocyte protoporphyrin levels. This morning he also began having some chest pain and difficulty taking deep breaths, and so his mother brought him to the emergency department. The patient has had several past admissions for his sickle cell disease for vaso-occlusive crisis pain management. He has a 3/6 systolic ejection murmur, and he has decreased breath sounds in his right lung base. His differential has 65% neutrophils, 25% lymphocytes, 8% monocytes, and 2% eosinophils. A chest radiograph reveals a small fluffy infiltrate in the right lower lobe of the lung. At this time, the patient most likely has which of the following complications of sickle cell disease The most common symptoms associated with acute chest syndrome in pediatric patients with sickle cell disease include all of the following except (A) hemoptysis (B) temperature higher than 101. The management of acute chest syndrome should include all of the following except (A) opioids for pain control (B) broad-spectrum antibiotics (C) aerosolized nitrous oxide (D) incentive spirometry (E) acetaminophen for fever 4. Which of the following antibiotics is the best initial choice in the management of a patient with sickle cell disease and fever Which of the following is not a side effect of the opioids used for pain management in children with sickle cell disease Acute chest syndrome is most common in patients with which of the following hemoglobin genotypes Recurrent acute chest syndrome is associated with all of the following complications except (A) chronic hypoxia (B) pulmonary hypertension (C) emphysema (D) cor pulmonale (E) anoxic brain injury 8. Which of the following is the most likely result of neonatal hemoglobin electrophoresis for patients with sickle cell trait Which of the following is the approximate hemoglobin S gene carrier frequency in the U. Which of the following findings on the peripheral blood smear is a feature of decreased splenic function in patients with sickle cell disease Renal complications of patients with sickle cell anemia include all of the following except (A) hyposthenuria (B) hematuria (C) proteinuria (D) glucosuria (E) renal failure 12. Gallstones found in patients with sickle cell anemia are composed primarily of which of the following compounds Acute hemiparesis in patients with sickle cell disease is best managed by which of the following All of the following are neurologic complications of strokes in pediatric patients with sickle cell disease except (A) recurrent stroke (B) cognitive delay (C) optic neuritis (D) seizure disorder (E) moyamoya 15. Which of the following has been shown to be most effective in preventing recurrence of strokes in patients with sickle cell disease Aplastic crises in patients with sickle cell disease are most commonly associated with which of the following infections Which of the following complications of sickle cell disease is most likely to occur during infancy Which of the following antibiotics is most effective for prophylaxis against S pneumoniae in patients with sickle cell disease Which of the following statements about hydroxyurea treatment in patients with sickle cell disease is false This amino acid substitution predisposes the hemoglobin molecule to polymerization, particularly under hypoxic or acidic conditions, with hemoglobin polymerization resulting in “sickling” of the red blood cell. Red blood cell sickling and the resulting microvascular obstruction is the cause of the wide range of complications associated with sickle cell disease. In a patient with sickle cell disease of any genotype, the combination of respiratory symptoms, fever, chest pain, and an infiltrate on chest radiograph after an episode of vaso-occlusive pain are all consistent with the diagnosis of acute chest syndrome. Acute chest syndrome occurs at least once in up to 50% of patients with sickle cell disease. The etiology of acute chest syndrome in patients with sickle cell disease is unclear but may include components of both pulmonary infection and infarction in addition to fat embolism from infarcted bone marrow. Therefore, any combination of the symptoms just listed should be treated as acute chest syndrome. Patients who have had prior episodes of acute chest syndrome are more likely to have recurrent episodes. Although hemoptysis occurs frequently in adult sickle cell patients with acute chest syndrome, it is rare in pediatric sickle cell patients. Other associated findings with acute chest syndrome include a drop in hemoglobin and an elevation in the baseline white blood cell count. Pain control to prevent respiratory “splinting” is important because the inability to take deep breaths will lead to further lung collapse and worsening of the acute chest syndrome. However, oversedation with respiratory depression should also be avoided, and so the opioid dose in patients with acute chest syndrome must be carefully titrated. Intravenous hydration is also important because dehydration contributes to further intravascular sickling. Overhydration with potential pulmonary edema and worsening symptoms must also be avoided. Antibiotics to cover the possible infectious etiologies (which include S pneumoniae, H influenzae, N meningitidis, Chlamydophila [Chlamydia] pneumoniae, and M pneumoniae, as well as many other bacteria and viruses) are important in the management of acute chest syndrome. Incentive spirometry to maintain alveolar patency is also important, and bronchodilator therapy can be a useful adjunct as well. Nitrous oxide therapy is not recommended for the management of acute chest syndrome. Red blood cell transfusions are the most effective therapy for acute chest syndrome. Patients with sickle cell disease generally have baseline hemoglobin values of 7-9 g/dL, and transfusions that raise the hemoglobin well above this range can lead to hyperviscosity and further sickle cell complications such as strokes. Those patients with baseline hemoglobin values higher than 10 g/dL should undergo exchange transfusion rather than simple transfusion to avoid hyperviscosity complications. The goal for blood transfusion or exchange transfusion should be to lower the percentage of sickled cells in the blood