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By V. Vigo. Point Loma Nazarene College. 2018.

Symptoms and signs maintenance it is also associated with increased risk of marrow failure (anaemia cheap effexor xr 37.5mg mastercard, recurrent infections and of development of leukaemia in comparison with ve- bleeding) may be present cheap 37.5mg effexor xr with mastercard. Chapter 12: Leukaemia and lymphoma 485 r Splenectomy may be required if the enlarged spleen Leukaemia and lymphoma is painful or to reduce transfusion requirements order effexor xr 150mg otc. Amyeloproliferative disorder characterised by increased platelets due to clonal proliferation of megakaryocytes Age in the bone marrow. Pathophysiology Platelets although increased in number have disrupted Sex function causing them to clump intravascularly lead- M = F ing to thrombosis, and to fail to aggregate causing bleeding. Risk factors include exposure to excessive ra- bleeding and cerebrovascular symptoms. Pathophysiology In acute leukaemias there is replacement of the normal Investigations bone marrow progenitor cells by blast cells, resulting in The blood film shows increased numbers of platelets and marrow failure. Bone marrow aspiration demonstrates from the lymphoid side of the haemopoetic system (see increased megakaryocytes. Patients with life-threatening haem- orrhagic or thrombotic events should be treated with Clinical features thrombocytopheresis in addition to hydroxyurea. An- Often there is an insidious onset of anorexia, malaise grelide is occasionally used. There is often a history of recurrent infections and/or easy bruising and mucosal Prognosis bleeding. Other presentations include lymph node en- Essential thrombocythaemia may eventually transform largement, bone and joint pain and symptoms of raised to myelofibrosis or acute leukaemia but the disease may intra cranial pressure. Phase 2 involves in- travenous chemotherapy (cyclophosphamide and cy- tosine) with oral 6-mercaptopurine. Lymphoid Stem Cell r Intensification: This involves intravenous metho- trexate and folinic acid, with intramuscular L- asparginase. Lymphoblast r Consolidation: This involves several cycles of chemotherapy at lower doses. Supportive treatment: Cytotoxic therapy and the leukaemia itself depresses normal bone marrow func- T Cell B Cell tion and causes a pancytopenia with resulting infection, anaemia and bleeding. Microscopy Prognosis The normal marrow is replaced by abnormal Prognosisisrelatedtoage,subtypeandinverselypropor- monotonous leukaemic cells of the lymphoid cell line. Over90%ofchildren The leukaemia is typed by cytochemical staining and respond to treatment, the rarer cases occurring in adults monoclonal antibodies to look for cell surface mark- carry a worse prognosis. Full Most common in the middle aged and elderly blood count shows a low haemoglobin, variable white count,lowplateletcount. Bonemarrowaspirationshows Sex increased cellularity with a high percentage of blast cells. On examination there Proerythroblast Myeloid Stem cell Megakaryoblast may be pallor, bruising, hepatosplenomegaly and lym- phadenopathy. Myeloblast Erythrocyte Platelet Microscopy Monoblast Promyelocyte Abnormal leukaemic cells of the myeloid cell line replace the normal marrow. Monocyte Myelocyte The leukaemia is typed by cytochemical staining and Granulocyte monoclonal antibodies to look for cell surface markers. Full blood count shows a low haemoglobin, variable white count, M2 Myelocytic leukaemia with differentiation low platelet count. Bone marrow aspiration shows in- M3 Acute promyelocytic leukaemia creased cellularity with a high percentage of the abnor- M4 Acute myelomonocytic leukaemia mal cells. Bone marrow cytogentic studies allow classi- M5 Acute monocytic leukaemia proliferation of mono- fication into prognostic groups (e. Supportive treatments in- particularly prone to disseminated intravascular co- clude red blood cell transfusions, platelet transfusions agulation due to the presence of procoagulants within and broad-spectrum antibiotics. Ninety-five 70% of those under 60 years will achieve remission with percent of patients with M3 are induced into remis- combination chemotherapy although the majority re- sion by treatment with high dose retinoic acid. Gum Chronic lymphocytic leukaemia hypertrophy and hepatosplenomegaly is common Definition within this subgroup. Clinical features Often there is an insidious onset of anorexia, malaise Incidence and lethargy due to anaemia. M > F Age Pathophysiology Bimodal distribution with a peak in young adults (15–34 Although there is a proliferation in B cells they have years) and older individuals (>55). On Aetiology examination there may be lymphadenopathy and hep- Infectious agents particularly Epstein Barr virus have atosplenomegaly. Involvement with intermittent chemotherapy such as chlorambucil of mediastinal lymph nodes may cause cough, shortness or fludarabine.

