Attendings will often use a line of questioning to lead off a teaching session and even the hardest questions of the morning are directed to the most junior person in the room first (always you) before it trickles up to the chief resident buy alfuzosin 10mg prostate cancer trials. Look at it as a chance to show what you’ve learned generic alfuzosin 10 mg otc androgen hormone questions, to have fun thinking on the fly and, above all, to learn in the process. Attending rounds are variable from specialty to specialty, and formal attending rounds may not exist on some of your rotations. Surgical attendings often walk round between or after cases with only the chief resident or fellow, or they may round with the entire team at the end of the day. While you may have the opportunity to give bullet presentations on these rounds, you will likely not give lengthy H&Ps. Alternatively, you will have many opportunities to present new patients directly to the attending during clinic hours. Seek advice from your residents about the length and degree of detail expected in these presentations. In general, focus on basic principles rather than minutiae, and remember that a concise and complete discussion is better than an exhaustive dissertation. If the attending specifies that he/she wants to hear a 5-minute presentation, be sure to keep it to 5 minutes because some attendings will cut you off if it’s too long. Here is a general outline of how to approach a topic presentation: 1) Try to pick a topic relevant to either a patient you are following or another patient on the service. Feel free to have almost all of what you are going to say on it or an outline from which you will add information from memory. However, it is always good to do a Pubmed search if possible to find a few original articles of interest or just a great review article. Call Because inpatient medical and surgical services have patients in the hospital all day, every day, members of the team must be in the hospital at all times to care for these patients. During these nights (known as call), house officers have responsibility for admitting new patients to the hospital and taking care of medical issues on old patients that can’t wait until morning. As a student, your call schedule and corresponding responsibilities will vary from rotation to rotation. On medicine and pediatric services, your primary objective will be to help admit one or two new patients that you can present to the attending the next morning. While waiting for an interesting admission to come to your service, you should help your resident with the more routine duties of patient management. Once your new patient has been admitted and settled for the night, you should get home to work on your presentation and do the appropriate relevant reading. Because you’re one of the few people in the hospital, you have greater responsibility and opportunity in the care of your patients. The specific call responsibilities for each clerkship are detailed in the individual clerkship sections later in this guide. The Chart The exact organization of a patient’s charted medical record is dependent on the hospital and ward in which that patient is located. It may be stored at the bedside, electronically, at some central nursing station, or in some cryptic combination of places. Fortunately, the essential components of the chart are consistent; they all contain sections for physician’s orders, administered medications, vitals, progress notes, lab and radiology results, etc. The chart is an important medical and legal document, so everything you write should be legible and clearly signed. The H&P You have already had a great deal of experience learning how to perform and write a History and Physical Exam. As time goes on, your H&P will change according to your individual style, the rotation, and the patient. Generally, your write-ups will grow more concise over the course of your clerkship year as you gain a better understanding of what is relevant and what is not relevant. At most institutions, your H&P will be placed on the chart, complemented by an addendum or, in some instances, an additional complete H&P written by the resident. Look at your admission note as an opportunity to organize your thoughts about the patient, to learn to be concise and pertinent, to adopt convention, and to demonstrate your understanding to the attending who will undoubtedly read most of what you contribute to the chart. In older patients, note their functional status here Marital status, Children, Living arrangements: Education: Tobacco hx: estimate total pack yrs, currently smoking? This should be very similar to the bullet you would deliver if your attending wanted a quick summary of the patient’s history and presentation. Each of the problems you list requires an in- depth assessment (especially in Medicine) which includes a detailed differential diagnosis. Support your thoughts with elements of the patient’s history, physical findings, lab data and procedure results. Don’t worry—your resident will almost always go over this with you the night before when you are on your 200 rotation! You don’t have to wait for all of the day’s data to come back before writing a daily progress note as you can always write an addendum.

