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By M. Topork. Franklin Pierce University.

She knew the depression was brought on by chronic illness and feelings of helplessness and hopelessness as things got inexplicably worse discount 50 mg precose amex. The only other condition of any significance she had ever experienced besides her thyroid disorder was alternating constipation and diarrhea generic precose 25mg line. Step Six: Categorize Your Current (and Prior) Significant Medical Prob- lems by Etiology generic precose 25 mg overnight delivery. In honestly con- sidering the various questions raised in this particular step generic precose 50mg with visa, Ellen would have answered yes to the question about whether she felt she had to be perfect order 25 mg precose overnight delivery. One of the most difficult things in her belief system was that she wanted to be the perfect wife and mother. She felt worse about not being perfect than she did about her physical symptoms. She also felt guilty about asking any- one to help her before she became ill (because, of course, she had to be perfect). Consequently, even when she would have liked to, she never asked her husband to feed the baby at night. After getting one night of total undis- turbed sleep (because of the sleeping pill her mother had given her) she already felt a little better. For this reason, Ellen would have wondered if lack of sleep had any bearing on or relevance to her medical problems. Ellen’s notebook would have been filled with clues that would have been helpful to any physician she might have seen, even if her path had never crossed Dr. Making the Diagnosis Ellen’s story is typical of most patients diagnosed with fibromyalgia. Multi- ple tender points, muscle and joint soreness/tenderness, and achiness along with fatigue are the key symptoms. You may recall Ellen not only noted widespread aches and pains in her muscles and joints, but she also experienced pain when her husband hugged her. Rosen- baum examined Ellen, the first thing he did was press on what are known as the trigger points. There are between eleven and eighteen of these points that are extremely painful when pressed in a patient with fibromyalgia. Other corollary clues that confirmed this diagnosis were sensitivity to light, noise, and tight clothing. There are two types of sleep: rapid eye movement (REM) sleep, also known as dream sleep, and non-REM sleep, known as nondream sleep. Non-REM sleep has four stages—one being the lightest and four being the deepest. Not achieving the right combination of sleep stages prevents the brain from producing endorphins. Endorphins are those “feel good” chemicals that get released when we are in love or after vigorous exercise. The phenomenon known as the jogger’s high—a sense of extraordinary well-being—results from the flood of endorphins released postexercise. When the boxing match ends, the body ceases to function in overdrive and the boxer reaches for a painkiller. Because they are natural pain regulators, endorphins allow ease of motion in the joints and prevent the pain and soreness associated with fibromyalgia. Without them, the muscle soreness, tender points, and gen- eralized body pain occur. In Ellen’s case, she had not had a solid night’s rest for more than thir- teen months after her baby was born. Although the true onset appeared at six months after her baby’s birth, the symptoms became too obvious to ignore at thirteen months. Rosenbaum firmly believed it was this sleep deprivation and the failure of her body to produce enough endorphins that caused Ellen’s condition. The reason Ellen felt better during the short time she was going to the gym was because endorphins were probably being released after her vigorous exercise routine.