while avoiding further complications. Even before this age, however, children with sickle cell disease are more susceptible to encapsulated organism infection and rapidly progressive sepsis in the absence of treatment. Potential organisms include S pneumoniae, H influenzae, N meningitidis, Salmonella species, and E coli. Therefore, children with sickle cell disease should receive all recommended vaccines on time, and those who have fevers should always be evaluated by a physician. They should undergo laboratory evaluation including complete blood count with a reticulocyte count, blood culture, urinalysis, urine culture, and chest radiograph. Ceftriaxone, a broad-spectrum third-generation cephalosporin, is the antibiotic most likely to cover most of the potential pathogens in children with sickle cell disease, and particularly S pneumoniae, the most common cause of infections and infectious morbidity in sickle cell patients. A macrolide such as azithromycin is frequently added to cover possible Chlamydia and Mycoplasma pulmonary infections. Although clindamycin and vancomycin are effective against most gram-positive bacteria, including S aureus, they are not effective against the encapsulated gramnegative bacteria that are potential causes of infections and therefore are not optimal choices for initial management. Anaerobic infections are not more frequent in patients with sickle cell disease, and so metronidazole is not an appropriate initial choice. Hematuria is not a side effect of opiates but does occur commonly in patients with sickle cell disease. Patients with beta-thalassemia do not have complications from red blood cell sickling, such as acute chest syndrome. Other factors, such as the amount of fetal hemoglobin (hemoglobin F), the presence of coexisting alpha-thalassemia or other unknown factors may play a role in modifying sickle cell disease severity. Chronic pulmonary infiltrates, chest pain, hypoxia, and the eventual development of pulmonary hypertension and cor pulmonale can all ensue. African Americans carry the hemoglobin S gene, resulting in a sickle cell disease frequency of approximately 1 in 600 African Americans. By comparison, approximately 4% of African Americans in the United States carry the hemoglobin C gene, 1% carry a gene mutation for beta-thalassemia, and 1-3% carry a gene mutation for alpha-thalassemia. Sickle cell disease can also be found in Middle Eastern, Indian, and Central and South American populations; the hemoglobin S gene mutation is extremely rare in whites. The prevalence of sickle cell disease has been linked to protection from malaria infection, with those patients with sickle cell trait or disease relatively spared from the severe complications of malaria. The presence of red blood cells with these bodies in the peripheral circulation suggests the loss of the splenic filtration function, either because of surgical splenectomy or functional splenectomy from progressive infarction that occurs in patients with sickle cell disease. Auer bodies are white blood cell inclusions found in patients with acute promyelocytic leukemia. Basophilic stippling is seen in lead poisoning and represents residual ribosomal material within the red blood cells precipitated as a result of the presence of toxins. Polychromasia refers to the presence of reticulocytes on the peripheral smear, which appear more purplish than the mature red blood cells. Although patients with sickle cell disease do have an increase in reticulocytes and have significant polychromasia on their peripheral smears, it is not associated with their splenic function. The kidney is particularly susceptible to injury in patients with sickle cell disease because of the relatively hypoxic environment of the renal medulla and the high oxygen requirements of the renal parenchyma. Also, up to 40% of adults with sickle cell disease have renal insufficiency, with many progressing to end-stage renal disease requiring dialysis and possibly renal transplant. Components of “sickle cell nephropathy” include hyposthenuria, hematuria, proteinuria, renal cortical infarction, papillary necrosis, pyelonephritis, and, rarely, renal cell carcinoma. Hyposthenuria refers to the inability of patients with sickle cell disease to concentrate their urine because of the infarction of and damage to the renal medulla. The presence of hyposthenuria can be found in sickle cell patients by 5-10 years of age and becomes irreversible by 15 years of age. Hyposthenuria can cause significant dehydration, particularly in patients experiencing complications of their sickle cell disease. Hematuria can be microscopic or gross and primarily arises from the left kidney (80% of cases), although in approximately 10% of cases, hematuria arises from both kidneys. Cholelithiasis with or without associated cholecystitis occurs in up to 70% of patients with sickle cell disease, and it can occur in children as young as 4 years of age. Approximately a third of children with gallstones have an underlying hemolytic anemia. Recurrent or severe abdominal pain is common in patients with sickle cell disease and frequently is a result of cholelithiasis or cholecystitis, although hepatitis, pancreatitis, and other intra-abdominal processes must be considered, in addition to abdominal vaso occlusive pain crises. Recurrent or severe abdominal pain in sickle cell patients with gallstones or episodes of acute cholecystitis are indications for cholecystectomy. Approximately 10% of children with sickle cell disease have at least one stroke episode by the mean age of 7-8 years. Symptoms can range from headaches, changes in vision, cranial nerve palsies, hemiparesis, seizures, coma, or death. The use of emergent exchange transfusion in a patient with sickle cell disease and acute neurologic symptoms decreases the percent of hemoglobin S to less than 30% and results in decreased symptom severity and decreased incidence of long-term complications. Simple red blood cell transfusions are not effective in the treatment of stroke in patients with sickle cell disease, and nonsteroidal anti-inflammatory agents and hyperbaric oxygen have no role in stroke management in these cases. Although