By M. Sancho. Marymount Manhattan College.

Family Medicine Rotation Structure: During your month of family medicine buy prevacid 30mg line gastritis bloating, you will be at a site with anywhere from 0-4 other medical students discount prevacid 15mg gastritis diet . Although the physicians with whom you work will have inpatients, you will be working mainly in the outpatient setting. You will be seeing patients presenting for routine check-ups and screening, well-child visits, ob/gyn concerns, sick visits, injuries, psychiatric concerns, and everything else you can think of. Depending on your site, you may have formal teaching sessions each day or on specific days during the week. Responsibilities: • Seeing Patients: In the beginning of your rotation, you may shadow a resident or an attending; however, at most sites you will quickly start to see patients on your own. You will be given their chief complaint and should focus your history on this complaint; however, remember that family medicine is all about preventive care, and so you should not forget the rest of your history either and should do a complete physical exam. This is a clinic that patients present to for acute problems, and some of these may be straightforward. This type of presentation is different from those on inpatient medicine in that it is done immediately after you see the patient. You are thus not expected to know every answer about the patient’s needs or to have expertise on their complaints. You should try to get comfortable presenting, know everything you can about your patient, and try to find time before presenting to organize your thoughts regarding possible interventions. Keep it brief and focused, and use the opportunity to practice presenting without detailed notes or planning. If you are told to write in the chart, this is all you need to do (be sure to leave some space for your attending to write). If you are told not to, you may want to take notes on an extra sheet while you interview the patient so that you can refer to these when you present. If you find a great article on an interesting patient, it won’t hurt to bring it in, but don’t go overboard. You will usually be done seeing your patients between 4 and 6pm, and you will have no on-call or weekend responsibilities. You will have didactics back on campus every Friday (usually all day)—and these are all required, with 36 no good way to make them up (you will lose points if you miss any, except in the case of true extenuating circumstances). As usual, be conservative; bring the white coat on the first day and ask your supervising attending about wearing it. The exam that you will take at the end of the block is not a shelf exam, but is a multiple choice exam based largely on online cases that you are expected to work through during the clerkship. There is also a standardized patient portion of the exam where you will demonstrate a joint exam (usually the shoulder exam). You are advised to study for the exam—don’t make the assumption that preparing for the medicine shelf will prepare you for the family medicine exam (people have failed this way in the past). On occasion, things may need to move quickly and you may not be given the opportunity to see your patient on your own or to give a full presentation. It is essential that you study during family med no matter when in the sequence you have it; you will not get this time back when you are on medicine. You will be seeing patients from all walks of life and with every type of concern, and part of being a physician is dealing with this respectfully. If you have a valid reason to leave early, just mention it early in the day or week – for the most part, attendings are very understanding. Pediatrics/Obstetrics and Gynecology Grouping the pediatrics and obstetrics/gynecology clerkships into a single clinical block facilitates an integrated curriculum designed to present topics from the perspective of both clinical disciplines. Each individual discipline will have its own teaching curriculum with didactic sessions and problem- based learning. The integrated teaching curriculum covers issues such as prematurity, adolescent health, domestic violence and reproductive technology. Pediatrics Introduction: Pediatrics is a 6-week course in which you will learn diagnosis and treatment of basic childhood diseases. At most practices you will have the opportunity to see both routine check-ups and sick visits—you usually see 2-5 patients per half day. You will perform history and physical exams and present your assessment and plan to the attending physician.