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Heparin biphasic energy those with ongoing ischaemic cardiac pain order 50mg precose overnight delivery, and those who have OR over 1 hour 50mg precose otc. Consider anticoagulation: Synchronised DC shock* precose 25 mg discount, DC shock* 50mg precose visa, if indicated over 1 hour precose 25mg lowest price. Immediate anticoagulation with heparin - Heparin if indicated repeated once if - Warfarin for later necessary and an attempt at cardioversion is recommended. This should synchronised DC shock*, if indicated be followed by an infusion of amiodarone to maintain sinus rhythm if it has been restored, or control ventricular rate in Doses throughout are based on an adult of average body weight situations in which atrial fibrillation persists or recurs. Patients with a ventricular rate of less than 100 beats/min, with no symptoms, and good peripheral perfusion constitute a low risk group. When the onset of atrial fibrillation is known to Algorithm for atrial fibrillation (presumed supraventricular tachycardia). London: Resuscitation have been within the previous 24 hours anticoagulation with Council (UK), 2000 heparin should be undertaken before an attempt is made to restore sinus rhythm, either by pharmacological or electrical means. Two drugs are suggested, amiodarone or flecainide, If cardioversion proves impossible or atrial fibrillation recurs, which are both given by intravenous infusion. It is also a should be used in an individual patient to minimise the risk of useful drug to increase the chances of successful cardioversion in patients with adverse features such as poor left ventricular pro-arrhythmic effects and myocardial depression. If atrial fibrillation is of longer standing (more than 24 hours) the decision to attempt to restore sinus rhythm should be made after careful clinical assessment, taking into account the chances of achieving and maintaining a normal rhythm. The majority of patients in this group will require initial anticoagulation with heparin while treatment with warfarin is Further reading stabilised. Br J Anaesthesia the patient has been anticoagulated for three to four weeks. The two groups of patients discussed so far represent the Amiodarone as compared with lidocaine for shock resistant two extremes of risk posed by atrial fibrillation. This group poses a difficult guidelines for adult advanced life support. Resuscitation challenge for treatment and in all cases expert help should be 2001;48:211-21. Further management depends on the ● International guidelines 2000 for cardiopulmonary resuscitation and emergency cardiac care—an international consensus on presence or absence of poor peripheral perfusion or structural science. Treatment depends on the length of time that 2000;46:135-53; Section 7C A guide to the international ACLS fibrillation has been present. Resuscitation 2000;46:169-84; Section 7D The patient should receive immediate anticoagulation with heparin tachycardia algorithms. Resuscitation 2000;46: followed by an attempt at cardioversion, either using drugs 185-93. If fibrillation has ● Kudenchuk PJ, Cobb LA, Copass MK, Cummins RO, Doherty been present for more than 24 hours, heparin and warfarin AM, Farenbruch CE, et al. Amiodarone for resuscitation after out-of-hospital cardiac arrest due to ventricular fibrillation should be started and elective cardioversion considered once (ARREST). This necessitates both an unobstructed bellows action by ● A respiratory minute volume of 6l/min air containing 21% oxygen, with a tidal volume of 500ml at 12 breaths/min the lungs to replace oxygen and eliminate carbon dioxide in ● An expired oxygen level of 16-17%, hence its use in expired the gas phase, and a continuous pulsatile action by the heart air resuscitation for effective delivery of the blood to the tissues. In the The “oxygen cascade” described by J B West 35 years ago presence of a normal haemoglobin level and arterial oxygen explains how oxygen is conducted down a series of tension saturation above 94%, this amounts to an oxygen availability gradients from the atmosphere to cellular mitochondria. These of 1000ml/min ● Average tissue oxygen extraction is only 25%, thereby “supply and demand” gradients increase when disease states or providing reserves for increased oxygen extraction during trauma interfere with the normal oxygen flux. Partial or total exercise, disease, or trauma where oxygen delivery is reduction of ventilation or blood flow are obvious examples impaired and form the fundamental basis for the ABC of resuscitation. Within the lung parenchyma at alveolar level, ventilation (V) and pulmonary artery perfusion (Q) are optimally matched to maintain an efficient V/Q ratio such that neither wasted ventilation (dead-space effect) nor wasted perfusion (shunt effect) occurs. Medical conditions and trauma—for example, aspiration, pneumonia, sepsis, haemorrhage, pneumothorax, pulmonary haematoma, and myocardial damage caused by infarction or injury—can severely impair pulmonary gas exchange and result in arterial desaturation. This causes hypoxaemia (low blood oxygen tension and reduced oxyhaemoglobin saturation). The resulting clinical cyanosis may pass unrecognised in poor ambient light conditions and in black patients. The use of pulse oximetry (SpO2) monitoring during resuscitation is recommended but requires pulsatile blood flow to function. A combination of arterial hypoxaemia and impaired arterial oxygen delivery (causing myocardial damage, acute blood loss, or severe anaemia) may render vital organs reversibly or irreversibly hypoxic. The brain will respond with loss of Pulse oximeter consciousness, risking (further) obstructed ventilation or unprotected pulmonary aspiration (or both). Impaired oxygen supply to the heart may affect contractility and induce rhythm disturbances if not already present.