most sickle cell patients have a complete neurologic recovery from their strokes, complications such as residual neurologic dysfunction, persistent seizure disorder, cognitive delay, behavioral changes, and recurrent strokes can occur. Optic neuritis is not a neurologic complication of strokes in patients with sickle cell disease. Stroke recurrence in patients with sickle cell disease can occur in up to 60% of patients within 3 years of the initial stroke in the absence of treatment. Slowly progressive cognitive delay because of recurrent, otherwise asymptomatic strokes is a common problem in children with sickle cell disease and requires early identification and intervention. Neovascularization occurs in the areas of the brain that are left underperfused by the stroke. The network of small, delicate vessels that appear as cloud-like puffs on an arteriogram are called moyamoya. The name derives from a disorder described most often in people of Japanese ancestry in which a similar network of vessels develops idiopathically. Bleeds from moyamoya can be extremely debilitating and even fatal in patients with sickle cell disease. The incidence of stroke recurrence can be decreased from 60% within 3 years of an initial stroke without treatment to less than 10% with regular blood transfusions. However, the hemoglobin should be maintained less than 10 g/dL to avoid hyperviscosity associated with higher hemoglobin levels and an increase in stroke risk. Therefore, patients with sickle cell disease, red blood cell enzyme deficiencies, or red blood cell structural defects are susceptible to aplastic crises from parvovirus B19. Parvovirus infects the erythroid precursors within the bone marrow, temporarily halting new red blood cell production. The otherwise normal patient, with a red blood cell lifespan of 120 days, will suffer a small, likely asymptomatic fall in total hemoglobin, followed by bone marrow recovery and new red blood cell production. Patients with a decreased red blood cell lifespan because of the inability of the marrow to produce new red blood cells appropriately have severe, possibly life threatening falls in hemoglobin levels. Dactylitis is characterized by painful nonpitting edema of the dorsal surfaces of the hands and feet bilaterally, without other locations of pain or swelling. The etiology is not completely understood but most likely involves vaso-occlusion within the distal extremities. Priapism is a condition of prolonged, painful erection that occurs in up to 40% of adolescent males with sickle cell disease and requires urgent intervention with intravenous fluids, pain control, and either medical or surgical interventions to reduce the erection.

The approach should be positive (to confirm the clinical diagnosis) rather negative (to exclude some remote possibility) symptoms 6 months pregnant buy 1mg finax mastercard. It hampers with the proper functioning of the hospital laboratories and results the reliability of the laboratory results because of load which cannot be handled medications such as seasonale are designed to purchase finax 1 mg with amex. Similarly treatment 02 purchase genuine finax on line, they must be fully aware of the ethical angle of their responsibilities and should carefully learn how to medicine 257 purchase finax master card take legally valid consent for the different hospital procedures/therapies etc brazilian keratin treatment buy generic finax 1 mg line. Faculty members from the department of medicine and the various subspecialties act as preceptors for these seminars symptoms kidney pain 1mg finax fast delivery. The department is making spiral-bound “Medicine Seminar” volumes for the departmental library. Service and teaching morning ward round Monday, Wednesday, Thursday and Saturday. In addition to postings in the 3 general internal medicine units, the Junior Residents are posted in different subspecialty departments namely Neurology, Cardiology, Gastroenterology, Nephrology, endocrinology as well as Casualty and Employee’s Health Service, for training. A junior Resident, while rotating in the subspecialty of cardiology, undergoes the following clinical/other teaching exercises and acquires knowledge of following procedures/investigations: Clinical Clinical work of a resident is closely guided and supervised by the Senior Resident and the consultants. A resident acquires the expertise/knowledge to diagnose and manage acute myocardial infection and its complications, common arrhythmias, cardiogenic shock and pericardial temponade etc. The resident also learn to perform the procedures and investigations (listed below) necessary to manage such patients in appropriate clinical setting. All formal bedside case presentations in any unit/specialty are supervised strictly by consultant(s). A Junior Resident, while rotating in the subspecialty of neurology, undergoes the following clinical/other teaching exercises and acquires knowledge and competencies of the following procedures/investigations: Clinical Clinical work of a resident is closely guided and supervised by the senior residents and the consultants. A Junior Resident is expected to work up patients, discuss them with the consultant(s) and suggest relevant investigations of common neurological problems, some of which are listed above. Teaching Schedule a) Formal bedside case presentations by the Junior Residents at regular intervals. A Junior Resident, while posted in the subspeciality of Gastroentrology, undergoes the following clinical/other teaching exercises and acquires knowledge of following procedures/investigations: Clinical Clinical work of a resident is closely guided and supervised by Senior Residents and consultants. At the end of the Gastroentrology posting the junior resident should have acquired practical knowledge of the following procedures (approximate minimum duration of time to be spent on each procedure is specified in brackets against each). Clinical Clinical work of a resident is closely guided and supervised by Senior Residents and consultants. Teaching (a) Formal bedside case presentations by Junior Residents once every 2 weeks. Course and Curriculum of M D Medicine 115 (c) Journal