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By U. Tuwas. Augustana College, Rock Island Illinois. 2018.

The best approach to reach a perforation in the left lower esophagus is a left thoracotomy cheap dilantin 100mg mastercard. You want to see the extent of the injured mucosa which often extends farther than the muscle injury purchase 100mg dilantin otc. If you find a hematoma in zone 2 when exploring the patient for blunt trauma, you do not have to explore it if it remains stable throughout the operation D. Zone 3 injuries, whether they are blunt or penetrating, always need to be explored Answer 20 C. If exploring a patient for blunt injury and you encounter a stable hematoma in zone 2, you do not have to explore it. If they are found intraoperatively and noted to be expanding, they need to be explored. Infection rates are significantly lower when antibiotics are given for a complete 5 day course C. There is no statistical difference when antibiotics are given within 2 hours of initial skin incision and when given within the first 3 hours when the skin incision is made D. There is no evidence supporting continuing abx beyond 24 hours even when the bowel is perforated E. The bullet is sterilized coming out of the handgun and the intra- abdominal organs themselves are the major source of wound infections in these patients Answer 1 D. Description of basic procedural standards of care Answer 3 E is not a part of informed consent Disclosure by the physician, patient comprehension, competency, and voluntariness all are. Question 4 Which of the following is true about the secretory diarrhea seen in gastrinoma patients? It may be the only complaint in around 20% of patients presenting with gastrinoma D. All of the above are true about gastrinoma Question 5 Which of the following forms does fat take to enter the lymphatic system and eventually reach the liver? Which of the following is the most appropriate initial treatment for this patient? A removable boot or appropriate shoe with monitoring of the wound is most appropriate Initial Treatment of Plantar Foot Ulcer in Diabetic Diabetes is the most common cause of neuropathy leading to loss of protective sensation on the plantar aspect of the foot Bony deformity can also occur as a result of neuropathy Combination of lack of protective sensation and deformity leads to pressure ulceration and infection Osteomyelitis can develop requiring bone resection or amputation Initial Treatment of Plantar Foot Ulcer in Diabetic Gold standard to treat diabetic foot ulcers- provide appropriate pressure relief Can be via a total contact cast or remoavable cast boot Further treatment o more advanced wounds includes debridement with removal of all necrotic tissue and to create a plantar grade foot Surgery may be necessary in those whose deformity doesnt respond to shoe modification Surgical goals- resect bony prominences and infected bone, restore bone architecture Question 7 A 38 yo female underwent a laparoscopic Nissen fundoplication and hiatal hernia repair 2 days ago that was technically difficult. Chest x-ray shows an effusion on the left and a small amount of free air under the diaphragm. Warfarin-induced skin necrosis occurs in patients started on coumadin without first being given heparin. It results from a relatively hypercoagulable state that occurs in some people due to the relatively short half-life of protein c & S. The tumor most likely to involve bilateral parotids at the same time a Warthins tumor Question 6 All of the following are true about pts that have undescended testicles except: A. The cancer risk is lower if both testicles are brought into the scrotum early D. The risk of developing cancer is the same even if the testicles are returned to the scrotum early. Bacteriostatic agents include chloramphenicol, tetracycline, clindamycin, erythromycin, and bactrim Question 8 Which of the following is not true about the treatment of anal margin squamous cell cancers? Sludging in the gallbladder and cholestatic jaundice are complications of ceftriaxone Question 11 The most common infection in pts with large (>35%) severe burns is: A. Alveolar macrophages are activated with atelectasis and cause fever Question 13 The most important prognostic factor in pts with sarcomas without metastases is: The most important prognostic factor in pts with breast cancer without metastases is: A. Morphine has a characteristic histamine release which can cause hypotension Question 8 4 days after an Ivor-Lewis esophagectomy you start enteral feeds through a j-tube. Long chain fatty acids enter the body through terminal lacteals (absorption through the lymphatic system) either as free long chain fatty acids or as chylomicrons Question 9 An overdose of fentanyl is treated with: An overdose of ativan is treated with: A. Ureterocystostomy When the ureter is accidentally ligated and the injury missed, the pt develops hydronephrosis and urosepsis. This can lead to pressure buildup and urine leak For minor injuries where there is a partial laceration, the ureter can be repaired over a stent For complete transections, primary closure should be attempted Below the pelvic brim, ureteroureterostomy can be difficult so a ureterocystostomy is the procedure of choice Question 11 Which of the following is a characteristic of a cutaneous lymphatic malformation? Cystic mass with overlying vesicles Cutaneous lymphatic malformations often occur as cystic masses with overlying vesicles. The most appropriate therapy for an extraperitoneal bladder rupture is urinary catheter drainage for several days The most appropriate therapy for an intraperitoneal bladder rupture is ex lap and primary repair. The patient had a prolonged transport and received 20 units of blood prior to arrival. Currently his peak airway pressures are 65, his abdomen is distended, he is not making urine, and his bladder pressure is 40.

