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By: Karen Patton Alexander, MD

  • Professor of Medicine
  • Member in the Duke Clinical Research Institute

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A 50-year-old man suffered a myocardial infarction as a result of thrombosis of the left anterior descending artery and collapsed order generic xifaxan on-line. Describe the structures that can possibly be affected as a result of such a blockage order 200 mg xifaxan visa. A 30-year-old lady developed right sided pleural effusion secondary to discount xifaxan uk pulmonary tuberculosis. Describe the structures that the needle has to pass through to reach the pleural cavity. Draw a neat, labelled diagram to show the boundaries and subdivisions of the mediastinum. Explain the role of the soleus muscle in promoting venous return from the lower limb. Pineal gland* * Please note that the slides marked with an asterisk are non-core competencies. Plain x ray of abdomen abdomen section at the level of T8, T10, L1 (transpyloric plane) 2. Explain the normal functioning of all the organ systems and their interactions for wellcoordinated total body function; 2. Assess the relative contribution of each organ system to the maintenance of the milieu interior; 3. List the physiological principles underlying pathogenesis and treatment of disease b. Attitude and communication skills: At the end of the course the student will be able to: 1. Integration: At the end of the integrated teaching the student should acquire an integrated knowledge of organ structure and function and the regulatory mechanisms. The procedures are to be performed by the students during practical classes to acquire skills. Those categorized as �Demonstrations� are to be shown to students during practical 72 classes. Questions based on these would be given in the form of data, charts, graphs, problems and case histories for interpretation by students during university examination. Effect of mild and moderate exercise on blood pressure, pulse rate and respiratory rate using Harvard step test. The minimum elements that needs to be included are mentioned in the template provided for log book. Type of questions Number of questions Marks for each question Total Marks Long essay 2 10 20 Short essay 10 5 50 Short answers 10 3 30 Total Marks 100 Blue print for theory question papers: Paper 1 (Max 100 marks) Paper 2 (Max 100 marks) Systems Marks Systems Marks Allocated Allocated General Physiology 05 Nerve and muscle Physiology 12 Hematology 20 Endocrine physiology 20 Cardiovascular Physiology 25 Reproductive physiology 15 Respiratory Physiology 20 Central nervous system 35 Gastrointestinal Physiology 15 Special senses 10 Renal Physiology 15 Integrated Physiology 08 Note: � All the questions should be structured compulsorily. However, a strict division of the subject may not be possible and some overlapping of systems is inevitable. The systems under each section of the paper (long essay, short essay and short answer) and the system from which the case vignette may be prepared can vary. However, marks allotted to the various systems as given in the above tables must be adhered to (with a variation of distribution of 1-2 marks between systems). The experiments kept under clinical examination should allow for an assessment of the marks allotted (and not be a very small component of the experiment for eg. Charts and graphs should be prepared on all systems which could be divided amongst 4 examiners (system-wise) and could be used in viva. Nerve muscle physiology � Myesthenia gravis, picture chart of neuromuscular junction iii. Hematology � clinical cases of anemia, blood indices, peripheral smear, jaundice (prehepatic, post hepatic and hepatocellular), iv. Endocrine system � clinical case histories / pictorial charts for various endocrine disorders ix. Reproductive system spinnbarkeit pattern pictorial chart, Fern pattern chart, clinical case history of infertility, hormonal changes during menstrual cycle graph, x. Integrated Physiology: Chart also includes Interpret growth chart*, Interpret anthropometric assessment of infants*: (*these two charts are �Non-core� competencies as per �Competency based Undergraduate Curriculum for the Indian Medical Graduate 2018: Medical Council of India�) xiv. These skills will be tested in normal, healthy volunteers or simulated environment 3.

