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During this time proven plaquenil 200mg, you will feel more like a “doctor” than you will on most other rotations – you will have quite a bit of responsibility and will hopefully feel like you’re learning something each day buy generic plaquenil 200 mg. Family medicine is a 4-week block that most students really enjoy order 200mg plaquenil overnight delivery, regardless of what they plan to go into. During this time, you will see patients of all ages and with a large variety of concerns, from children needing well-child care, to pregnant patients, to the elderly. In this case, each hemi-team has its own supervising resident, as well as two interns or one intern and one sub-intern, and one or two medical students (i. Sub-I’s carry their own patients 29 (approximately 10 patients) and interact directly with the senior resident. They are usually very approachable and good people to ask questions that you are afraid may be stupid. For the most part, your intern will give you as much autonomy as you like in terms of caring for your patients; however, s/he is ultimately responsible for patient well-being and will have to cosign all of your orders. Your intern isn’t grading you directly, but having a good relationship with them is essential for doing well on your medicine rotation. During this time, you will present new patients in full, as well as giving a brief overview of the care of known patients. This is an attending who has admitting privileges to a certain hospital, but is not necessarily part of the Penn faculty. If this happens, you will care for the patient on a daily basis, but will not discuss that patient in rounds with your attending; rather, the private attending will read your note each day to determine what has happened with the patient. This situation isn’t ideal, as you have to do the work without the benefit of attending teaching (or face time for evaluation by your “real” attending), but your resident may want you to pick up a private patient if the case is interesting or a good learning experience. Almost all of the “private attendings” do not mind discussing their patients with you, and you can page them to ask them questions about the patient and/or discuss the case. Your responsibilities: As a part of your team, you will be responsible for carrying 1-4 patients at all times (usually 2-3). For each patient you are carrying, you will see the patient daily prior to rounds, write daily progress notes, discuss the case daily in rounds, read up on the patient’s chief complaint, write daily orders, and prepare the patient for discharge. You are expected to pick up 2 patients per call night (although in the beginning you may only be asked to pick up 1 patient), with your intern. You will work with your intern to admit your 1-2 patients; as your rotation goes on, you will do more and more of this yourself, but in the beginning, your intern will help you. Many interns prefer to go with you when you see the patient so that the patient doesn’t have to be seen twice, but others will tell you to go ahead by yourself. Others will have a multitude of medical problems and no clear diagnosis, and admitting them can be overwhelming. Methods of order- writing will vary with your site, and your intern will show you how to enter orders. This is a formal presentation that requires you to speak in front of your team – it is not meant to be intimidating, but it can be. You should be ready to present a comprehensive differential diagnosis (although you may not have time in rounds to present the entire list), but you should also take a stand about what you think the most likely diagnosis is and what the plan should be (talk to your intern/resident for help with this! Many attendings also appreciate if once or twice on the rotation you bring in an article (not from UpToDate) that may contribute to your patient’s care (but this is not necessary for every patient—and you will look like a serious gunner if you bring an article for every patient you present…try to limit it to an occasional unusual and/or interesting patient). Medical students also give periodic topic presentations on rounds, and these are often on topics related to your patients. Often attendings will ask for these at some point during the rotation, but if something interesting comes up with one of your patients, feel free to offer. These presentations are typically less than 10 31 minutes and should answer a focused clinical question in an evidence-based manner. If you have a choice about what to present, try to pick something that will help you out for shelf exam studying instead of something so obscure you will never see it again!