In 1980 buy 100 mg dilantin with amex, there were 37 100 mg dilantin,189 female physi- physicians are much more likely to report burnout cians in the United States. The physicians in the United States experience more influence of women in medicine is suggested by burnout than their male U. Some The first publicly funded midwife training program of these career satisfaction differences may be due to the began in 1911 (Rooks, 1997). In the White House Conference on Child Health and Protection that same year, it was noted that trained midwives surpass the Midwives record of physicians in normal deliveries (Rooks, History and Training. However, by the 1930s, midwives attended only from mid or with and wife or woman (Rooks, one eighth of U. In early times, seen as a standard model of care in other developed midwives were also known as wise women or countries (Rooks, 1997). This was and in the United Kingdom there is a growing use of unpopular with the church, because of the belief that midwifery-led, freestanding birth centers (Brodie, 2002). In this same report, Australian midwives reported Midwives, as women healers, were felt to have feeling dominated by medicine as the amount of med- special knowledge about the female mystery of birth. There During the Middle Ages, midwives were persecuted for was also concern raised about difficulties in keeping up using pagan birth rituals, and witch hunts of the 1400s skills in rural areas, due to lack of continuing education and 1500s killed many midwives. Men were often excluded from child- professional midwifery, and in the poorer areas, birth, and male barber-surgeons were called in only 7095% of births are attended by traditional midwives. Women were not permitted to practice almost all births occur in hospitals, due to national surgery (Ehrenreich & English, 1973). Bridget Lee Fuller was a British midwife brought and breast-feeding are important advantages. In the United States, midwives were minority women or immigrants who approximately 99% of midwives are women (Rooks, had trained in other countries (Reed & Roberts, 2000). Although midwifery and medicine differ, there health professions, pharmacy has one of the highest are some similarities as well (Rooks, 1997). With current growth has been described as a celebration of life rather than trends, the proportion of women in pharmacy may a medical procedure (Romero, 2002) and the midwife eventually exceed the proportion of women in the tends to focus on the woman and the experience of nursing field (Francke, 1987). Women in pharmacy practice pregnancy include efforts for smoking cessation and are rather novel in the United States and the first domestic violence prevention. Russia and the Philippines almost all pharmacists are Ideally, a pregnant woman is followed by the same women (Slining, 2000). There are concerns that this will lead decades, nurse-midwifery has expanded significantly to a shortage in the field, as women tend to work fewer (Reed & Roberts, 2000). This concern is licensing standards for midwives vary from state to state partially fueled by the recruitment pitch that a career in (Reed & Roberts, 2000; Rooks, 1997). However, national pharmacy can allow a woman to combine work with certification is necessary for the practice of nurse- having a family, and pharmacy can be practiced part midwifery in almost all states. In 2000, there were 45 programs accredited why women are interested in the field of pharmacy. These include the ability to use scientific knowledge Direct entry midwives (midwives not previously trained while being able to serve people. It has midwives may prescribe medications to patients been suggested that women pharmacists are superior in (Reed & Roberts, 2000). Native Americans have the highest Academic institutions have been slow to hire percentage of midwife births, followed by African female pharmacists and 50 years ago faculty were almost Americans and Hispanics, at much higher rates than exclusively male. It is thought that women are not hired as frequently wives continue to practice in underserved areas such as because women had not pursued Pharm. Finally, nurse-midwives salaries are much increases, the prevalence of male-dominated faculty is lower than that of obstetricians (Achterberg, 1990). The first female dean of a are briefly discussed, although it must be noted that this pharmacy school was appointed in 1987, and in 2000 is by no means a complete list of health professions that approximately 36% of full-time professors were women women practice. In 1981, the American treatment and prevention of tooth, mouth, and gum Pharmaceutical Associations Task Force on Women in diseases. There are many different health care profes- Pharmacy Final Report recommended that women insist sionals in this field including dental hygienist, dental on equal pay and should seek out management assistant, and dentist. While dentistry is a fast-growing occupational A 1978 study compared male and female pharma- area for women, barriers to job advancement and career cists salary and benefits (Shoaf & Gagnon, 1980). This satisfaction may continue to occur for women entering study found that 29% of women worked part-time, com- these professions. There was no difference in almost 27% of dental hygienists reported sexual harass- disability insurance, sick days, or paid vacation. It was ment, with the majority reporting their employer/dentist found that men had higher salaries, because they had as the perpetrator. They usually would have participated in a Another study examined the perceptions of work dental assistant program at a community college level. This study found no difference in the graduate level coursework and then graduate from a perceived amount of time spent performing clinical dental school.

