S. Inog. University of Connecticut.

Role of a critical pathway or practice guideline in delivering high quality cheap lopressor 100mg hypertension pregnancy, cost- effective care for patients presenting with symptoms of chest pain in the outpatient clinic discount lopressor 12.5 mg heart attack band, emergency room or hospital. History-taking skills: Students should be able to obtain, document, and present an appropriately complete medical history that differentiates among the common etiologies of chest pain. Physical exam skills: Students should be able to perform a focused physical exam that includes the following elements: • Accurate measurement of arterial blood pressure and recognition of the typical blood pressure findings that occur in patients with aortic stenosis, aortic insufficiency, and pulsus paradoxus. When a heart murmur is present, students should be able to: o Identify timing (systolic vs. Laboratory interpretation: Students should be able to recommend when to order diagnostic and laboratory tests and be able to interpret them, both prior to and after initiating treatment based on the differential diagnosis, including consideration of test cost and performance characteristics as well as patient preferences. Test interpretation should take into account: • Important differential diagnostic considerations including the “must not miss” diagnoses. Communication skills: Students should be able to: • Communicate the diagnosis, prognosis and treatment plan to patients and their families. Management skills: Students should be able to develop an appropriate evaluation and treatment plan for patients that includes: • Identification of the indications, contraindications, mechanisms of action, adverse reactions, significant interactions, and relative costs of the following medications: o Anti-platelet agents (aspirin, clopidogrel). Understand the emotional impact of a diagnosis of coronary artery disease and its potential effect on lifestyle (work performance, sexual functioning, etc). Recognize the importance of early detection and modification of risk factors that may contribute to the development of atherosclerosis. Demonstrate commitment to using risk-benefit, cost-benefit, and evidence- based considerations in the selection of diagnostic and therapeutic interventions for chest pain. Recognize the importance and demonstrate a commitment to the utilization of other healthcare professions in the treatment of chest pain. There are several common etiologies for cough of which a third year medical student should be aware, as well as more clinically concerning etiologies. A proper understanding of the pathophysiology, diagnosis, and treatment of cough is an important learning objective. Symptoms, signs, pathophysiology, differential diagnosis, and typical clinical course of the most common causes cough: • Acute cough: o Viral tracheitis. History-taking skills: Students should be able to obtain, document, and present an age-appropriate medical history that differentiates among the etiologies of disease, including: • Onset. Physical exam skills: Students should be able to perform a physical exam to establish the diagnosis and severity of disease, including: • Accurately determining respiratory rate and level of respiratory distress. Differential diagnosis: Students should be able to generate a prioritorized differential diagnosis recognizing history, physical exam, and laboratory findings that suggest a specific etiology of cough. Laboratory interpretations: Students should be able to recommend when to order diagnostic and laboratory tests and be able to interpret them, both prior to and after initiating treatment based on the differential diagnosis, including consideration of test cost and performance characteristics as well as patient preferences. Laboratory and diagnostic tests should include, when appropriate: • Chest radiograph. Communication skills: Students should be able to: • Counsel and educate patients about environmental contributors to their disease, pneumococcal and influenza immunizations, and smoking cessation. Management skills: Students should be able to develop an appropriate evaluation and treatment plan for patients that includes: • Describing the indications, contraindications, mechanisms of action, adverse reactions, significant interactions, and relative costs of the various treatments, interventions, or procedures commonly used to diagnose and treat patients who present with symptoms of cough. Demonstrate commitment to using risk-benefit, cost-benefit, and evidence- based considerations in the selection of diagnostic and therapeutic interventions for cough. Respond appropriately to patients who are non-adherent to treatment for cough and smoking cessation. Demonstrate ongoing commitment to self-directed learning regarding diagnosis and management of cough. Appreciate the impact that an acute or chronic cough has on a patient’s quality of life, well-being, ability to work, and the family. Recognize the importance and demonstrate a commitment to the utilization of other healthcare professions in the treatment of cough. It has a very large number of etiologic possibilities— some benign but many potentially life-threatening. Major organ systems/pathologic states causing dyspnea and their pathophysiology, including: • Cardiac.