clubs Once a week (d) Nephropathology conference 2 per month (e) Nephroradiology conference once per week (f) Dialysis Transplantation review discussion 1 per week Procedures At the end of the posting in Nephrology, the Junior Resident should have acquired the knowledge of and should be able to carry out the following procedures: Renal biopsy Peritoneal dialysis Investigations By the end of the Nephrology posting the Junior Resident should have practical and theoretical knowledge of following investigations: Urine examination essential Serum and urine osmotality Glomerular and renal function test studies. Immunological tests related to renal diseases Cyclosporin immuno-assay Interpretation of renal biopsy of common renal disease. A Junior Resident, while rotating through Casualty, undergoes the following clinical/other teaching exercises and acquires knowledge of following procedures/investigations: Clinical Clinical work of a resident is closely guided and supervised by the Senior Residents and the consultants. At the end of the Casualty posting the Junior Resident should be able to diagnose and manage the following medical problems in the casualty. The unit has modem monitoring facilities as well as volume cycled ventilation with all modes. This posting is behind to provide an important component in the training of a resident in the Department of Medicine. Insert central venous lines using Triple humen catheters, record haemodynosics invasive methods. Evaluation of certain attributes such as interpersonal relationships, professional responsibility, sensitivity to patient’s need for comfort, ethical Course and Curriculum of M D Medicine 117 behavior etc. At the end of each clinical posting in each of the medicine units and the subspecialties mentioned above, the residents are assessed in a formal format (given below) by the faculty staff of the concerned unit/department. This formative assessment of the candidates is taken into account at the time of the final M. Attitude, behavior and interpersonal relationship: (i) Behavior with patients and relatives 5. The examination is conducted by two internal examiners with the help of two external examiners. The content of knowledge which is evaluated in the theory examination includes basic sciences as applied to medicine, epidemiology, etiopathogenesis, pathology and clinical manifestations of diseases processes, principles of therapeutics, principles of the management of medical diseases with particular emphasis on newer concepts and recent advances. Paper 1 includes questions on “Basic Sciences” as applied to medicine; Paper 2 covers topics of general medicine excluding neurology, therapeutics, infectious disease and tropical medicine; Paper 3 includes general medicine not covered in paper 2; and Paper 4 includes preventive medicine, community medicine, other allied specialties as applied to general medicine. Written examination may be conducted with the help of traditional essay type question papers, or more objective type of questions requiring short or very short answers. The Department of Medicine, in consultation with the Dean and the residents may recommend any of the above mentioned patterns of written examination, and may vary them over the years depending upon the feedback from several sources. However, in order to test the various skills, the examiners may evaluate the candidates on a structured format, namely, history taking, physical examination, diagnostic reasoning, choice of diagnostic investigations, general management strategies, and general attitude and demeanor towards the patient and the examiners. Patient material selected for examination is usually sufficiently representative of the type of patients for whom an internist may be called upon to give an opinion. Requirement of Thesis Currently the residents at the All India Institute of Medical Sciences are required to submit a thesis based on a research protocol developed by them with the help of one or more members of the faculty of the Department of Medicine or allied subspecialties. Introduction to research methodology is considered desirable for the residents so that they can understand the concepts of validity and generalizability of the observed findings. All competent internists must keep themselves in touch with current medical literature. The these written by the residents are evaluated and graded by two external examiners in terms of research design, methodology employed, analytical methods used, and validity of the conclusions reached. Although these grades are not added to the theory or clinical assessment, acceptance of thesis as being satisfactory is a pre-requisite for a resident to be able to take the M. Case work up All the cases admitted under the charge of Junior Resident in-charge need to be worked up in detail including clinical, social, personal family and occupational aspects of history. Patients should be examined in detail with special reference to the involved system(s). The resident should make his own diagnosis with differential diagnosis giving full justification for each differential diagnosis. Formal presentation in the round, Junior Resident should write down consultant’s Course and Curriculum of M D Medicine 119 opinion on the separate page. He should then chalk out a plan for further investigations and management in a manner outlined below. Senior resident should make a brief note of relevant features, pen down his opinion and plan for further management. Junior Resident may take the help of his colleagues, senior resident/or and consultant so as to divide appropriate course of action. File Keeping For each admitted patient, a case record file with face sheet is to be meticulously maintained. On admission, Provisional Diagnosis needs to be entered after the initial work up. At the time of discharge, the final diagnosis, secondary diagnosis and complications need to be entered. All the face sheets at discharge, or at the time of death need to be properly filled in and must be duly signed by the senior resident. This is a dynamic list, and can be altered, dictated and formed from new information (derived from history, examination or investigations). The