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There was no strong evidence on which to set an age threshold above which surgery should not be considered cheap 10 mg alfuzosin free shipping prostate cancer janssen. The consensus of the group was that previously fit patients with a lobar haemorrhage with hydrocephalus purchase 10 mg alfuzosin amex androgen hormone zone, or those who are deteriorating neurologically where draining of the haematoma might improve outcome should be referred for surgery. However, the consensus was that patients with cerebellar haematoma should be carefully and regularly monitored for changes in neurological status that might indicate the development of coning or hydrocephalus by specialists in neurosurgical or stroke care. R58 People with intracranial haemorrhage should be monitored by specialists in neurosurgical or stroke care for deterioration in function and referred immediately for brain imaging when necessary. R59 Previously fit people should be considered for surgical intervention following primary intracranial haemorrhage if they have hydrocephalus. It has a mortality rate of 80%192 and usually presents within 2–5 days of stroke onset. There have been a number of reports of benefit from decompressive hemicraniectomy, but concerns remain as to the benefits in terms of both survival and good clinical outcome. Neurosurgeons in many centres have been reluctant to operate partly because of their experiences of hemicraniectomy in other conditions. Poor outcomes may be related to late referral of patients when surgery is performed after brain damage has become irreversible. Timely referral is vital to ensure that intervention takes place before damage is irreversible. The clinical question is which patients with malignant middle cerebral artery infarction should be referred for surgery. Data were included only for patients aged 18 to 60 years treated within 48 hours of randomisation. Level 1++ One systematic review (12 retrospective and prospective case series) (N=138 (129 plus nine patients added from the authors’ own institution) reported a pooled analysis of the outcomes associated with decompressive surgery. A dictomotimised outcome score was used with a good outcome defined as functional independence or mild to moderate disability and a poor outcome as severe disability or death. The mortality rate was also significantly higher after surgery in patients older than 50 years compared with those 50 years or less. The consensus of the group was that those patients identified in the pooled analysis 111 Stroke study194 should be referred for decompressive hemicraniectomy. The evidence base supports the use of decompressive hemicraniectomy up to the age of 60. The meta-analysis showed that there is a significant increase in morbidity in patients over 50 years old, which suggests added caution is needed in selecting patients over 50 years for hemicraniectomy. It should be noted that the evidence relates only to patients under the age of 60 years; this condition is not seen in older people probably because with the inevitable loss of brain volume with age, there is additional intracranial space to accommodate oedema with cerebral infarction. The data from a large non-randomised series suggested that outcome is substantially improved if treatment is initiated within 24 hours of stroke onset as compared to longer time windows for treatment. The pooled analysis took into account patients referred up to 45 hours, but the consensus of the group was that the prospective studies suggest that earlier referral is associated with better outcome. It is vital that patients at risk of malignant middle cerebral artery infarction are identified early, undergo careful, regular neurological monitoring by specialists in stroke or neurosurgical care, and deteriorating patients are referred immediately to a neurosurgical centre. R62 People who are referred for decompressive hemicraniectomy should be monitored by appropriately trained professionals, skilled in neurological assessment. Does modified-release dipyridamole or clopidogrel with aspirin improve outcome compared with aspirin alone when administered early after acute ischaemic stroke? How safe and effective is very early mobilisation delivered by appropriately trained professionals after stroke? Diagnostic accuracy of stroke referrals from primary care, emergency room physicians, and ambulance staff using the face arm speech test. Paramedic identification of stroke: community validation of the melbourne ambulance stroke screen. Risk of stroke early after transient ischaemic attack: a systematic review and meta- analysis. Validation and refinement of scores to predict very early stroke risk after transient ischaemic attack. Evaluating models – what is the optimum model of service delivery for transient ischaemic attack? Population based study of early risk of stroke after transient ischaemic attack or minor stroke: implications for public education and organisation of services. Presence of acute ischaemic lesions on diffusion-weighted imaging is associated with clinical predictors of early risk of stroke after transient ischaemic attack. Reference costs 2006–7 collection: costing and activity guidance and requirements. Diffusion-weighted imaging-negative patients with transient ischemic attack are at risk of recurrent transient events. Impact of abnormal diffusion-weighted imaging results on short- term outcome following transient ischemic attack.