Chemical: Ethanol: You can ferment and distil your own although care needs to be taken so you don’t produce toxic alcohols (e quality 12.5 mg lopressor arrhythmia prevalence. Good for small cuts order 50mg lopressor fast delivery arrhythmia hypokalemia, surface preparation (including skin prep for surgery – toxic to deeper tissues and will sting ++), and instrument sterilisation. For instruments it is recommended that soaking in > 70% (ideal is >95%) solution for >12 hrs is ideal. This time can be shortened to several hours by the addition of formaldehyde solution to the alcohol. Polyvidone-iodine (Betadine): There are some military reports of using to sterilise water for drinking. For soaking instruments 1 part 10% solution (Betadine) to 3 parts water for 15 min. Soak for 15 min but no longer than 30 min – bleach solutions are corrosive to metal instruments. Bleach breaks down relatively rapidly and most commercial solutions will have lost their active ingredients after 12-18 months. Start with a dilute concentration initially (1:60) if pain results from this concentration dilute it again by the same volume (out to 1:120), and increase the contact time. Other chemical disinfectant agents: Tosylchloramide Chloramine T 2% solution, 20g/litre for 15 min Ethanol 70%, 8 parts of 90% ethanol in 2 parts water for 15 min. Other options: Wines prepared from grapes may be useful as wound washes and antiseptics. If pain results from application of a small amount of wine to a wound the wine should be diluted using clean water until it can be applied without undue pain. The antiseptic effects of wine are due both to the ethanol present in the wine and to the presence of some antibiotic materials. Absent any other disinfectant or sterilising remember “the solution to pollution is dilution;" wash the instruments with soap and copious amounts of water or lavage a wound with large amounts of water. When you need to repeatedly wash a wound out making the last wash a normal saline wash can help maintain the right osmolality but this is not essential - 54 - Survival and Austere Medicine: An Introduction Chapter 7 The Basic Laboratory The basics of a diagnosis can generally be reached by a careful history and physical examination. However there are some simple laboratory tests which can be performed with very little equipment or chemicals. The problem is that even basic tests require some equipment ranging from simple test strips to a microscope and a few chemicals. Obviously what you are preparing for will dictate what tests you may want to be able to perform. These can test for the presence of protein, glucose, ketones, nitrates, red blood cells, and white blood cells. The strips can be used to diagnose urinary infections, toxaemia in pregnancy, dehydration, diabetes (outside pregnancy), and renal stones/colic. The following is a quote on analysing urine from a book to be published on the practice of medicine under relatively primitive conditions. Visual and olfactory - 55 - Survival and Austere Medicine: An Introduction examination of a urine sample alone can provide considerable information. Urine which is pink, red, or red-orange may contain blood although it is important to remember that these colors may also be seen in those who have eaten certain foods such as beets, blackberries, or rhubarb. Urine which is green or blue-green, or which takes on these hues on standing may indicate diseases of the liver or gall bladder. Bright yellow or yellow-orange urine is indicative of kidney dysfunction (if there is no reason for the urine to be concentrated and if the colour is maintained for several days). Cloudy urine may result from abnormally high levels of phosphates or carbonates in the urine, and may be a precursor of kidney stones. Cloudy urine may also indicate the presence of an infection particularly if the fresh urine has an odour of ammonia or other disagreeable odour (note that urine will develop an ammonia odour on standing). It is possible to approximately localize an infection that is producing cloudy urine by using the three-glass test. This test requires three clean containers (glasses) of which at least one (the second used) will need a capacity of at least 500 ml. In this test, the first 5 ml is voided into the first container, the second container is used until the patient is almost done, and then the third container is used to collect the last 5 ml. If the urine in the first container is the cloudiest, with decreasing cloudiness in the remaining containers, a urethral infection is the most likely cause.