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Don’t assume that physician patients need less explana- recommendations as with other patients generic 75 mg effexor xr otc. Remember that a physician’s knowledge of therapeutics in an area of practice not his or her own Introduction quickly become dated after medical school discount effexor xr 150 mg mastercard. Intellectualizing for your own self-comfort or being drawn helping doctors buy discount effexor xr 37.5 mg on-line,” or “extending professional courtesy,” caring into talking shop is not in the best service of your pa- for colleagues is an important tradition in medicine. They may quoted maxim that “The physician who treats himself has a have specifc ideas or concerns that are not shared by other fool for a patient. What does it mean to “immi- Within our current medical culture there is clear endorsement grate to the nation of the sick? For • Physicians should have a family physician and an age- example, not all physicians are fnancially sound or have appropriate health assessment as an occupational overhead and/or disability insurance. Thoroughness, including a complete physical examination, • Physicians should not self-medicate through self- cannot be sacrifced. Physicians are observant and expect prescribing, the sample cupboard or workplace supplies. It provides comfort and trust in the physician– Robert Klitzman has invited physicians to be aware of “post- patient relationship. The demonstration of empathy is as important as in other and denying symptoms, worrying too little, self-diagnosing and physician–patient relationships. Physicians worry about the transforma- colleagues we need to be aware of our own reactions. At times, particularly if they our physician patient’s response to illness close to home? The end of the visit should involve more than education, Case resolution involvement in decision-making and enquiring whether The program director reviewed some of the key prin- your patient got what they needed. As treating physicians ciples involved in treating colleagues and the importance we need to be clear and explicit about our practice with of maintaining appropriate roles and boundaries in such regard to prescriptions, consultations and investigations. The resident acknowledged being irritable, not download the physician roles and responsibilities to fatigued and hungry that evening after being on call your physician patient. We all deserve confdentiality and privacy in our health ing in the emergency room for a second opinion refused. However, we may also need to refect with our physi- The resident and program director discussed a mutually cian patient on how privacy issues or maintaining secrets agreeable approach to address the complaint. This may be especially relevant when physician patients the frustration, fear, and disappointment the patient had are suffering from diseases of degeneration (including experienced. As a result, the resident gained a deeper aging), psychiatric illness or substance use disorders. We must be aware that illness is not unprofessional conduct and that there is a difference between illness and impairment. Physicians for physicians: when doctors be- treatment are as effective for physicians as they are for come patients. In caring for our colleagues we would do well to remember the words of Rabia Elizabeth Roberts: “We learn that our human- ity is more powerful than our expertise alone” (Hanlon 2008). Richard Gunderman would invite us to adopt our part of the highway and to care for one another as colleagues the best way we can. By practising the best kind of philanthropy; the result will beneft the health of all our patients. If a physician is diagnosed with a reportable condi- tory agency, tion, the treating physician is required to report the case to the • outline the consequences of a failure to report, and individual or offce designated in the legislation. Residents who • identify sources of support to guide decision-making in are being treated for serious health issues must also consider this area. A number of colleges include questions Case on licence applications or renewal forms pertaining to alcohol A third-year resident involved in treating a surgeon in or drug dependence and any physical or mental conditions Manitoba is aware that the surgeon suffers from alcohol that might affect ftness to practise. The resident suggests that the surgeon not per- more information in these circumstances. The surgeon continues to practise medicine, Reporting a physician who is not a patient but has assured the resident that they do not drink or take Residents may also have an ethical and legal duty to report a drugs before performing surgeries. What are the resident’s colleague to their governing college in certain circumstances, obligations in the circumstances? Introduction Most statutes and policies require the reporting physician to Reporting another physician to a medical regulatory authority have reasonable grounds for reporting.

