Jeffrey A Brinker, M.D.
- Professor of Medicine
- Joint Appointment in Radiology and Radiological Science
The appearance is a radial array likened to purchase minocin on line amex antibiotics for pneumonia the design of medieval castles quality 50mg minocin antibiotic resistance video clip, not simply of battlements purchase cheap minocin antibiotic 3 day dose. Hence these are more complex visual phenomena than simple ashes of light (photopsia) or scintillations. They are thought to result from spreading depression, of possible ischaemic origin, in the occipital cortex. The visions of Hildegard von Bingen (1098–1179), illustrated in the twelfth century, are thought possibly to reect migrainous fortication spectra. Cross References Aura; Hallucination; Photopsia; Teichopsia Foster Kennedy Syndrome the Foster Kennedy syndrome consists of optic atrophy in one eye with optic disc oedema in the other eye, Anosmia ipsilateral to optic atrophy may also be found. Similar clinical appearances may occur with sequential anterior ischaemic optic neuropathy, sometimes called a pseudo-Foster Kennedy syndrome. Retrobulbar neuritis as an exact diagnostic sign of certain tumors and abscesses in the frontal lobe. Cross References Optic atrophy; Papilloedema Fou Rire Prodromique Fou rire prodromique, or laughing madness, rst described by Fere in 1903, is pathological laughter which heralds the development of a brainstem stroke, usually as a consequence of basilar artery occlusion. Pathological crying as a prodrome of brainstem stroke has also been described (‘folles larmes prodromiques’). Basilar artery occlusion associated with pathological crying: “folles larmes prodromiques” Freezing Freezing is the sudden inability in a patient with parkinsonism to move or to walk, i. This is one of the unpredictable motor uctuations in late Parkinson’s disease (associated with longer duration of disease and treatment) which may lead to falls, usually forward onto the knees, and injury. Two variants are encountered, occurring either during an off period or wearing off period, or randomly, i. Treatment strategies include use of dopaminergic agents and, anecdotally, L-threodops, but these agents are not reliably helpful, particularly in random freezing. Freezing may also occur in multiple system atrophy and has also been reported as an isolated phenomenon. The term is also sometimes used for weakness of little nger adduction (palmar interossei), evident when trying to grip a piece of paper between the ring and little nger. Damage to the frontal lobes may produce a variety of clinical signs, most frequently changes in behaviour. Such changes may easily be overlooked with the traditional neurological examination, although complained of by patient’s relatives, and hence specic bedside tests of frontal lobe function should be utilized, for example: • Verbal uency. A useful clinico-anatomical classication of frontal lobe syndromes which reects the functional subdivisions of the frontal lobes is as follows: • Orbitofrontal syndrome (‘disinhibited’): disinhibited behaviour (including sexual disinhibition), impulsivity inappropriate affect, witzelsucht, euphoria emotional lability (moria) lack of judgement, insight distractibility, lack of sustained attention; hypermetamorphosis motor perseverations are not a striking feature • Frontal convexity syndrome (‘apathetic’): apathy; abulia, indifference motor perseveration difculty set-shifting, stimulus boundedness reduced verbal uency decient motor programming. A‘dysexecutive syndrome’ has also been dened, consisting of difculty planning, adapting to changing environmental demands (impaired cognitive exibility. These frontal lobe syndromes may be accompanied by various neurological signs (frontal release signs or primitive reexes). Other phenomena associated with frontal lobe pathology include imitation behaviours (echophenomena) and, less frequently, utilization behaviour, features of the environmental dependency syndrome. Frontal lobe syndromes may occur as a consequence of various pathologies: • Neurodegenerative diseases: especially frontal or behavioural variant frontotemporal lobar degeneration; occasionally in Alzheimer’s