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Submersion incidents involving children usually happen in familiar surroundings and can happen quickly (even in the time it takes to answer the phone) discount lopressor 25 mg with mastercard heart attack upper back pain. In a comprehensive study of drowning and submersion incidents involving children under 5 years old discount lopressor 50 mg without a prescription heart attack kid lyrics, 77% of the victims had been missing from sight for 5 minutes or less. The Commission notes that toddlers, in particular, often do something unexpected because their capabilities change daily. Child drowning is a silent death, since there is no splashing to alert anyone that the child is in trouble. As an alternative to wading pools, sprinklers provide water play opportunities that are not potential hazards for drowning or disease transmission. Water toys such as water guns should be washed, rinsed, sanitized, and air dried after each use. Influenza (flu), pneumococcal (pneumonia), and pertussis (whooping cough) vaccines can prevent some serious respiratory illnesses. When you are at the clinic or hospital:  Cover your cough or sneeze with a tissue and dispose of the used tissue in the waste basket. Follow procedures outlined in the childcare or school’s Bloodborne Pathogen Exposure Plan. They suck their fingers and/or thumbs, put things in their mouths, and rub their eyes. These habits can spread disease, but good handwashing can help reduce infection due to these habits. Caregivers who teach and model good handwashing techniques can reduce illness in childcare settings and schools. Recommendations for hand hygiene products  Liquid soap - Recommended in childcare and schools since used bar soap can harbor bacteria. If hands were visibly soiled, hands must be washed with soap and warm running water as soon as it is available, because the alcohol-based hand rubs are not effective in the presence of dirt and soil. Use the nailbrush after diapering or assisting with the toilet activities, before and after food preparation, and whenever nails are soiled. They can break off into food and have been implicated in disease outbreaks in hospital nurseries. Check with the local licensing agency regarding any food codes that may restrict staff from wearing artificial nails when handling and preparing food. Ways for staff to keep hands healthy  Cover open cuts and abrasions less than 24 hours old with a dressing (e. They need to wash their hands after going to the bathroom, after the diapering process, after helping a child with toileting, before preparing food, after handling raw meat, before a change of activities, before eating, after playing out of doors, and after nose blowing. After drying their hands, children and caregivers need to turn off the faucets with a paper towel. Key concepts of prevention and control:  Handwashing (see pgs 57-60) – the single most effective way to prevent the spread of germs. The purpose of using barriers is to reduce the spread of germs to staff and children from known/unknown sources of infections and prevent a person with open cuts, sores, or cracked skin (non-intact skin) and their eyes, nose, or mouth (mucous membranes) from having contact with another person’s blood or body fluids. Examples of barriers that might be used for childcare and school settings include: - Gloves (preferably non-latex) when hands are likely to be soiled with blood or body fluids. This prevents the escape of bodily fluids rather than protecting from fluids that have escaped. Other examples that most likely would not be needed in the childcare or school setting are: - Eye protection and face mask when the face is likely to be splattered with another’s blood or body fluid. Proper use of safety needle/sharp devices and proper disposal of used needles and sharps are also part of standard precautions. Possible blood exposure Participation in sports may result in injuries in which bleeding occurs. The following recommendations have been made for sports in which direct body contact occurs or in which an athlete’s blood or other body fluids visibly tinged with blood may contaminate the skin or mucous membranes of other participants or staff:  Have athletes cover existing cuts, abrasions, wounds, or other areas of broken skin with an occlusive dressing (one that covers the wound and contains drainage) before and during practice and/or competition. Caregivers should cover their own non-intact skin to prevent spread of infection to or from an injured athlete.