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Ovalle F purchase xifaxan 400mg mastercard, Azziz R: Insulin resistance buy cheap xifaxan 200 mg online, polycystic ovary syndrome buy xifaxan online, and type 2 diabetes mellitus. Eifel P, et al: Simultaneous presentation of carcinoma involving the ovary and uterine corpus. Gordon T, et al: Dysgerminoma: a review of 158 cases from the Emil Novak ovarian tumor registry. Zhou Y, et al: Preeclampsia is associated with failure of human cytotrophoblasts to mimic a vascular adhesion phenotype: one cause of defective endovascular invasion in this syndrome Chilosi M, Piazzola E, Lestani M, et al: Differential expression of p57kip2, a maternally imprinted cdk inhibitor, in normal human placenta and gestational trophoblastic disease. In humans, paired mammary glands rest on the pectoralis muscle on the upper chest wall. The breast is composed of specialized epithelium and stroma that give rise to both benign and malignant lesions specific to the organ (Fig. The keratinizing squamous epithelium of the overlying skin continues into the ducts and then abruptly changes to a double-layered cuboidal epithelium. In the adult woman, the terminal duct branches into a grapelike cluster of small acini to form a lobule (Fig. Each ductal system typically occupies over a quarter of the breast, and the systems extensively overlap each other. In some women, ducts extend into the subcutaneous tissue of the chest wall and into the axilla. Figure 23-1 Normal breast anatomy and anatomical location of common breast lesions. In this setting, mass-forming lesions or calcifications can be difficult to detect. E, Mammograms become more radiolucent (darker) with age owing to the increase in adipose tissue. Over a 10-year period, 372 women over the age of 40 made 539 visits to a health maintenance organization for the listed [9] breast symptoms. The most commonly encountered lesions are invasive carcinomas, fibroadenomas, and cysts. Approximately 50% of carcinomas arise in the upper outer quadrant, 10% in each of the remaining quadrants, and about 20% in the central or subareolar region. Nipple discharge is a less common presenting symptom but is of concern when it is spontaneous and unilateral. A discharge produced by manipulating the breast is normal and unlikely to be associated with a pathologic lesion. A milky discharge (galactorrhea) is associated with increased production of prolactin. It can also occur in patients taking oral contraceptives, tricyclic antidepressants, methyldopa, or phenothiazines. Bloody or serous discharges are most commonly associated with benign lesions but, rarely, can be due to a malignancy. A normal bloody discharge can also occur during pregnancy, possibly due to the rapid formation of new lobules. Discharge is associated with carcinoma in 7% of women younger than 60 years and in 30% of women older than 60 years. The most common etiologies for discharge are a solitary large duct papilloma, cysts, or carcinoma (Fig. Carcinomas presenting as nipple discharge not associated with a [10] palpable mass are equally divided between invasive and in situ carcinomas. There is considerable interest in developing the cytologic examination of induced nipple discharge into a screening test for breast cancer. Mammographic screening was introduced in the 1980s as a means to detect small, nonpalpable breast carcinomas not associated with breast symptoms. As the dense, fibrous interlobular tissue of the young woman is replaced by the fatty tissue of the older woman, it becomes easier to detect small masses and calcifications. Also, with increasing age, benign lesions become less frequent and malignant lesions become more frequent.

Pseudocysts can be extraor intrapancreatic order line xifaxan, single or multiple cheap xifaxan 400mg without prescription, small or large anechoic structures with well-defined borSystemic�Metastatic Tumors ders and posterior acoustic enhancement (Fig cheap xifaxan 400mg free shipping. Debris the pancreas may be encased or displaced by adjacent tumors, may indicate hemorrhage or infection (Fig. Mature pseudocysts require at least 4 weeks to involvement in childhood lymphoma is unusual, may occur form, are relatively permanent, and change little in shape or with widely disseminated preterminal disease, is most common location, whereas acute peripancreatic or pancreatic fluid colwith large-cell lymphoma, and is sporadic with Burkitt lymlections are transient, poorly encapsulated, and variable in size phoma. The pancreas (open arrowhead) is diffusely and significantly enlarged, lobulated, and hypoechoic. The renal pyramids (arrows) and splenic parenchyma (S) are of identical echogenicity. The pseudocyst is seen between the pancreatic head (h) and tail (t) and contains a hypointense fluid�fluid level, consistent with hemorrhage. Histologically, pancreatic cystic consists of fibrous and granulation tissue (fibrotic pseudocaptumors include serous (microcystic) and mucinous (macrocyssule), in contrast to the epithelial lining of a true cystic lesion of tic) neoplasms. A clinical history of pancreatitis distinguishes a located in the pancreatic tail, and have seldom been reported in pseudocyst from tumor. Their sonographic appearance varies from a homogeCongenital cysts are caused by anomalous development of neous solid mass to a homogeneous liquid mass with occasional the pancreatic ducts. Multiple congenital cysts are seen tadenocarcinoma) or potentially malignant and have been in patients with adult polycystic disease or with von Hippel� described in elderly women. In individuals with von Hippel� Lindau disease, although this usually occurs in a much older age Lindau disease, simple cysts, serous cystadenomas, and neurogroup, not in the pediatric population. In children, particularly older encountered in Beckwith�Wiedemann syndrome and Meckel� children, large islet cell tumors and large solid pseudopapillary Gruber syndrome. There is an anechoic intrapancreatic pseudocyst (arrow) with ragged edges and posterior Fig. There is a second pseudocyst in 1-month boy with the antenatal diagnosis of a cyst. Note the lack of a thin-walled epigastric cyst (c) with debris at its dependent aspect capsule, ill-defined borders (open arrowheads), and multiple internal (arrow). Tips from the Pro Meticulous evaluation of the size and echogenicity of the pancreas may aid in the dierential diagnosis of conditions with diuse pancreatic involvement (Table 12. Von Hippel�Lindau Acute pancreatitis disease Source: Modified from Berrocal T, Prieto C, Pastor I, Gutierrez J, al-Assir I. Pancreatic tumors may be mistaken 2009; 39 Suppl 2: S153�S157 De Boeck K, Weren M, Proesmans M, Kerem E. Pancreatitis among patients with cysfor neuroblastoma or hepatoblastoma, and vice versa. Pediatrics 2005; ferential diagnosis of focal pancreatic lesions based on echoge115: e463�e469 nicity and multiplicity is listed in Table 12. Pancreatic duct dilatation usually indicates acute pancreatitis Radiol Clin North Am 2012; 50: 467�486 Enriquez G, Vazquez E, Aso C, Castellote A, Garcia-Pena P, Lucaya J. Pediatric panwhen mild and chronic pancreatitis when severe; it may also creas: an overview. Pancreas and biliarysystem: imagingofdevelopmental anomalies and disings in 10 patients and review of the literature. The child should be well hydrated, and a prelarly important with children who are still in their nappies. The examination is Adjust the gain behind the bladder; otherwise, it is easy to performed with both curved and linear array, high-frequency miss dilated ureters. Start with an assessment of the bladder shape, Color Doppler can be applied to dierentiate prominent hilar wall, and neck, and try to identify the ureter ostium and distal vessels from the renal pelvis (Fig. Proceed with the retrovesical space, where the internal Do not forget to assess the kidneys from behind the back to genitalia can be visualized behind the full bladder. The bladder must also be assessed before and after micturition, and the residual urine volume should be measured. In the neonate, the glomeruli occupy twice obtain measurements of the kidney in three planes.