disease; • Structural lesion: tumour (intrinsic, extrinsic), normal pressure hydrocephalus; • Cerebrovascular event; • Head injury; • Inammatory metabolic disease: multiple sclerosis, X-linked adrenoleucodystrophy. Cross References Abulia; Akinesia; Akinetic mutism; Alternating st closure test; Apathy; Attention; Disinhibition; Dysexecutive syndrome; Emotionalism, Emotional lability; Fist-edge-palm test; Frontal release signs; Hypermetamorphosis; Hyperorality; Hyperphagia; Hypersexuality; Incontinence; Perseveration; Utilization behaviour; Witzelsucht Frontal Release Signs Frontal release signs are so named because of the belief that they are released from frontal inhibition by diffuse pathology within the frontal lobes (usually vascular or degenerative) with which they are often associated, although they may be a feature of normal ageing. Some of these responses are present during infancy but disappear during childhood, hence the terms ‘primitive reexes’ or ‘developmental signs’ are also used (Babinski’s sign may therefore fall into this category). The term ‘psychomotor signs’ has also been used since there is often accompanying change in mental status. The frontal release signs may be categorized as: • Prehensile: Sucking reex (tactile, visual) Grasp reex: hand, foot Rooting reex (turning of the head towards a tactile stimulus on the face) • Nociceptive: Snout reex Pout reex Glabellar (blink) reex Palmomental reex the corneomandibular and nuchocephalic reexes may also be categorized as ‘frontal release’ signs. Concurrent clinical ndings may include dementia, gait disorder (frontal gait, marche a petit pas), urinary incontinence, akinetic mutism, and gegenhalten. Common causes of these ndings are diffuse cerebrovascular disease and motor neurone disease, and they -151 F Fugue may be more common in dementia with Lewy bodies than other causes of an extrapyramidal syndrome. Primitive reex evaluation in the clinical assessment of extrapyramidal syndromes. Prevalence of primitive reexes and the relationship with cognitive change in healthy adults: a report from the Maastricht Aging Study. Cross References Age-related signs; Babinski’s sign (1); Corneomandibular reex; Gegenhalten; Grasp reex; Marche a petit pas; Palmomental reex; Pout reex; Rooting reex; Sucking reex Fugue Fugue, and fugue-like state, is used to refer to a syndrome characterized by loss of personal memory (hence the alternative name of ‘twilight state’), automatic and sometimes repetitive behaviours, and wandering or driving away from normal surroundings. Fugue may be: • Psychogenic: associated with depression (sometimes with suicide); alcoholism, amnesia; ‘hysteria’ • Epileptic: complex partial seizures • Narcoleptic Some patients with frontotemporal dementia may spend the day walking long distances, and may be found a long way from home, unable to give an account of themselves, and aggressive if challenged; generally they are able to nd their way home (spared topographical memory) despite their other cognitive decits. Cross References Amnesia; Automatism; Dementia; Poriomania; Seizures Functional Weakness and Sensory Disturbance Various signs have been deemed useful indicators of functional or ‘non-organic’ neurological illness, including • Collapsing or ‘give way’ weakness • Hoover’s sign • Babinski’s trunk–thigh test • ‘Arm drop’ • Belle indifference • Sternocleidomastoid sign • Midline splitting sensory loss • Functional postures, gaits: monoplegic ‘dragging’ uctuation of impairment 152 Funnel Vision F excessive slowness, hesitation ‘psychogenic Romberg’ sign ‘walking on ice’ uneconomic posture, waste of muscle energy. How to identify psychogenic disorders of stance and gait: a video study in 37 patients. Depressing the tongue with a wooden spatula, and the use of a torch for illumination of the posterior pharynx, may be required to get a good view. There is a palatal response (palatal reex), consisting of upward movement of the soft palate with ipsilateral deviation of the uvula; and a pharyngeal response (pharyngeal reex or gag reex) consisting of visible contraction of the pharyngeal wall. Lesser responses include medial movement, tensing, or corrugation of the pharyngeal wall.