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Laboratory interpretation: Students should be able to recommend when to order diagnostic and laboratory tests and be able to interpret them effexor xr 75mg sale, both prior to and after initiating treatment based on the differential diagnosis effexor xr 37.5 mg otc, including consideration of test cost and performance characteristics as well as patient preferences order effexor xr 150 mg otc. Laboratory and diagnostic tests should include, where appropriate: • Pulse oximetry. Communication skills: Students should be able to: • Communicate the diagnosis, treatment plan, and subsequent follow-up to the patient and his or her family. Demonstrate commitment to using risk-benefit, cost-benefit, and evidence- based considerations in the selection of diagnostic and therapeutic interventions for venous thromboembolic disease. Respond appropriately to patients who are non-adherent to treatment for venous thromboembolic disease. Demonstrate ongoing commitment to self-directed learning regarding venous thromboembolic disease. Appreciate the impact venous thromboembolic disease 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 venous thromboembolic disease. Emerging strategies in the prevention of venous thromboembolism in hospitalized medical patients. D-dimer for the exclusion of acute venous thrombosis and pulmonary embolism: a systematic review. In Rwanda, however, as in much of sub-Saharan Africa, the discipline of emergency medicine is in its infancy and emergency care training and infrastructure is limited. Delayed medical response to acute conditions such as injuries from road traffic accidents, severe malaria, obstetric complications and diarrhea contributes significantly to mortality. In addition, currently in Rwanda, the vast majority of healthcare providers lack the basic training necessary to triage and provide patients with adequate care in medical emergencies. The need for emergency care training in Rwanda is particularly significant as the country is undergoing an epidemiologic transition where, communicable diseases and emergency obstetric conditions, injuries resulting from road traffic accidents and industrial accidents, and non communicable disease constitute an increasingly large proportion of the national burden of disease. Both of these broad condition domains require specific emergency care training and expertise in order to secure adequate patient management and favorable outcomes. The clinical guidelines and protocols for the practice of emergency medicine presented in this document are designed to be a useful resource not only for those wishing to become emergency medicine specialists, but also for general practitioners and other healthcare providers tasked with caring for patients in hospital emergency departments. The guidelines are intended to standardize care at both district and referral hospitals. The emergency care provider must employ an assessment system that rapidly identifies and addresses critical illness or injury first and foremost. This initial system needs to be systematic and simple to quickly and efficiently perform, but also effective and robust to not miss anything life-threatening. Once these critical problems are addressed, the provider then moves through another and deeper cycle of assessment and treatment known as the secondary survey. Secondary Survey: First 15 minutes of patient encounter • More in-depth history • Complaint-specific physical exam o Include bedside ultrasound assessment here • Other time-sensitive interventions o Chest drain, anti- seizure medications, etc. Both the primary and secondary survey should be completed in less than 20 minutes, correcting problems along the way. Providers do not move on to the secondary survey until problems with the primary survey have been addressed. Initial approach to assessment and management Assess for evidence of airway obstruction: • Are there abnormal breathing noises? If the patient remains obstructed, you must proceed to an advanced airway device: • Place a laryngeal mask airway (if available in the district hospital) or proceed directly to endotracheal intubation (if trained to do so) If airway devices are not available, arrange for immediate transfer to referral center Figure 1. Though breathing assessment and management should only proceed after any airway issues have been addressed, airway and breathing are often dealt with simultaneously. Emergency care providers must be efficient and effective in the almost simultaneous management of airway and breathing problems. Develop a clear approach to organize all of the information gathered from often limited history and physical exam. In acutely unwell patients with breathing problems, treatment must be started at the same time that a differential diagnosis is being generated.

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