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Blood Plasma Like other fluids in the body generic plaquenil 200 mg free shipping, plasma is composed primarily of water: In fact cheap plaquenil 200mg mastercard, it is about 92 percent water buy discount plaquenil 200 mg on line. There are literally hundreds of substances dissolved or suspended in the plasma, although many of them are found only in very small quantities. Serum, one of the specimen types included, refers to a sample of plasma after clotting factors have been removed. Plasma Proteins About 7 percent of the volume of plasma—nearly all that is not water—is made of proteins. These include several plasma proteins (proteins that are unique to the plasma), plus a much smaller number of regulatory proteins, including enzymes and some hormones. The three major groups of plasma proteins are as follows: • Albumin is the most abundant of the plasma proteins. Manufactured by the liver, albumin molecules serve as binding proteins—transport vehicles for fatty acids and steroid hormones. Recall that lipids are hydrophobic; however, their binding to albumin enables their transport in the watery plasma. Albumin is also the most significant contributor to the osmotic pressure of blood; that is, its presence holds water inside the blood vessels and draws water from the tissues, across blood vessel walls, and into the bloodstream. Albumin normally accounts for approximately 54 percent of the total plasma protein content, in clinical levels of 3. The alpha and beta globulins transport iron, lipids, and the fat-soluble vitamins A, D, E, and K to the cells; like albumin, they also contribute to osmotic pressure. The gamma globulins are proteins involved in immunity and are better known as an antibodies or immunoglobulins. Although other plasma proteins are produced by the liver, immunoglobulins are produced by specialized leukocytes known as plasma cells. These include various electrolytes, such as sodium, potassium, and calcium ions; dissolved gases, such as oxygen, carbon dioxide, and nitrogen; various organic nutrients, such as vitamins, lipids, glucose, and amino acids; and metabolic wastes. When more than a few drops of blood are required, phlebotomists perform a venipuncture, typically of a surface vein in the arm. They perform a capillary stick on a finger, an earlobe, or the heel of an infant when only a small quantity of blood is required. After collection, the blood may be analyzed by medical laboratories or perhaps used for transfusions, donations, or research. While many allied health professionals practice phlebotomy, the American Society of Phlebotomy Technicians issues certificates to individuals passing a national examination, and some large labs and hospitals hire individuals expressly for their skill in phlebotomy. The information they provide is essential to the primary care providers in determining a diagnosis and in monitoring the course of a disease and response to treatment. Although one type of leukocyte called memory cells can survive for years, most erythrocytes, leukocytes, and platelets normally live only a few hours to a few weeks. When you donate a unit of blood during a blood drive (approximately 475 mL, or about 1 pint), your body typically replaces the donated plasma within 24 hours, but it takes about 4 to 6 weeks to replace the blood cells. The process by which this replacement occurs is called hemopoiesis, or hematopoiesis (from the Greek root haima- = “blood”; -poiesis = “production”). Sites of Hemopoiesis Prior to birth, hemopoiesis occurs in a number of tissues, beginning with the yolk sac of the developing embryo, and continuing in the fetal liver, spleen, lymphatic tissue, and eventually the red bone marrow. Following birth, most hemopoiesis occurs in the red marrow, a connective tissue within the spaces of spongy (cancellous) bone tissue. In children, hemopoiesis can occur in the medullary cavity of long bones; in adults, the process is largely restricted to the cranial and pelvic bones, the vertebrae, the sternum, and the proximal epiphyses of the femur and humerus. This process is referred to as extramedullary hemopoiesis (meaning hemopoiesis outside the medullary cavity of adult bones).

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However in recent years purchase 200mg plaquenil otc, the addiction medications have been noted and pharmaceutical industry has cut back safety concerns raised--particularly with regard dramatically on investments in the development 223 of new pharmaceutical therapies for these and to smoking cessation treatments buy plaquenil 200mg with mastercard, side effects 233 exist for many medications aimed at treating other mental health conditions cheap 200mg plaquenil otc. The large other health conditions and typically are profits that pharmaceutical companies were able acknowledged as an acceptable risk of treatment. Addiction treatment providers do not speak with Coupled with the rising cost of research and clarity or consistency about what the goals of development, the fact that pharmaceutical treatment are, what counts as quality treatment, companies face dramatic losses once the patents how performance and outcomes should be on many of their largest money-making drugs measured and what practices should be expire makes the current climate for the implemented to improve treatment and achieve development of new innovative medications * 239 measurable outcomes. For example, transporters that underlie addiction and that are organizations like the Council on Graduate promising targets for the development of Medical Education and the National Advisory 235 medications to prevent and treat addiction. Council on Nurse Education and Practice are public-private partnerships with Congressional Aside from economic concerns, other factors mandates to provide sustained assessment of the inhibiting investments in new pharmaceutical 241 needs of the medical and nursing fields. Even for which states that every physician must assume smoking cessation, which offers a huge clinical responsibility for the diagnosis and potential market, investments are negligible referral of patients with addiction and explicates