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Steps to follow in an emergency If a child is found with a poison or medicine which they have taken: 1 Stay calm but act quickly buy discount lopressor 50mg arrhythmia pvc treatment. A recent development in this area is the availability of home drug testing kits which purchase 12.5 mg lopressor pulse pressure sites, through either a urine sample or saliva swab, allow you to identify what drugs (normally cocaine, amphetamines, ecstasy, cannabis, opiates such as heroin and benzodiazepines) have been used. Drug testing is a procedure which is normally performed within the context of an explicit medical relationship and there are concerns that availability outside of a clinical setting is potentially problematic. If a school, or a parent is considering the use of such a product, there are a number of ethical, legal and practical issues to consider: 1 How will the test impact on the relationship between the young person and their parents or the school in terms of trust? Whilst the test will give an objective result, the use of such a procedure may undermine the relationship between the young person and those testing; and it is this relationship which will be crucial if the young person does need help 2 How will a urine sample (the most common way of testing) be obtained? Any degree of coercion has quite serious legal implications for either the parents or the school in terms of the young person’s rights 3 Are the test results reliable? There are a number of factors to consider here: y The norm is that tests like these are carried out by medical personnel trained in appropriately obtaining the sample, carrying out the test and interpreting the results – can you guarantee the same with a home drug testing kit? The following gives approximate times for how long it takes the body to clear the drug after which urine analysis will be negative. Cocaine 2 to 4 days Amphetamine 3 days Ecstasy 3 to 4 days Cannabis 3 to 8 days, potentially up to a month with heavy users Opiates such as heroin 3 to 8 days Benzodiazepines 2 to 28 days 5 The test says nothing about the amount of the drug used, the type of use (experimental, recreational, habitual) or the circumstances of use. Given the factors detailed above and the nature of drug use in adolescence, the use of drug testing in the context of the home and school has the potential to achieve very little and may possibly cause problems to escalate, perversely increasing the level of risk to the child if trust between him/her and their parents and teachers is broken down. In terms of observed signs and symptoms (outside of either habitual or dependent use where an individual is pre-occupied with drugs to the exclusion of other activities over a significant period of time; or observing acute intoxication as a result of bingeing – which is more likely with adolescents) it is very difficult to identify consistently present and observable signs which would indicate that a young person is involved in irregular experimentation. In fact, it is often only when drug use becomes problematic that these signs may be manifest. The other caveat with the following list157 of signs and symptoms is that most are not exclusively linked to drug use and are normative aspects of the experience of adolescence. They should in no way be seen as an alternative to maintaining a positive, active relationship with a young person whether as a teacher or parent, based on mutual dialogue and respect for each other’s needs and responsibilities. In serious cases, the person may begin to look unwell, alternated with periods of more energetic behaviour. If a young child is misusing drugs, s/he will tend to mix with older children and drop former friends. Specific to schools, it states the need to “… maximise the effectiveness of school-based programmes through efforts to keep young people engaged in school and the identification and provision of supports for at-risk children, management of drug-related incidents and a broad-based curriculum which supports all aspects of the child’s development”. However, “effective teaching about drugs has the same characteristics as good teaching in 76 The National Drug Strategy and School Policy on Substance Use any subject”. Extract from ‘Guidelines for developing a School Substance use Policy – Department of Education and Science, Health Promotion Unit and the Regional Health Boards 2002’: Introduction The National Drugs Strategy 2001-2008 sets out a detailed programme of action to be implemented by Government Departments and Agencies to combat the very serious problem of drug misuse in our society. The strategy highlights the important contribution that schools can make in the area of education and prevention and requires them to have substance use policies in place. The central objective of a school’s substance use policy is the welfare, care and protection of every young person in line with the Education Act, 1998 and the Education (Welfare) Act, 2000. The policy should address both education concerning alcohol, tobacco and drugs and the procedures for managing incidents relating to these substances. It should be developed through existing consultative structures within the school and should build on existing school policy, e. While the school substance use policy should cover alcohol, tobacco and drugs, different issues may need to be addressed under each of these three headings. Schools need to reflect upon how they might provide for the needs of their student cohort and respond appropriately to what are sometimes sensitive and emotive issues. A substance use policy sets out, in writing, the framework within which the whole school community manages issues relating to substance use. It should reflect the unique ethos of the school and should aim to develop a shared understanding of the term ‘drugs’. A partnership approach based on the ‘whole school’ model is recommended for the development of the policy. The policy applies to the entire school community, including teachers, students, parents/guardians and users of the school building. It is strongly recommended that schools within the same community should collaborate on policy development. Within Local Drug Task Force Areas primary schools can contact the Walk Tall Support Officers (see contacts sections) or the Task Force Office. Research has demonstrated that this approach to social, personal and health education is at best ineffective and in some instances detrimental.

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