By C. Tangach. Lindsey Wilson College.

Two days after undergoing surgical repair of a ruptured abdominal aortic aneurysm avana 200mg otc, a 67-year-old man requires increasing ventilatory support generic avana 100 mg without a prescription. A previously healthy 62-year-old man comes to the physician because of a 2-month history of cough generic avana 200 mg mastercard. Fasting serum studies show a total cholesterol concentration of 240 mg/dL and glucose concentration of 182 mg/dL cheap avana 50 mg online. A 3-year-old girl is brought to the emergency department because of left leg pain after falling at preschool 2 hours ago 200mg avana amex. She has consistently been at the 10th percentile for height and weight since birth. An x-ray shows a new fracture of the left femur and evidence of previous fracturing. B - 131 - Emergency Medicine Advanced Clinical Systems* General Principles, including ethics and patient safety 1%–5% Immunologic Disorders 1%–5% Diseases of the Blood 5%–10% Mental Disorders 1%–5% Diseases of the Nervous System 10%–15% Cardiovascular Disorders 15%–20% Diseases of the Respiratory System 10%–15% Nutritional and Digestive Disorders 10%–15% Gynecologic Disorders 1%–5% Renal, Urinary, Male Reproductive Systems 5%–10% Obstetric Disorders 1%–5% Diseases of the Skin 1%–5% Musculoskeletal and Connective Tissue Disorders 5%–10% Endocrine and Metabolic Disorders 5%–10% Physician Task Promoting Health and Health Maintenance 1%–5% Understanding Mechanisms of Disease 5%–10% Establishing a Diagnosis 25%–35% Applying Principles of Management 45%–55% Patient Age Birth to 17 5%–10% 18 to 65 60%–65% 66 and older 15%–20% *A subset of items across the organ systems includes content that focuses on resuscitation/trauma (~15%) and environmental/toxicologic disorders (~15%). A 32-year-old woman comes to the emergency department 3 hours after the sudden onset of a severe headache. A 24-year-old nulligravid woman is brought to the emergency department after a syncopal episode at work. She has had progressively severe cramps in the lower abdomen over the past 6 hours. She has had spotty vaginal bleeding for 2 days; her last menstrual period began 7 weeks ago. Examination shows blood in the vaginal vault and diffuse abdominal tenderness; there is pain with cervical motion. A 15-month-old girl is brought to the emergency department after a generalized tonic-clonic seizure at home. The seizure stopped spontaneously after 2 minutes, and she seemed sleepy afterward. Her parents state that yesterday she had a mild runny nose but otherwise has been well. An 18-year-old man is brought to the emergency department 10 minutes after he sustained a stab wound to his chest. His pulse is 130/min, respirations are 8/min and shallow, and palpable systolic blood pressure is 60 mm Hg. Examination shows a 2-cm wound at the left sixth intercostal space at the midclavicular line. A 27-year-old man is brought to the emergency department 20 minutes after his roommate found him unconscious on their bathroom floor. B - 136 - Internal Medicine Advanced Clinical Systems General Principles 5%–10% Immunologic Disorders 1%–5% Diseases of the Blood 5%–10% Mental Disorders 1%–5% Diseases of the Nervous System 5%–10% Cardiovascular Disorders 10%–15% Diseases of the Respiratory System 10%–15% Nutritional and Digestive Disorders 10%–15% Female Reproductive System 1%–5% Renal, Urinary, Male Reproductive Systems 5%–10% Diseases of the Skin 1%–5% Musculoskeletal and Connective Tissue Disorders 1%–5% Endocrine and Metabolic Disorders 8%–12% Physician Task Promoting Health and Health Maintenance 5%–10% Understanding Mechanisms of Disease 5%–10% Establishing a Diagnosis 35%–45% Applying Principles of Management 40%–50% Site of Care Emergency Department 20%–30% Inpatient 70%–80% Patient Age 17 to 65 65%–75% 66 and older 25%–35% - 137 - 1. A previously healthy 67-year-old man is admitted to the hospital because of lethargy, confusion, muscle cramps, and decreased appetite for 7 days. A 67-year-old woman is brought to the emergency department because of severe chest pain 4 hours after undergoing outpatient endoscopy and dilatation of an esophageal stricture caused by reflux. Rectal examination shows no masses; test of the stool for occult blood is positive. A 72-year-old woman is brought to the emergency department 1 hour after the sudden onset of right facial droop and weakness of the right arm and leg. One day after undergoing cholecystectomy, a 37-year-old man becomes increasingly tremulous and anxious. Administration of which of the following is the most appropriate next step in management? Fourteen hours after admission to the hospital for treatment of severe hypertension, a 32-year-old woman has stridor. Her pulse is 140/min, respirations are 32/min, and blood pressure is 140/85 mm Hg. E - 141 - Comprehensive Basic Science The Comprehensive Basic Science Examination is a general, integrated achievement test covering material typically learned during basic science education, with somewhat more emphasis on second-year courses in medical schools with traditional curricula. Systems General Principles of Foundational Science 15%–20% Biochemistry and molecular biology Biology of cells Human development and genetics Biology of tissue response to disease Pharmacodynamic and pharmacokinetic processes Microbial biology Normal age-related findings and care of the well patient Immune System 1%–5% Blood & Lymphoreticular System 5%–10% Behavioral Health 1%–5% Nervous System & Special Senses 5%–10% Skin & Subcutaneous Tissue 1%–5% Musculoskeletal System 5%–10% Cardiovascular System 5%–10% Respiratory System 5%–10% Gastrointestinal System 5%–10% Renal & Urinary System 5%–10% Pregnancy, Childbirth, & the Puerperium 1%–5% Female Reproductive System & Breast 1%–5% Male Reproductive System 1%–5% Endocrine System 5%–10% Multisystem Processes & Disorders 5%–10% Biostatistics, Epidemiology/Population Health, & Interpretation of the Medical Lit. A 16-month-old boy is brought to the physician by his mother for a well-child examination.