Simultaneously buy 50 mg minocin fast delivery antibiotic vitamin c, the primary neuron of the Total knee replacement 19–43 Cesarean section 12 pain pathway releases substances into the area around peripheral nerve endings discount 50 mg minocin otc antimicrobial growth promoters, which Breast augmentation 13–38 Dental surgery 5–13 contribute to generic 50 mg minocin otc antibiotics for acne blackheads this process – this results in peripheral sensitization. If the C fbers permanently transmit signals from the painful area to the central nervous system (fring), neurons in the spinal Prostatectomy 35 Painful ejaculation after inguinal hernia repair 1 dorsal horns enhance their response, their receptive area expands and the number of spinal receptors stimulating nociceptive pathways increases, which produces central sensitization (= lowering the threshold for response to other stimuli). Guidelines on the Management of Postoperative nia – a painful response to a normally innocuous stimulus. Management of Postoperative Pain: A Clinical Practice Guideline From the American of sensory areas in the brain occurs. It is not yet clear, however, why some patients are Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the Amercaught in this vicious circle resulting in postoperative pain chronifcation, and others ican Society of Anesthesiologists’ Committee on Regional Anesthesia, Executive Committee, are not. Sometimes it is caused by peripheral nerve injury or by a sustained stimulation and Administrative Council. Br J Anaesth, 2008;101(1):77–86 Currently, the identifcation of a high-risk patient may be based solely on the presMalek J, Kurzova A, Ambrus M, et al. A clinical study proved that the incidence of neurogenic kych,2006;145(3):209-14 pain and the size of the hyperalgesic area around the surgical wound measured on the Reddi D. However, the impact of this fnding on the common clinical practice is difcult iasp. April 14, 2017 At the current state of knowledge, the possibilities for prevention are very limited. Lancet 2011; 377: 2215–25 Even as obvious methods at frst glance as limiting the extent of surgical trauma did not produce defnite results. Based on the information that chronic pain is related to intense perioperative pain, much hope was pinned on preemptive analgesia – the administration of medications inhibiting primary and central sensitization before they might occur, i. Unfortunately, in human medicine, the results were not clearly positive and following the information boom at the turn of this century, studies on preemptive analgesia are becoming less frequent (see section 6. Similar controversial conclusions are drawn in studies on the importance of locoregional methods in comparison with general anesthesia or a combination of local and general anesthesia compared to general anesthesia alone. Pain intensity on the frst day after surgery: a prospective cohort study comparing 179 surgical procedures. Improving analgesia alone may not be sufcient to reduce stress response to surgery. We must also infuence other physiological processes and restore homeostasis, which will in turn shorten the length of hospital stay, reduce morbidity and mortality. Measuring physiological changes (heart rhythm), response to stress (plasma cortisol), or changes in behavior (facial expression) can provide important information on the intensity of pain. Only then optimal analgesia may be achieved, which is a mild, tolerable The most widely used method of numerical assessment of pain intensity is the visual sensation of pressure in the surgical wound with minimal adverse efects. The patient should feel sufcient empathy on the part score often increases with movement, depending on the range of motion. The examination of acute pain should include medical used to evaluate the efcacy of treatment. When taking a patient’s history, our focus is on the cause and circumstances of An alternative to numerical scale may be an expanding color circle sector or Faces the onset of pain, speed of onset, location, radiation, quality of the pain, and accomPain Scale, which shows facial expressions ranging from the state of well-being to panying symptoms (nausea, vomiting, tremor, sweating, etc. This scale is preferred in young children, who are not able to acof pain and its efect is also evaluated. The type and extent of surgical trauma, the type curately describe or quantify the intensity of pain. Acute pain should be routinely of anesthesia, the quality of postoperative care, and the incidence of complications monitored in intensive care as well. In non-cooperative, critically ill patients, Behavplay a key role in postoperative pain management. During physical examination, we ioral Pain Scale or Critical-Care Pain Observation Tool are recommended. Monitoring focus on the site of maximum tenderness, but also on distant structures, which may pain by observing changes in vital signs is not recommended. They allow simple b) quality of the pain – dull, sharp, throbbing, shooting, burning, etc. Tese questionnaires