treatment chart should preferably be written in capitals, so that there is less problem in understanding, by other doctors, and paramedical staff. Page 4-5: Investigation Chart (i) Investigations chart with date, time (if relevant), nature of investigations, result, normal range (if it is not mentioned in the form or is not a routine investigations). Page 6: Consultant’s Opinion with Date and Time Page 6-10: History and Examination (or more pages, if required) Course and Curriculum of M D Medicine 121 Page 11: (Onwards) Progress notes should be entered daily for all patients and round the clock for sick patients with special reference to the following points; (i) Vital signs. These can be structured on the basis of those problems which have been identified. Student: Period of Posting: Part ‘A’ (Total 50 marks) Marks Awarded Marks Allotted (i) Formal Periodic Case Presentation 1st case: 12. Theoretical as well as practical training is imparted to the candidates in the subspecialities viz. Bacteriology, Virology, Parasitology, Immunology and Mycology so that they can participate in good patient care and prevention of infectious diseases in the community. They are introduced to basic research methodology so that they can conduct fundamental and applied research. They are also imparted training in teaching methods in the subject which may enable them to take up teaching assignments in Medical Colleges/Institutes. Establish good clinical microbiological services in a hospital and in the community in the fields of bacteriology, virology, parasitology, immunology and mycology. Measurement of immunological parameters Course and Curriculum of M D Microbiology 125 20. Gram positive cocci of medical importance including Staphylococcus, Micrococcus, Streptococcus, anaerobic cocci etc. Gram negative cocci of medical importance including Neisseria, Branhamella, Moraxella etc. Gram positive bacilli of medical importance including Lactobacillus, Coryneform organisms, Bacillus & aerobic bacilli, Actinomyces, Nocardia, Actinobacillus and other actinomycetales, Erysipelothrix, Listeria, Clostridium and other spore bearing anaerobic bacilli etc. Gram negative bacilli of medical importance including Vibrios, Aeromonas, Plesiomonas, Haemophilus, Bordetella, Bruce/la, Gardnerella, Pseudomonas & other non-fermenters, Pasture/ la, Francisella, Bacteroides, Fusobacterium, Leptotrichia and other anaerobic gram negative bacilli etc. Protozoan parasites of medical importance including Entamoeba, Free living amoebae, Giardia, Trichomonas, Leishmania, Trypanosoma, Plasmodium, Toxoplasma, Sarcocystis, Cryptosporidium, Microsporidium, Cyclospora. Helminthology of medical importance including those belonging to Cestoda (Diphyllobothrium, Taenia, Echinococcus, Hymenolepis, Dipyllidium, Multiceps etc. Mycelial fungi of medical importance including Aspergillus, Zygomycetes, Pseudoallescheria, Fusarium, Piedra, other dematiaceous hyphomycetes and other hyalohyphomycetes etc. Dimorphic fungi including Histoplasma, Blastomyces, Coccidioides, Paracoccidioides, Sporothrix, Penicillium marneffei etc. Vaccinology: principle, methods of preparation, administration of vaccines information technology (Computers) in microbiology 9. Animal & human ethics involved in microbiological work Psychomotor Skills for Postgraduates Students in M. Preparation, examination & interpretation of direct smears from clinical specimens 3. Plating of clinical specimens on media for isolation, purification, identification and quantitation purposes. Preparation and pouring of media like Nutrient agar, Blood Agar, Mac-conkey agar, Sugars, Serum sugars, Kligler iron agar, Robertson’s cooked meat broth, Lowenstein Jensens medium, Sabouraud’s dextrose agar etc. Operation of autoclave, hot air 9ven, distillation plant, filters like Sietz and membrane filters 9. Care and maintenance of common laboratory equipments like water bath, centrifuge, refrigerators, incubators etc. Tests for Motility:hanging drop, Cragie’s tube, dark ground microscopy for spirochaetes 17. Preparation of antibiotic discs; performance of antimicrobial susceptibility testing, eg. Kirby Bauer, Stoke’s method, Estimation of Minimal Inhibitory/Bactericidal concentrations by tube/ plate dilution methods 20. Quantitative analysis of urine by pour plate method and semi quantitative analysis by standard loop tests for finding significant bacteriuria 28. Maintenance & preservation of bacterial cultures Bacteriology Desirable to acquire 1. Enterotoxigeniciiy tests like rabbit ileal loop, intragastric inoculation of infant mouse, Sereny’s test. Collection of blood by venepuncture, separation of serum and preservation of serum for short and long periods 2. Preparation & preservation of complement & complement titration Immunology Desirable to acquire 1. Isolation and identification of medically important fungi & common laboratory contaminants 6. Special techniques like Wood’s lamp examination, hair baiting, hair perforation, paraffin baiting and slide culture 7. Calcofluor staining & examination under fluorescent microscope Parasitology Must acquire 1. Examination of blood for protozoa and helminths by wet mount, thick and thin stained smears 5. Maintenance of parasites in laboratory either in vivo in animals or by in-vitro cultures 2. In-vitro culture of parasites like Entamoeba, Leishmania, p falciparum, Acanthamoeba etc. Handling of mice, rats and guinea pigs for collection of blood, pathogenicity tests, etc. Preparation of monkey kidney cells (primary) and maintenance of continuous cell lines by subculture. Performance of haemadsorption for Parainfluenza, Haemagglutination of Influenza, Immunofluorescence, Neutralisation for Enteroviruses and Respiratory viruses. Basic Sciences (a) Modes of radioactive decay elementary aspect of the structure of matter. Mathematics, Statistics & Computer Sciences (a) Basic Mathematical Concepts, Counting Statistics, Probability distribution and parametric and non-parametric statistics. Course and Curriculum of M D Nuclear Medicine 133 (e) Electronic instruments, such as pulse amplifiers, pulse height analyzer, count rate meters and computer interfaces including gating systems.