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In all cases buy xifaxan 200 mg visa, clinical judgment consistent with the standards of good medical practice should be used when applying the Guidelines 200 mg xifaxan otc. Guideline determinations are made based on the information provided at the time of the request cheap xifaxan 200mg line. It is expected that medical necessity decisions may change as new information is provided or based on unique aspects of the patient�s condition. The treating clinician has fnal authority and responsibility for treatment decisions regarding the care of the patient and for justifying and demonstrating the existence of medical necessity for the requested service. The Guidelines are not a substitute for the experience and judgment of a physician or other health care professionals. Any clinician seeking to apply or consult the Guidelines is expected to use independent medical judgment in the context of individual clinical circumstances to determine any patient�s care or treatment. Simultaneous Ordering of Multiple Studies In many situations, ordering multiple imaging studies at the same time is not clinically appropriate because: Current literature and/or standards of medical practice support that one of the requested imaging studies is more appropriate in the clinical situation presented; or One of the imaging studies requested is more likely to improve patient outcomes based on current literature and/or standards of medical practice; or Appropriateness of additional imaging is dependent on the results of the lead study. When multiple imaging studies are ordered, the request will often require a peer-to-peer conversation to understand the individual circumstances that support the medically necessity of performing all imaging studies simultaneously. These include: Oncologic imaging � Considerations include the type of malignancy and the point along the care continuum at which imaging is requested Conditions which span multiple anatomic regions � Examples include certain gastrointestinal indications or congenital spinal anomalies Repeated Imaging In general, repeated imaging of the same anatomic area should be limited to evaluation following an intervention, or when there is a change in clinical status such that imaging is required to determine next steps in management. At times, repeated imaging done with different techniques or contrast regimens may be necessary to clarify a fnding seen on the original study. During the peer-to-peer conversation, factors such as patient acuity and setting of service may also be taken into account. Advanced imaging based on nonspecifc signs or symptoms is subject to a high level of clinical review. At a minimum, this includes a differential diagnosis and temporal component, along with documented fndings on physical exam. Additional considerations which may be relevant include comorbidities, risk factors, and likelihood of disease based on age and gender. The following indications include specifc considerations and requirements which help to determine appropriateness of advanced imaging for these symptoms. Sentinel headache and the risk of rebleeding after aneurysmal subarachnoid hemorrhage. Clinical warning criteria in evaluation by computed tomography the secondary neurological headaches in adults. Comparison of magnetic resonance imaging sequences with computed tomography to detect low-grade subarachnoid hemorrhage: Role of fuid-attenuated inversion recovery sequence. A systematic review of causes of sudden and severe headache (Thunderclap Headache): should lists be evidence based Donington J, Ferguson M,Thoracic Oncology Network of American College of Chest Physicians; Workforce on Evidence-Based Surgery of Society of Thoracic Surgeons, et al. Clinical policy: Critical issues in the evaluation and management of adult patients presenting to the emergency department with acute headache. The incidence and prevalence of cluster headache: A meta-analysis of population-based studies. Evidence-based guidelines in the primary care setting: neuroimaging in patients with nonacute headache. Screening for intracranial aneurysms in autosomal dominant polycystic kidney disease. Computed tomography angiography or magnetic resonance angiography for detection of intracranial vascular malformations in patients with intracerebral haemorrhage. Choosing wisely in headache medicine: the american headache society�s list of fve things physicians and patients should question. Incidental fndings on brain magnetic resonance imaging: systematic review and meta-analysis. Sentinel headaches in aneurysmal subarachnoid haemorrhage: What is the true incidence Neurophysiological tests and neuroimaging procedures in non-acute headache (2nd edition). Cost-effectiveness of magnetic resonance angiography versus intra-arterial digital subtraction angiography to follow-up patients with coiled intracranial aneurysms.

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References:

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