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Start this protection the first day you joints may subluxate or dislocate dilantin 100 mg on-line, especially the hip buy 100 mg dilantin otc, knee, diagnose a reaction. You can treat tuberculous joints successfully and cheaply; When there are signs of recovery, as shown by pain if you make the diagnose in the first few weeks. If it is already involved when you first see the Even so, your error rate is likely to be small. Suggesting other forms of arthritis: a history of This will overcome spasm, prevent the softened bone from dysentery, brucellosis, or gonorrhoea. Use the anterolateral completed, warn that the joint may flare up again at any approach, as for septic arthritis (7. The range of movement of distinguishing tuberculosis from late, imperfectly-treated the joint may be limited or absent, so make sure that it is staphylococcal arthritis. If the leg moves into external rotation, as you do this, (7-17), it is a sign that the upper femoral epiphysis is slipping. He dragged himself along in arthritis (or spontaneous slipping of the epiphysis, a sitting position, with both knees and hips fully flexed. If a child requires an arthrodesis of the knee, Rest the arm in a sling, and then gradually encourage try to delay this until after adolescence, so as not to hinder movements without it. An elbow fixed in the position of function sheaths of the hand, or bursae round the shoulder develop, (7-16), is likely to be better than a stiff painful one. In children presenting with a painful hip or a limp (1),Wait 4-6wks, before committing yourself to long-term (32. This will control pain If deformity prevents satisfactory walking, and prevent a flexion contracture. If pain and inflammation continue, and there is no Skin traction should have corrected any flexion contracture bony injury and no ligament rupture, start another full (if present) by this time. Aspirate it repeatedly with a wide-bore needle, introducing the needle through a long oblique track, so that a sinus is less likely to form. If the abscess is very large, explore it, clear out its contents, and close the wound to prevent the secondary infection. If a sinus develops, it is the result of an abscess opening on to the skin, and occurs in immuno-compromised patients. A biopsy from the track is unlikely to confirm tuberculosis, because non-specific granulation tissue lines it. If a joint becomes warm & tender, with deteriorating radiographic signs, and there is fever and malaise, this is a flare-up. The spine is the most common and the most dangerous site for skeletal tuberculosis. It may start as early as 3yrs, but it more often starts It seldom involves the lamina. The result is that, as the at 7-8yrs; it progresses most rapidly from 12-14yrs, bodies of the vertebrae collapse, the spine angles forwards and gets worse until he stops growing. If possible, to produce a kyphus (an increase in the normal convex fit a back (Milwaukee) brace, and if necessary get the curve of the spine; a scoliosis is a lateral curvature). If this is not possible, The shape of the spinal deformity depends on how many reassure the parents that, although the back will always be vertebrae are diseased. Persistent Test the reflexes in the legs, and their tone, power, localized pain at a specific place not relieved by rest or and sensation (32. Remember to get areas where this is the commonest cause of paraplegia chest films too. If you do see must continue, and that it will take some months to have bridging, it is more likely to be due to late staphylococcal much effect. Confirming the diagnosis may have to depend on the aspiration and examination of pus from the spine, 32. In early cases it is due to an inflammatory oedema round a paraspinal abscess, and later to compression. Suggesting a congenital lateral hemivertebra causing Paraplegia may be the presenting symptom, and is usually scoliosis or dorsal hemivertebra causing kyphosis treatable. In most cases it is motor only (unless it comes on (usually mild): half of one of the vertebrae is missing. Although tuberculous osteitis affects deformity does not progress with age, and needs no the various regions of the spine in the following order of treatment. When the lung collapses, a because the spinal canal is wide there, and the cauda collapsed thoracic cage may result. The spine itself needs equina, a loose bundle of nerves & nerve roots from L2-S5 no treatment.