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Allan Dwyer died in Sydney on February 13 precose 25 mg with amex, 1975 cheap precose 50 mg on line, just 9 months Allan Dwyer’s father was a general practitioner after the onset of the illness that caused the tragic and his mother a warm order precose 25mg overnight delivery, perceptive and capable end of an inspiring career buy precose 50mg without prescription. From Christian Brothers School at Lewisham discount precose 25 mg online, he secured a scholarship in medicine and a bursary of residence at St. He graduated with honors in 1942 and became resident medical officer at St. After war service in Borneo with the Australian Army Medical Corps, he returned to general prac- tice with his father and started as a clinical assis- tant in the orthopedic department of St. This association was to nurture and develop Allan’s life-long enthusiasm for orthope- dic surgery. After obtaining the degrees of FRACS and MS in 1948, he rapidly began to show an outstanding ability for original thought and critical evaluation. His earlier work on the correction of severe defor- mity of the toes gave excellent results and won him countless grateful patients. His more recent work centerd on such formidable problems as scoliosis, the improvement of the rate of spinal 93 Who’s Who in Orthopedics hip resurfacing arthroplasty that he had seen there. This concept, which he developed, became known as the Indiana conservative hip. One of his proudest days was in the summer of 1979, when the American Academy of Orthopedic Surgeons sponsored a course in Indianapolis on resurfacing arthroplasty of the hip. He would internally stabilize intertrochanteric fractures on a standard operating table, using two plain radiographs to verify the correct position after placement of the nail. These nails were not cannulated, and the inferior fin was several millimeters longer than the other two. EICHER lectual stimulation and camaraderie, and traveled 1904–1988 frequently with fellow members to Europe and Canada. Eicher was an associate clinical professor in Berne, Indiana, to Mennonite parents whose of orthopedic surgery at the Indiana University ancestors came from Bern, Switzerland. He was at his fun-loving best attended Indiana University and received his MD with medical students, interns, and residents. After internship at Indianapolis and his wife, Pluma, often entertained students General Hospital, he began the practice of general and house staff in their home, and he greatly medicine, in 1933, in Decatur, Indiana. He repeatedly Had it not been for World War II, he probably insisted that the years of postgraduate training would not have chosen to enter orthopedic train- were the best because of the rapid pace of ing. He joined the United States Army Medical assimilation of knowledge and the absence of Corps in 1942 and served a tour of duty in the the socioeconomic pressures of practice. On returning to the United States, When Pluma died of neoplasia in January he requested assignment to an orthopedic service, 1978, Dr. In even if it meant that he would not receive a 1982, after a bilateral cataract operation, a urinary promotion. He was assigned to the orthopedic tract infection led to a brain abscess. Next came service at Cushing General Hospital, Springfield, a mitral valve replacement and then a mediastinal Massachusetts, of which Nelson Hatt was chief. Hatt for his innovative except the severe visual impairment, which was a ideas. Eicher attained the rank of Major before great setback because of his insatiable reading being discharged, in 1945. In addition to his wife, his oldest son, 1948, strong Hoosier ties brought Dr. A son, Dan, and a his family to Indianapolis, where he practiced daughter, Julie, survive. Eicher’s primary interest, and he became a pioneer in the develop- ment of the intramedullary stemmed femoral prosthesis. Müller in Saint Gallen, Switzerland, he became interested in the double-cup type of 94 Who’s Who in Orthopedics strengthened by his knowledge of medicine in general, of medical administration, of public affairs and by his ability to assess the characters of other men. Ellis was, above all, a wise man and he possessed the urbanity and detachment that would have made him a good judge or colonial governor. Yet these qualities were not such as to attract the attention of the crowd or even of the profession at large. He was not a brilliant inno- vator or a popular orator, and his talents were con- cealed by a natural reserve that could be a little forbidding. Those who knew him well instinctively sought his opinion, and even his verdict, not only on clini- cal problems but on difficult matters of adminis- tration.