On the whole cheap 100mg avana with visa, absence of evidence of an effect is not the same thing as evidence of absence of an effect discount avana 200mg with mastercard. Conclusion The study results should be accurately reflected in the conclusion section generic 50 mg avana overnight delivery, a one-paragraph summary of the final outcome avana 100mg visa. The reader should be aware that pitfalls in the inter- pretations of study conclusions include the use of biased language and incorrect interpretation of results not supported by the data discount avana 50mg. Studies sponsored by drug companies or written by authors with other conflicts of interest may be more prone to these biases and should be regarded with caution. All sources of con- flict of interest should be listed either at the start or at the end of the article. Bibliography The references/bibliography section demonstrates how much work from other writers the author has acknowledged. This includes a comprehensive reference list including all important studies of the same or similar problem. You will be better at interpreting the completeness of the bibliography when you have immersed yourself in a specialty area for some time and are able to evaluate this author’s use of the literature. Be wary if there are multiple citations of works by just one or two authors, especially if by the author(s) of the current study. The New England Journal of Medicine is a great place for medical students to start. It publishes important and high quality studies and includes a lot of correlation with basic sciences. There are also excellent case discussions, review articles, and basic-science articles. Remember, that what you read in the abstract should not be used to apply the results of the study to a clinical scenario. Initially, we will focus on learning how to criti- cally evaluate the most common clinical studies. These skills will help you to grade the quality of the studies using a schema outlined in Appendix 1. Later the book will focus on studies of diagnostic tests, clinical decision making, cost analyses, prognosis, and meta-analyses or systematic reviews. But as for certain truth, no man has known it, for all is but a woven web of guesses. This requires one to develop an effective search strategy for a clinical question. By the end of this chapter you will understand how to write a clinical question and formulate a search of the literature. Once an answerable clinical question is written and the best study design that could answer the ques- tion is decided upon, the next task is to search the literature to find the best avail- able evidence. This might appear an easy task, but, unless one is sure of which database to use and has good searching skills, it can be time-consuming, frus- trating, and wholly unproductive. This chapter will go through some common databases and provide the information to make the search for evidence both effi- cient and rewarding. Introduction Finding all relevant studies that have addressed a single question is not an easy task. The exponential growth of medical literature necessitates a systematic 33 34 Essential Evidence-Based Medicine searching approach in order to identify the best evidence available to answer a clinical question. While many people have a favorite database or website, it is important to consult more than one resource to ensure that all relevant informa- tion is retrieved. Developed by the National Library of Medicine at the National Institutes of Health in the United States, it is the world’s largest gen- eral biomedical database and indexes approximately one-third of all biomedi- cal articles. Since it was the first medical literature database available for elec- tronic searching, most clinicians are familiar with its use. Due to its size and breadth, it is sometimes a challenge to get exactly what one wants from it. This will be the first database discussed, after a discussion of some basic principles of searching. The database selected depends on the content area and the type of question being asked. If search- ing for the answer to a question of therapy or intervention, then the Cochrane Library might be a particularly useful resource. It provides systematic reviews of trials of health-care interventions and a registry of controlled clinical trials.

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