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Female Sexuality Obstetrics was slow to be incorporated in the medical profession; it was rejected by the American Historically an interest in and enjoyment of sexual College of Physicians as an ungentlemanly profession cheap dilantin 100mg overnight delivery. As an By the early 19th century buy dilantin 100 mg on line, however, obstetrics became example, masturbation and sexual arousal were thought part of the medical curriculum. The suppression of sexual feelings uterus, its pathology, and details in measuring the could be achieved by removing the clitoris; clitoridec- pelvis to predict difficulties in childbirth became impor- tomies were performed in America until the late 1930s tant components of obstetrics. Ergotamine was intro- and continue to be performed to date in many regions duced in the early 1800s to control postpartum of Africa. A significantly higher rate of infections Female sexuality remains severely underre- was observed among women attended by physicians, searched. In 1953, a report published by Michael Kinsey compared to those who were attended by midwives. These findings challenged the techniques by physicians performing autopsies on widely held belief that womens role in lovemaking was women who had died as a result of postpartum fever, to satisfy the husband. The biological framework in and who later attended to women during delivery, which sexuality is studied, and the medicalization of it, resulting in the transmission of infectious agents. In the medical context, erec- women were meant to suffer in childbirth, pursuant to tile function is considered paramount in the study of the Biblical imposition of labor pain as a punishment for male sexuality, with numerous studies on impotence. However, the higher cost, although some historians believe women number of studies on female sexual dysfunction and its advocated for it. The use of diagnostic and interventional considered to be focal events in reproductive life. The treatment of infertility, which led to a health and its research in very important ways. The movement favoring natural childbirth and The human egg was not discovered until early 1800s, breast-feeding, which recognizes pregnancy and child- although it is much larger in size than the sperm. The profession of midwifery experienced a of abortions, as antiabortion laws encourage illegal rebound during this time. Later, birthing centers were and clandestine practice of abortions, most often per- developed and were designed to simulate a homelike formed in nonoptimal conditions, leading to adverse environment in a hospital setting. The legalization of heightened interest in home deliveries and doulas, or abortions has contributed to dramatic reductions in laypersons providing physical, emotional, and informa- maternal mortality. Contraception Efforts to prevent pregnancy can be traced to as far Abortion back as ancient Greece. Until a few decades ago, Abortions were not considered illegal until the 19th however, women relied on breast-feeding that serves as century when Britain and the United States passed their a fairly effective means of contraception, through the first antiabortion laws. Freeing themselves from the con- ers, vaginal douches with toxic solutions, or ingestion stant function of reproduction was perceived as the key of strong chemicals. The psychological stress was also considered information on birth control as obscene, significant. One had been well rooted in these societies, abortions con- Package, Margaret Sanger and the Federal Legislation tinued to be performed openly, and juries refused to on Birth Control were successful in arguing that convict abortionists. Supreme Court held that limiting a the Comstock Law that prohibited the dissemination womans right to terminate her pregnancy violated of information on contraceptives. In 1976, the Hyde of the last state laws prohibiting the use of contracep- Amendment banned the use of Medicaid funds for abor- tives by married couples. To date, many faiths and institutions, such federally funded program to serve low-income women. Early versions of the birth control female population is likely to serve lesbian women as pill contained high levels of estrogen; their use was well as women of other sexual orientations (heterosex- associated with elevated risks of blood clots, heart ual and bisexual) and the physician must be prepared disease, and stroke. As a result, increasing use was to provide an adequate environment for optimal care. For instance, it has been contributed to the decline in teen births in the United reported that only a few hours are devoted to the study States during the last decade. The use of insurance, because they may not be eligible to receive contraceptives requires careful planning; unfortunately, coverage under their partners policies. It has been access to contraceptives may be limited in some circum- reported that in 2000, only 99 (or 20%) of Fortune 500 stances. The use of some of the most effective forms of companies, and 8 state governments offered benefits to family planning methods requires consultation with a domestic partners. Even when those benefits were physician and a willingness to undergo a gynecologic available, many employees were reluctant to disclose exam. This poses a significant impediment to young their sexual orientation in the workplace for fear of women who may find the physical exam and the disclo- compromising their employment position. Some have attempted to bility of ensuring family planning is ideally shared by explain cessation of menstrual blood flow through sexual partners, the burden engendered by unprotected the presence of insufficient pumping force through sexual activity is typically borne by women. The boundaries between normal physiology Lesbian Health and pathology with regard to menopause were not delin- Lesbian health has been part of public debate only eated until recently. That menopause was a natural in recent years, and the Healthy People 2010 (the federal process and that symptoms were not fatal was first governments guidelines for health care in the next cen- explained in a 1904 publication by Pancoast and others, tury) has specifically called for the elimination of dis- entitled Beautiful Womanhood: Guide to Mental and parities in the health of gay and lesbian communities. Nail salons have been identified as ality, osteoporosis (or loss of bone mass), as well as a possible venue for the transmission of various infec- changes in mood and cognition. These include an increased risk of injury due to falls, low back pain due to compensatory reliance on different parts of the musculoskeletal system Body Image to achieve balance, and osteoarthritis of the knee.