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The response to bacillary multiplication provokes caseous necrosis that eventually blends and progresses to liquefaction discount 30mg prevacid gastritis diet . Tubercle bacilli buy generic prevacid 30mg on-line gastritis symptoms shortness breath, whose multipli- cation had been until then inhibited by granuloma formation, find favorable condi- tions for population growth after liquefaction of the caseum and subsequent cavita- 8 tion, and may produce more than 10 bacilli per cavity with a diameter of less than 2 cm. The natural evo- lution of post-primary lesions in immunocompetent persons can lead to dissemina- tion and death in about 50 % of cases, and to chronicity in about 25 % to 30 %. Natural cure can also occur in 20 % to 25 % of cases, when the host immune re- sponse is able to re-establish control of the disease (Bates 1980, Melo 1993). In most non-immunosuppressed persons infected by the tubercle bacillus, disease will occur in the first three to five years after the initial exposure. The remaining cases occur at any time during a 494 Tuberculosis in Adults lifetime, especially when there are other diseases or weakening conditions, for example malnutrition, diabetes, prolonged treatment with corticosteroids, immuno- suppressive therapy, chronic renal disease, gastrectomy, and others. The post- primary disease presents a great spectrum of manifestations, which are related to the affected organ. The lungs are most commonly affected, usually in the upper lobes or apical segments of inferior lobes. The disease can also affect other organs, including lymph nodes, pleura, kidneys, the central nervous system, and bones. With respect to respi- ratory signs and symptoms, the patient may complain of cough of insidious evolu- tion, at any hour of the day, which as initially dry and later on productive with purulent or mucous expectoration. Hemoptysis and bloody sputum occur in less than a quarter of patients, with the worst cases originating from lesions invading blood vessels. Few crackles can be noticed on auscultation after deep inspiration and also ronchi and tubular sounds. Such delays in diagnosis may be due to low diagnostic suspicion by the medical personnel, lack of access to health services, because the patient may not acknowledge being sick or may not seek medical help due to eco- nomic or cultural reasons. An early diagnosis is critical for controlling transmission of the disease in the community, especially in congregated institutions, such as hospitals, prisons, and shelters. It is crucial to perform the diagnosis in the initial phase of this type of presentation in patients with recent symptoms (less than four weeks) (Figure15-6). If diagnosis is delayed, the disease may evolve rapidly, destroying the pulmonary parenchyma (Figures 15-7 and 15-8). In the past, it was recognized as a sign of the tubercle bacilli seeking a route for air- borne dissemination (Figure 15-7). Tuberculosis disease 495 a b c Figure 15-6: Parenchymal infiltrate in the upper left lung, in posteroanterior (a and b) and lordotic position (c). After achieving cure, respiratory symptoms such as a productive cough persist in some patients for several years. When the patient refers to recurrent hemoptysis with elimination of more than 15-50 mL of sputum per day, bronchiectasis and/or a fungus ball may be present (Figure 15-10). Figure 15-10: Chest X-ray showing fibrotic infiltrate and cavity with a fungus ball in the upper left lobe. After this, tubercle bacilli can multiply at any time when there is a decrease in the host’s immune capacity to contain the bacilli in their implantation sites. The specific signs and symptoms will depend on the affected organ or system, and are characterized by inflammatory or obstructive phenomena. For this reason, the extrapulmonary disease gener- ally has an insidious presentation, a slow evolution and paucibacillary lesions and/or fluids. Access to the lesions through secretions and body fluids is not always possible, and for this reason, invasive techniques may be necessary in many cases, to obtain material for diagnostic investigation. Tissues and/or body fluids should be submitted to laboratory examination, in particular bacteriological culture for myco- bacteria and histopathological analysis. Nevertheless, the chest X-ray is mandatory for the evaluation of evidence of primary infection lesions, which provide a good verification to support the diag- nosis (Rottenberg 1996). Its onset may be either insidious or abrupt, depending on the bacillary load and/or the host immune situation, with unvacci- nated infants, elderly and immunodeficient patients being the most susceptible (Lester 1980, Thornton 1995). Other specific symptoms depend on the organs affected, and involvement of the central nervous system occurs in 30 % of cases. The physical examination is unspecific, and the patient can present 498 Tuberculosis in Adults with variable degrees of wasting, fever, tachycardia and toxemia. Chest X-ray shows a characteristic diffuse, bilateral and symmetrical micronodular infiltrate (Figure 15-8). The onset of the disease may be insidious or abrupt, with fever, systemic complaints, dyspnea, dry coughs, and pleuritic thoracic pain.

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Endocrine cells produce and secrete hormones that are sent throughout the body prevacid 15mg line gastritis diet mayo, and certain immune cells produce and secrete large amounts of histamine purchase 30mg prevacid gastritis diet potatoes, a chemical important for immune responses. The membrane of the vesicle fuses with the cell membrane, and the contents are released into the extracellular space. The tiny black granules in this electron micrograph are secretory vesicles filled with enzymes that will be exported from the cells via exocytosis. The genetic disease is most well known for its damage to the lungs, causing breathing difficulties and chronic lung infections, but it also affects the liver, pancreas, and intestines. This characteristic – puzzled researchers for a long time because the Cl ions are actually flowing down their concentration gradient when transported out of cells. Cilia on the epithelial cells move the mucus and its trapped particles up the airways away from the lungs and toward the outside. In order to be effectively moved upward, the – mucus cannot be too viscous; rather it must have a thin, watery consistency. The transport of Cl and the maintenance + of an electronegative environment outside of the cell attract positive ions such as Na to the extracellular space. As a result, through osmosis, water moves from cells and extracellular matrix into the mucus, “thinning” it out. This is how, in a normal respiratory system, the mucus is kept sufficiently watered-down to be propelled out of the respiratory system. The absence of ions in the secreted mucus results in the lack of a normal water concentration gradient. The resulting mucus is thick and sticky, and the ciliated epithelia cannot effectively remove it from the respiratory system. Bacterial infections occur more easily because bacterial cells are not effectively carried away from the lungs. All living cells in multicellular organisms contain an internal cytoplasmic compartment, and a nucleus within the cytoplasm. Cytosol, the jelly-like substance within the cell, provides the fluid medium necessary for biochemical reactions. An organelle (“little organ”) is one of several different types of membrane-enclosed bodies in the cell, each performing a unique function. Just as the various bodily organs work together in harmony to perform all of a human’s functions, the many different cellular organelles work together to keep the cell healthy and performing all of its important functions. Organelles of the Endomembrane System A set of three major organelles together form a system within the cell called the endomembrane system. These organelles work together to perform various cellular jobs, including the task of producing, packaging, and exporting certain cellular products. The organelles of the endomembrane system include the endoplasmic reticulum, Golgi apparatus, and vesicles. The smooth and rough endoplasmic reticula are very different in appearance and function (source: mouse tissue). These products are sorted through the apparatus, and then they are released from the opposite side after being repackaged into new vesicles. If the product is to be exported from the cell, the vesicle migrates to the cell surface and fuses to the cell membrane, and the cargo is secreted (Figure 3. Some of these products are transported to other areas of the cell and some are exported from the cell through exocytosis. Enzymatic proteins are packaged as new lysosomes (or packaged and sent for fusion with existing lysosomes). Lysosomes Some of the protein products packaged by the Golgi include digestive enzymes that are meant to remain inside the cell for use in breaking down certain materials. The enzyme-containing vesicles released by the Golgi may form new lysosomes, or fuse with existing, lysosomes. A lysosome is an organelle that contains enzymes that break down and digest unneeded cellular components, such as a damaged organelle. For example, when certain immune defense cells (white blood cells) phagocytize bacteria, the bacterial cell is transported into a lysosome and digested by the enzymes inside. In the case of damaged or unhealthy cells, lysosomes can be triggered to open up and release their digestive enzymes into the cytoplasm of the cell, killing the cell.

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