You order renal ultrasonography that demonstrates a solitary left kidney with compensatory hypertrophy medications you can take during pregnancy discount 1 mg finax. Glomerular filtration rate represents the ultrafiltration of plasma across the glomerular capillary and correlates with the number of functioning nephrons medications that cause weight loss generic finax 1 mg with mastercard. These single kidneys appear larger on renal ultrasonography because of hypertrophy of the functioning nephrons symptoms bipolar discount 1 mg finax overnight delivery. Conditions associated with variable urea production in patients with renal injury and tubular urea reabsorption are seen frequently medicine 319 purchase finax australia. She was born to treatment for bronchitis 1mg finax for sale a 32-year-old gravida 1 z pak medications buy finax on line, para 0 mother with a history of chronic hypertension. Due to severe preeclampsia, the neonate was delivered by cesarean delivery after the mother received 1 dose of betamethasone. In the delivery room, the neonate required positive pressure ventilation for 30 seconds due to poor respiratory effort. On physical examination, she has mild intercostal retractions and nasal flaring with decreased breath sounds throughout. She is currently receiving nasal continuous positive airway pressure with FiO2 of 50%. The chest radiograph for this neonate shows bilateral homogenous pulmonary opacities. For this reason, newborns with respiratory distress syndrome with risk factors for infection should be treated with antimicrobial therapy. Other less common causes of early onset sepsis with respiratory manifestations include Listeria monocytogenes, Mycobacterium tuberculosis, and herpes simplex virus. Respiratory distress syndrome is a disease of premature neonates born before 37 weeks of gestation due to inadequate surfactant production. At a cellular level, lack of adequate surfactant production decreases lung compliance, causing microatelectasis. Chest radiographs shows poor lung expansion and a homogenous ground glass appearance and air bronchograms. Symptomatic neonates may be treated with exogenous surfactant based on clinical signs and symptoms. Treatment with exogenous surfactant in premature neonates is associated with lower rates of death, pneumothorax, pulmonary interstitial emphysema, and bronchopulmonary dysplasia. Pneumothorax describes air that has moved from the lung parenchyma into the space between the lung and rib cage. It may be visible on chest radiograph as a lucency at the heart border or lung base. Pneumothorax is not apparent on the chest radiograph for the infant in this vignette. However, with significant hypoplasia, ventilation and oxygenation are impaired, requiring mechanical ventilation. There is often a prenatal history of oligohydramnios with postnatal pulmonary hypoplasia. A portion of lung tissue is disconnected from the main bronchial tree and has a separate blood supply. There is a delayed transition in Na-K transporters in the lung from influx to efflux of fluid postnatally. Transient tachypnea of the newborn typically resolves within the first 24 hours of life. Surfactant-replacement therapy for respiratory distress in the preterm and term neonate. The father mentions that the family recently completed renovations on their home, which was originally built in 1925. Since she is at risk of lead exposure, you recommend that the girl have a blood lead level drawn at the visit today. You discuss with him the risks of lead toxicity, as well as the presentation of children with lead exposure. However, the vast majority of children with elevated lead levels are asymptomatic. Children are at greater risk for lead toxicity than adults because of oral exploration, enhanced gastrointestinal absorption, preferential deposition of lead in soft tissues as opposed to bone, and increased permeability of the blood-brain barrier. There are sociodemographic and racial disparities in lead exposure and lead poisoning, with African-American children, immigrants, international adoptees, publicly insured children, and those living in urban or poor neighborhoods disproportionately affected. Use of this type of paint was banned in the United States in 1977, but home disrepair or renovation can disrupt the paint already present and create lead-laden dust. Other sources of lead exposure include stagnant water in lead containing pipes, soil contaminated by leaded gasoline, and certain folk remedies, imported foods, and candies. Home renovation can increase the risk of asbestos exposure, if insulation or older ceiling materials are disrupted without proper containment. Certain parental hobbies and occupations, such as soldering or automobile repair, increase the risk of toxin exposure for children in the household. Agricultural families may be exposed to various pesticides that have been shown to have deleterious health effects in cases of preconception, prenatal, or childhood contact. The cough has been present for 8 weeks, is dry and harsh in quality, and is notably worse immediately before bedtime. No improvement was seen with a short-acting b-agonist, nonsedating antihistamine, antibiotic, or oral steroid administration. While you are obtaining the history from the parents, the child appears mildly anxious. You also note that his cough appears to lessen while he is playing games on his mobile phone. His nasal turbinates are normal without drainage, and his oropharynx is clear without postnasal drip, erythema, or cobblestoning. The most frequent cause of cough is an uncomplicated viral illness, and may