Prescribed drugs were also included in this She practiced in Kentucky and 100mg dilantin for sale, although she was study; lifetime use of tranquilizers was 20% and known as Mrs 100 mg dilantin with mastercard. It was noted that the rate of pre- a man who was thereafter known as a practicing scription drug use was comparable to that of male and physician. During the Civil War, Mary Walker served as female physicians and this may relate to the fact that a doctor, while disguised as a man (Dickstein, 1996). In 1847, Blackwell was accepted with higher neuroticism have higher perceptions of to the Geneva College of Medicine in New York, and stress and therefore are more likely to use alcohol to graduated at the top of her class in 1849 (Chin, 2002; cope with this stress (Collins et al. In 1850, the Womens Medical College of Pennsylvania opened (Chin, 2002), Gender Differences in the Nursing Profession. In 1940, American female physician trained in the United States only 1% of nurses were men and in 1984, only 4%. Compared to women nurses, men are typically older This progress was not without controversy. In 1874, upon entering the field, more likely to be married, and Harvard professor Edward Clarke reported that women have a history of being in the military. One study com- who attended medical school would develop mon- paring job satisfaction between male and female nurses strous brains and puny bodies; abnormally active cere- found that men appear to be more satisfied with their bration and abnormally weak digestion; flowing thought supervisors and felt more motivated by their job com- and constipated bowels (Chin, 2002). This number Australia surveyed patient gender preferences for nurse remained below 10% until the 1970s (Chin, 2002). Furthermore, this were also finally admitted into the American Medical was found to be particularly true for female patients Association (Chin, 2002). Federal legislation facilitated the increased cians practice in primary care settings such as pediatrics numbers of women in medicine into the 1970s and or internal medicine. This may lead to a need for more total pediatricians to treat patients (Cull et al. A typical medical school From 1988 to 1998, the income of women physi- curriculum lasts 4 years after completion of an under- cians was gaining on the income of men at a rate of graduate degree. However, ing and clinically based rotations in health care women in internal medicine still earn less than 80% of settings. Wallace and Weeks (2002) reported that the new doctors choice of generalist or specialty field. Residency In academic settings, women medical school faculty often falls during a womans childbearing years, and is earn less, and receive promotions more slowly than their quite physically as well as mentally challenging due to male counterparts (McMurray et al. The less often than men with similar qualifications, and only highest percentages of women residents can be found 8% of medical school chairs are women (Nora, 2002). One former obstetrical resident who left Physician burnout occurs when doctors under pres- her program due to her desire to be a mother wrote sure are overloaded with the demands of caring for residency is a barbaric training process during which sick patients within constraints of fewer organizational new physicians can have the humanity literally worked resources. This has been explained as the silent anguish of the heal- Specialty Choice, Career Advancement, and Job ers (Spickard et al. In 1980, there were 37,189 female physi- physicians are much more likely to report burnout cians in the United States. The physicians in the United States experience more influence of women in medicine is suggested by burnout than their male U. Some The first publicly funded midwife training program of these career satisfaction differences may be due to the began in 1911 (Rooks, 1997). In the White House Conference on Child Health and Protection that same year, it was noted that trained midwives surpass the Midwives record of physicians in normal deliveries (Rooks, History and Training. However, by the 1930s, midwives attended only from mid or with and wife or woman (Rooks, one eighth of U. In early times, seen as a standard model of care in other developed midwives were also known as wise women or countries (Rooks, 1997). This was and in the United Kingdom there is a growing use of unpopular with the church, because of the belief that midwifery-led, freestanding birth centers (Brodie, 2002). In this same report, Australian midwives reported Midwives, as women healers, were felt to have feeling dominated by medicine as the amount of med- special knowledge about the female mystery of birth. There During the Middle Ages, midwives were persecuted for was also concern raised about difficulties in keeping up using pagan birth rituals, and witch hunts of the 1400s skills in rural areas, due to lack of continuing education and 1500s killed many midwives. Men were often excluded from child- professional midwifery, and in the poorer areas, birth, and male barber-surgeons were called in only 7095% of births are attended by traditional midwives. Women were not permitted to practice almost all births occur in hospitals, due to national surgery (Ehrenreich & English, 1973). Bridget Lee Fuller was a British midwife brought and breast-feeding are important advantages. In the United States, midwives were minority women or immigrants who approximately 99% of midwives are women (Rooks, had trained in other countries (Reed & Roberts, 2000). Although midwifery and medicine differ, there health professions, pharmacy has one of the highest are some similarities as well (Rooks, 1997).

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