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All of the sinuses communicate with the nasal cavity (paranasal = “next to nasal cavity”) and are lined with nasal mucosa purchase 10mg alfuzosin free shipping prostate implant. These produce swelling of the mucosa and excess mucus production purchase 10mg alfuzosin with visa prostate operation side effects, which can obstruct the narrow passageways between the sinuses and the nasal cavity, causing your voice to sound different to yourself and others. This blockage can also allow the sinuses to fill with fluid, with the resulting pressure producing pain and discomfort. This irregular space may be divided at the midline into bilateral spaces, or these may be fused into a single sinus space. These are paired and located within the right and left maxillary bones, where they occupy the area just below the orbits. Because their connection to the nasal cavity is located high on their medial wall, they are difficult to drain. It is located within the body of the sphenoid bone, just anterior and inferior to the sella turcica, thus making it the most posterior of the paranasal sinuses. The lateral aspects of the ethmoid bone contain multiple small spaces separated by very thin bony walls. These are located on both sides of the ethmoid bone, between the upper nasal cavity and medial orbit, just behind the superior nasal conchae. The largest are the maxillary sinuses, located in the right and left maxillary bones below the orbits. The most posterior is the sphenoid sinus, located in the body of the sphenoid bone, under the sella turcica. The ethmoid air cells are multiple small spaces located in the right and left sides of the ethmoid bone, between the medial wall of the orbit and lateral wall of the upper nasal cavity. Hyoid Bone The hyoid bone is an independent bone that does not contact any other bone and thus is not part of the skull (Figure 7. It is a small U-shaped bone located in the upper neck near the level of the inferior mandible, with the tips of the “U” pointing posteriorly. The hyoid serves as the base for the tongue above, and is attached to the larynx below and the pharynx posteriorly. The hyoid is held in position by a series of small muscles that attach to it either from above or below. Movements of the hyoid are coordinated with movements of the tongue, larynx, and pharynx during swallowing and speaking. It consists of a sequence of vertebrae (singular = vertebra), each of which is separated and united by an intervertebral disc. The vertebrae are divided into three regions: cervical C1–C7 vertebrae, thoracic T1–T12 vertebrae, and lumbar L1–L5 vertebrae. The vertebral column is curved, with two primary curvatures (thoracic and sacrococcygeal curves) and two secondary curvatures (cervical and lumbar curves). Regions of the Vertebral Column The vertebral column originally develops as a series of 33 vertebrae, but this number is eventually reduced to 24 vertebrae, plus the sacrum and coccyx. The vertebral column is subdivided into five regions, with the vertebrae in each area named for that region and numbered in descending order. In the neck, there are seven cervical vertebrae, each designated with the letter “C” followed by its number. The single sacrum, which is also part of the pelvis, is formed by the fusion of five sacral vertebrae. However, the sacral and coccygeal fusions do not start until age 20 and are not completed until middle age. An interesting anatomical fact is that almost all mammals have seven cervical vertebrae, regardless of body size. This means that there are large variations in the size of cervical vertebrae, ranging from the very small cervical vertebrae of a shrew to the greatly elongated vertebrae in the neck of a giraffe. Curvatures of the Vertebral Column The adult vertebral column does not form a straight line, but instead has four curvatures along its length (see Figure 7. When the load on the spine is increased, by carrying a heavy backpack for example, the curvatures increase in depth (become more curved) to accommodate the extra weight. Primary curves are retained from the original fetal curvature, while secondary curvatures develop after birth. In the adult, this fetal curvature is retained in two regions of the vertebral column as the thoracic curve, which involves the thoracic vertebrae, and the sacrococcygeal curve, formed by the sacrum and coccyx. Each of these is thus called a primary curve because they are retained from the original fetal curvature of the vertebral column. The cervical curve of the neck region develops as the infant begins to hold their head upright when sitting. Disorders associated with the curvature of the spine include kyphosis (an excessive posterior curvature of the thoracic region), lordosis (an excessive anterior curvature of the lumbar region), and scoliosis (an abnormal, lateral curvature, accompanied by twisting of the vertebral column). Kyphosis, also referred to as humpback or hunchback, is an excessive posterior curvature of the thoracic region.