last as long as 6 to 8 weeks. An average 10-year-old child will have 5 to 8 respiratory illnesses each year, with younger children likely to have even more. Most children with cough will not have a serious or chronic illness, and most episodes of cough will subside spontaneously. The differentiation between wet and dry cough has not been shown to be predictive of etiology or response to empiric treatment. Since fewer than 5% of coughs persisting for longer than 8 weeks are postinfectious in etiology (an exception is pertussis), further investigation and treatment may be warranted in this population. The boy in the vignette has symptoms that are most suggestive of a habitual cough. A habitual cough is often initiated by an identifiable infectious or inflammatory process, but the cough fails to resolve as expected when the inciting process resolves. The associated cough is typically loud, harsh, and brassy, and may be described as “honking. Acute bronchitis may occur with mycoplasmal associated illness, however, bronchitis or an inflammation of the larger airways is much less common in children than in adults. Protracted bacterial bronchitis, characterized by a chronic wet cough, has recently been described in the pediatric population. Bronchoscopic analysis and lavage reveals an intense neutrophilic airway inflammation. Commonly isolated organisms on culture include: Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. This diagnosis should not be routinely entertained during a period of acute and viral symptoms. Foreign body aspiration is most frequently encountered in children less than 3 to 5 years of age. Associated cough may arise from a foreign body located in the airway, esophagus, or external ear canal (Arnold nerve). Affected children may present acutely with cough and wheezing, but may also present later, after a “honeymoon period,” with a chronic cough. A history of a witnessed choking or aspiration event is present in fewer than 40% of cases. Inspiratory and expiratory or lateral decubitus radiography is recommended when aspiration of a foreign body is suspected. However, because very few (6%-15%) aspirated materials are radio-opaque, this may not establish the diagnosis. A high index of suspicion and a low threshold for otolaryngologic evaluation of the airway are required. Alternatively, cough receptors at the larynx may be activated by laryngopharyngeal reflux events. Lastly, refluxate may enter the airway during microaspiration events and stimulate tracheobronchial cough receptors. Cough may provoke reflux events through increased intrathoracic and intra-abdominal pressures and transient lower esophageal sphincter relaxations. The cough is often worse in the supine position (thus, typically at night) because of postnasal drip. Young children, however, often do not report classic symptoms, and a chronic cough may be the only presenting feature. Risk for sinusitis may be increased by predisposing factors for sinus ostial obstruction or infection, such as nasal polyps, allergic rhinitis, ciliary dysfunction, cystic fibrosis, and immunodeficiency. Criteria that suggest acute bacterial rather than viral rhinosinusitis include persistent symptoms lasting 10 or more days without evidence of improvement, onset with severe symptoms/signs for at least 3 to 4 days, or worsening symptoms after a typical time course of upper respiratory symptoms. Because of the symptom overlap between viral and bacterial sinusitis, treatment with antibiotics is not generally recommended in the first 48 to 72 hours of illness. The differential diagnosis of chronic cough in children also includes tracheo and bronchomalacia, vascular malformations, airway neoplasm, infection (eg, pertussis or parapertussis), and neurologic disorders such as Tourette syndrome. A thorough history and physical examination should be performed to optimally direct diagnostic testing and therapeutic interventions. You diagnosed him with intellectual disability and recommended that he should receive special education resources in school. As you review your records today, you notice your error regarding the fragile X results and disclose your mistake to the mother. In the case in the vignette, there was an error in diagnosis; the correct diagnosis was not made despite the fragile X test results showing 250 repeats (normal is 5-44 repeats, full mutation is more than 200 repeats). Brief descriptions are listed in this critique, but the reader is referred to the Suggested Readings for detailed definitions. Medical negligence is a legal term referring to a situation where there is an act or an omission that results in injury to the patient. In the case described in this vignette, there was no injury to the patient, so this is not a case of medical negligence. In healthcare, a “near miss” is an event that had the potential to cause harm but did not. An example of this is a patient being prescribed the wrong dose of a medication, but not having any adverse effects from taking that dose or the wrong dose being caught by the pharmacist prior to administration. Sentinel events are unexpected events that result in death or significant injury, for example, amputating the wrong limb. There was no significant injury to this patient in the event, so this is not a sentinel event. A systems error is an error attributable to the healthcare delivery process, for example, the lack of sufficient nursing staff leading to delays in medication administration in the hospital. When errors occur, it is important to disclose the error to the patient (when appropriate) and family, as was done in this