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There is some evidence that students do order precose 25mg overnight delivery, in the long term discount 25 mg precose with amex, recall more information in the context of patient problems when taught in thePBLway when compared with students taught in the disciplinary-based way order 50 mg precose with amex. What is strikingly apparent is that students prefer this approach and become much more motivated to learn buy precose 50mg otc, a prerequisite to the desirable deep approach to learning discussed in Chapter 1 generic precose 25 mg mastercard. Other educational objectives believed to be addressed by PBL are, according to Barrows, the development of effective clinical reasoning skills and self directed learning skills. However, several recent reviews in the literature reveal little evidence of major differences between graduates from schools with a problem-based curriculum and those fromschools with a more traditional curriculum. Whether this is actually true or reflects limitations of the indicators used to evaluate outcomes is unclear. IMPLEMENTATING PROBLEM-BASED LEARNING Problem-based learning will have different implications if you are involved on a curriculum committee than if your involvement is as a tutor to a group of students undertaking a PBL exercise. In the former situation you will be engaged in reviewing the evidence for the effectiveness of PBL, in discussing the politics and practicalities of making such a major change to the curriculum, and in conducting or 111 arranging information sessions and workshops for the staff of the medical school in order to gain their support. Having decided in principle to proceed, your school may choose one of several implementation models (Figure 7. You may decide to convert the whole curriculum to PBL along the lines of the innovative schools of which McMaster University in Canada is the exemplar. Alternatively you may want to follow the path of schools such as New Mexico or Harvard and commence with two tracks, running the PBL track parallel to the conventional track with the advantage of gaining experience and undertaking com- parative evaluation. If you wish to be more cautious another alternative is to introduce PBL as a component of the curriculum or into individual courses with or without the expectation that the whole course will eventually change to PBL. COURSE DESIGN CONSIDERATIONS The basic principles of course design are the same as those in any other course (see Chapter 6). There is no single best way of approaching this task and it will be important to 112 ascertain which of the many styles of PBL you are expected to implement. In general,PBLcurricula are constructed in a modular format with blocks of several weeks being committed to a common theme (e. Factors to be taken into account will include: The major purposes of the module There are generally two major purposes to be achieved in a PBL module. One is the attainment of specific learning objectives in the form of an integrated knowledge and understanding of a defined problem (e. The other is skill in the process of problem-solving and self- directed learning. These are combined in various proportions in the Guided Discovery and Open Discovery approaches. In the Guided Discovery approach the emphasis is on both content and process. The course is carefully structured as a series of modules containing problems which direct students into learning the appropriate basic science and clinical content. While it is essential to allow the students to discover the learning issues from the problem, written guidelines are provided and tutor prompting occurs to ensure that all content areas are considered. The framework of the course and the problems may be the same as in the Guided Discovery approach but the students have much greater responsi- bility for determining what they should learn. The method of instruction PBL is usually conducted in small groups consisting of 5-10 students with a tutor. As a rule, the tutor is there to facilitate the process rather than to be a provider of content knowledge. In some schools tutors are deliberately chosen to be non-experts particularly where the Open Discovery approach is predominant. Small group activities are supported by independent study for which curriculum time must be carefully protected. Where tutor resources are limited it is possible to conduct PBL in large group 113 settings using student-led groups for discussion or by relying to a greater degree on independent study. We have used this approach successfully in a foundation course using PBL for first-year medical students (see later). The selection of the problems This is one of the most important considerations in course design. The problems must be of the kind that will ultimately be faced by the students after they graduate but must also be both broad enough and specific enough to engage the students in learning activities which match the curriculum objectives. In general they should be patient problems or health problems which will require students to go through the following process: Analysis of the problem.

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