Unlike the bones of the pectoral girdle 10 mg alfuzosin visa man health report garcinia testvol usx, which are highly mobile to enhance the range of upper limb movements discount 10mg alfuzosin free shipping mens health 15 minute meals, the bones of the pelvis are strongly united to each other to form a largely immobile, weight-bearing structure. This is important for stability because it enables the weight of the body to be easily transferred laterally from the vertebral column, through the pelvic girdle and hip joints, and into either lower limb whenever the other limb is not bearing weight. Thus, the immobility of the pelvis provides a strong foundation for the upper body as it rests on top of the mobile lower limbs. The paired hip bones are the large, curved bones that form the lateral and anterior aspects of the pelvis. Each adult hip bone is formed by three separate bones that fuse together during the late teenage years. The ilium forms the large, fan-shaped superior portion, the ischium forms the posteroinferior portion, and the pubis forms the anteromedial portion. The pubis curves medially, where it joins to the pubis of the opposite hip bone at a specialized joint called the pubic symphysis. Ilium When you place your hands on your waist, you can feel the arching, superior margin of the ilium along your waistline (see Figure 8. Inferior to the anterior superior iliac spine is a rounded protuberance called the anterior inferior iliac spine. Muscles and ligaments surround but do not cover this bony landmark, thus sometimes producing a depression seen as a “dimple” located on the lower back. This is located at the inferior end of a large, roughened area called the auricular surface of the ilium. The auricular surface articulates with the auricular surface of the sacrum to form the sacroiliac joint. Both the posterior superior and posterior inferior iliac spines serve as attachment points for the muscles and very strong ligaments that support the sacroiliac joint. The shallow depression located on the anteromedial (internal) surface of the upper ilium is called the iliac fossa. The inferior margin of this space is formed by the arcuate line of the ilium, the ridge formed by the pronounced change in curvature between the upper and lower portions of the ilium. The large, inverted U-shaped indentation located on the posterior margin of the lower ilium is called the greater sciatic notch. This serves as the attachment for the posterior thigh muscles and also carries the weight of the body when sitting. Projecting superiorly and anteriorly from the ischial tuberosity is a narrow segment of bone called the ischial ramus. The slightly curved posterior margin of the ischium above the ischial tuberosity is the lesser sciatic notch. The bony projection separating the lesser sciatic notch and greater sciatic notch is the ischial spine. The enlarged medial portion of the pubis is the pubic This OpenStax book is available for free at http://cnx. The superior pubic ramus is the segment of bone that passes laterally from the pubic body to join the ilium. The narrow ridge running along the superior margin of the superior pubic ramus is the pectineal line of the pubis. The pubic arch is the bony structure formed by the pubic symphysis, and the bodies and inferior pubic rami of the adjacent pubic bones. Together, these form the single ischiopubic ramus, which extends from the pubic body to the ischial tuberosity. The inverted V-shape formed as the ischiopubic rami from both sides come together at the pubic symphysis is called the subpubic angle. Pelvis The pelvis consists of four bones: the right and left hip bones, the sacrum, and the coccyx (see Figure 8. Its primary role is to support the weight of the upper body when sitting and to transfer this weight to the lower limbs when standing. It serves as an attachment point for trunk and lower limb muscles, and also protects the internal pelvic organs. In this position, the anterior superior iliac spines and the pubic tubercles lie in the same vertical plane, and the anterior (internal) surface of the sacrum faces forward and downward. The three areas of each hip bone, the ilium, pubis, and ischium, converge centrally to form a deep, cup-shaped cavity called the acetabulum. The large opening in the anteroinferior hip bone between the ischium and pubis is the obturator foramen. This space is largely filled in by a layer of connective tissue and serves for the attachment of muscles on both its internal and external surfaces. The largely immobile sacroiliac joint is supported by a pair of strong ligaments that are attached between the sacrum and ilium portions of the hip bone. These are the anterior sacroiliac ligament on the anterior side of the joint and the posterior sacroiliac ligament on the posterior side. The sacrospinous ligament runs from the sacrum to the ischial spine, and the sacrotuberous ligament runs from the sacrum to the ischial tuberosity.

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