compared with the costs associated with the particular competencies needed to fulfill that developing medications to treat the responsibility. Despite these and other efforts by government and professional Translating the rapidly-evolving science of organizations to put forth guidelines and addiction into science-based treatments will principles aimed at ensuring proper training in require dramatic changes in incentives for the risky substance use and addiction, physicians pharmaceutical industry to invest in innovative continue to be insufficiently equipped to address medications, increased public understanding that 242 the needs of their substance-involved patients. Such inconsistency in goals makes and outcome measurement, including limited measuring and assessing the effectiveness of consensus regarding core quality standards and treatment very difficult. The primary goals of medical care are the prevention, diagnosis and treatment of illness, injury and disease, and the consequent 246 relief of pain and suffering. The picture is not as clear in addiction treatment: there is little agreement among addiction treatment providers about what the goals of treatment are or should be and whether successful treatment is defined by abstinence, a reduction in clinical symptoms or a reduction in negative health and social 247 * consequences. Program Staff Further complicating the measurement of Directors Providers outcomes is the failure to understand that Tobacco addiction in many cases is a chronic disease that Complete abstinence 49. Government and private funders Inadequate Insurance Coverage and insurance companies increasingly are pressing addiction treatment programs to In spite of recent expansions in coverage for demonstrate the effectiveness of their programs intervention and addiction treatment through 250 health care parity laws and the Affordable Care and services. However, most programs do not measure performance or treatment outcomes or Act, insurance coverage for addiction and have reliable evaluation data to demonstrate the related services remains severely limited 251 compared with coverage for other health efficacy of their services. This lack of insurance coverage 252 for effective--and cost-effective--intervention addiction treatment. The asked about the three main ways that their end result is that millions of Americans are program evaluates how well it is doing, the most denied treatment, health care costs continue to common response offered was “program rise as do social consequences and costs, and 257 completion rates” (68. Its strength is a clear and long- to conduct and support “research, training, overdue recognition of the nature of the disease health information dissemination and other of addiction and the importance of addressing it programs with respect to the cause, diagnosis, in a unified way. The result is a disjointed array of programs and  Shifting evaluation efforts from a focus on efforts that often have quite different performance-based measures that document perspectives and approaches to addressing the the process of service delivery to a focus on issues surrounding substance use and addiction, patient outcomes, and rewarding those which further contributes to the segmented view programs that demonstrate positive patient 265 of addiction as multiple substance- and outcomes; and behavior-specific problems, rather than a single disease with different manifestations. Although these supporting research and prevention are steps in the right direction, the research efforts; advocating for state and federal documented in this report demonstrates clearly policies that would expand access to that the current treatment infrastructure is treatment; and working to establish riddled with barriers to closing the vast gap addiction medicine as a recognized 267 271 between research evidence and practice. Such brief trainings use, including tobacco, alcohol and have proven effective in improving health other drugs. Recent research within the alcohol and other drugs, and to promote Medicaid and Veterans Health more broadly the adoption of these Administration systems demonstrates the 277 286 practices in the medical field. For example, in 2012, the Joint Commission announced new, * voluntary measures for hospitals that choose Screening, Brief Intervention, Referral and to provide screening, brief intervention and Treatment. The performance Our perspective is that, although tactically measurement sets related to alcohol and impressive, the [Joint Commission’s] other drugs include screening, brief measure set [regarding tobacco screening and interventions, treatment, discharge planning cessation services] is strategically flawed 287 291 and follow up. Hospitals are with risky substance use than all the urging required to choose four out of 14 possible and pleading we’ve undertaken for the past core performance measurement sets, with no 292 25 to 30 years. However, other sets of measures that hospitals may choose to be held accountable for include those that they already perform routinely, limiting the reach of this promising development which would require more effort and resources than most other 290 measurement sets. Effective, evidence-based interventions and treatment options exist that can and should be delivered through the health care system. A substantial body of research demonstrates that providing effective prevention, intervention, treatment and disease management services yields improvements in health and considerable reductions in costs to government and taxpayers; research also suggests that providing these services does not result in significant increases in insurance costs. In the face of these facts, it is unethical, inhumane and cost prohibitive to continue to deny effective care and treatment for the 40. No one group or sector alone can realize the changes required in health care practice, government regulation and spending, insurance coverage, and public understanding to bring addiction prevention and treatment and reductions in risky substance use in line with the standard of care for other public health and medical conditions.

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