case. Offering an apology is also appropriate, regardless of whether there is injury to the patient. Barriers to disclosing errors should be recognized; these can include the belief that the family would not want to know about the error or that the family might not understand the error that was made. Overcoming barriers to disclosing medical errors is important in creating and maintaining a bond between providers and families and in fostering a culture of patient safety. Vital signs show a temperature of 39°C, heart rate of 160 beats/min, blood pressure of 70/40 mm Hg, and respiratory rate of 30 breaths/min. On initial physical examination, he is tired appearing and in moderate respiratory distress. Ten minutes after the infusion of vancomycin is started, he develops itching, flushing, and an erythematous rash covering his trunk and upper extremities. Since administration of appropriate antimicrobials impacts mortality, decreasing the rate of the vancomycin infusion is the best choice presented. Severe manifestations include generalized erythema, intense pruritis, and distributive shock. Hydrocortisone can be helpful in anaphylactic reactions, but this clinical scenario does not fit anaphylaxis. Examples of idiosyncratic reactions include drug-induced hemolysis in patients with glucose-6-phosphate dehydrogenase deficiency and aspirin sensitivity causing bronchospasm. A serious adverse drug event is any undesirable consequence of a medical product in a patient that results in death, hospitalization, disability, birth defect, or a required intervention to prevent damage. This is an important system to evaluate safety concerns of medications and medical devices. In patients who depend on this medication for survival (for example, the child in this vignette with fever, neutropenia, and septic shock), slowing the infusion is the most appropriate course of action. An intravenous line is placed and his hypoglycemia is corrected with rapid infusion of 2 mL/kg of 10% dextrose in water followed by a continuous infusion of 10% dextrose in water. A serum sample obtained prior to correction of his hypoglycemia and run in the laboratory later returns at 20 mg/dL (1. Physical examination after correction of his hypoglycemia shows a rectal temperature of 37°C, heart rate of 120 beats/min, respiratory rate of 30 breaths/min, and blood pressure of 65/40 mm Hg. The right testicle is not palpable and the left testicle is palpable high in the scrotum.

Syndromes

• Antibiotics
• Herniated or "slipped" disc (cervical radiculopathy)
• Do you have eye pain or other symptoms, including headache, stuffy or runny nose, or joint or muscle aches?
• Bright red rash that gets bigger
• CBC
• Narrowing of the tube that carries urine out of the bladder (urethral stricture) in males

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Treatment denial, avoid osis provided that viability, ischaemia of a sufciently large territory ing referral to dedicated centres and operators, appears particularly 241 cruel in symptomatic patients who experience major symptom relief and/or anginal symptoms are present. The technique primarily works via the ’gate control’ studied with intracoronary haemodynamics. More data of the dorsal column bres, which activate the inhibitory interneur are needed before establishing a potential recommendation. The pulse generator is connected to the epidural lead with a Primary care physicians have a key role in ensuring that patients subcutaneous connection wire. It was demonstrated that while there was an factors—including smoking—is important in modifying the athero improvement in the more subjective outcome measures (including sclerotic disease process. As a con for further evaluation, to exclude high-risk coronary anatomy that clusion,overallmortalitywasnotincreased. This technology uses low-intensity shockwaves (one ability of the inclusion criteria, skewing the population studied tenth the strength of those used in lithotripsy) that are delivered towards the high-risk patients treated in tertiary referral academic tomyocardialischaemictissue. While the ’leitmotif’ of these Guidelines decades (reduction of the smoking habit; attention to healthy is the warning against the excessive use of redundant diagnostic tests diet)—may have improved the results of medical treatment. The and unnecessary interventions, we must caution the reader that revascularization techniques have also greatly improved, with stable coronary syndromes are still under-diagnosed and under better long-term results with the use of the internal mammary treated, especially in terms of secondary prevention. The existing trials deal with an angiographically selected sive and sophisticated imaging modalities that are still of limited avail low-risk population, with outcomes skewed by a high percentage ability, with great emphasis on clinical ndings and risk factors. The concept of plaque characterization and the difference is only caused by different end-point selection, with vulnerability remains a challenge for the future. Modern pharmacol no changes in either trial on ’hard’ endpoints, such as mortality. Highpreva References lence of a pathological response to acetylcholine testing in patients with stable 1. Eur Heart J lines for the management of acute coronary syndromes in patients presenting 2012;33:1787–1847. Third of coronary artery disease in the cardiac catheterization laboratory: a scientic universal denition of myocardial infarction. Effect of endurance trainingon coronaryartery size and functioninhealthy 30:1821–3. 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