are not routinely used in the assessment of acute postoperative pain. The measurement of postoperative pain: a comparison of intensity scales in younger and older surgical patients. Vysetrovani osob s algickymi syndromy a klinicke a experimentalni metody hodnoceni Incidence and intensity of bolesti (Examination of patients with pain and clinical and experimental pain assessment – in Czech). Working party of Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine. Most papers on postoperative pain begin by stating that, despite all available information and recommendations for the treatment of acute postoperative pain, there is still a high percentage of patients sufering from severe postoperative pain. It is a well-known fact that there are diferences in experiencing pain among various populations due to diferent genetics, as well as social and cultural background. Terefore, the results of these studies cannot be easily applied to countries with diferent conditions and traditions. For example, in the Czech Republic, one of the two earlier pilot studies carried out by the author has shown that, although patients felt less fear before surgery (35. In the second study, pain was the cause of signifcant negative experience after surgery in 36% of patients (in descending order: 51. According to a very recent study conducted at the same department (the results have not been published yet), there has been an improvement: severe postoperative pain was reported by less than 20% of respondents, none of them reported excruciating pain and 6 hours after surgery the incidence of severe pain fell below 10%. Intense pain immediately after surgery was a predictor of severe postoperative pain, which highlights the role of the anesthesiologist in the prevention of severe postoperative pain. It should be noted, however, that patient satisfaction with postoperative care itself is not a guarantee of adequate analgesia.
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Pathophysiology Persistent hyperglycemia causes osmotic diuresis discount 50mg minocin mastercard antimicrobial mouth rinse, resulting in water and electrolyte losses purchase minocin in india cowan 1999 antimicrobial. Although there is not enough insulin to buy genuine minocin on-line antibiotics for uti during first trimester prevent hyperglycemia, the small amount of insulin present is enough to prevent fat breakdown. This condition occurs most frequently in older people (50 to 70 years of age) who have no known history of diabetes or who have type 2 diabetes. Nursing Management See “Nursing Management” under “Diabetes Mellitus” and “Diabetic Ketoacidosis” for additional information. Fluid status and urine output are closely monitored because of Hypertension (and Hypertensive Crisis) 375 the high risk of renal failure secondary to severe dehydration. H Hypertension (and Hypertensive Crisis) Hypertension is deflned as a systolic blood pressure greater than 140 mm Hg and a diastolic pressure greater than 90 mm Hg, based on two or more measurements. Hypertension carries the risk for premature morbidity or mortality, which increases as systolic and diastolic pressures rise. Prolonged blood pressure elevation damages blood vessels in target organs (heart, kidneys, brain, and eyes). Essential (Primary) Hypertension In the adult population with hypertension, between 90% and 95% have essential (primary) hypertension, which has no identiflable medical cause; it appears to be a multifactorial, polygenic condition. Hypertensive Crisis H-1 Hypertensive crisis, or hypertensive emergency, exists when an elevated blood pressure level must be lowered immediately (not necessarily to less than 140/90 mm Hg) to halt or prevent target organ damage. Hypertensive urgency exists when blood pressure is very elevated but there is no evidence of impending or progressive target organ damage. Close hemodynamic monitoring of the patient’s blood pressure and cardiovascular status is required. Hypertensive emergencies and urgencies may occur in patients whose hypertension has been poorly controlled, whose hypertension has been undiagnosed, or in those who have abruptly discontinued their medications (see Box H-1). Secondary Hypertension Secondary hypertension is characterized by elevations in blood pressure with a speciflc cause, such as narrowing of the renal arteries, renal parenchymal disease, hyperaldosteronism (mineralocorticoid hypertension), certain medications, pregnancy, and coarctation of the aorta. Hypertension can also be acute, a sign of an underlying condition that causes a change in peripheral resistance or cardiac output. Clinical Manifestations • Physical examination may reveal no abnormality other than high blood pressure. Hypertension (and Hypertensive Crisis) 377 • Symptoms usually indicate vascular damage related to organ systems served by involved vessels. Medical Management the goal of any treatment program is to prevent death and complications by achieving and maintaining an arterial blood pressure at or below 140/90 mm Hg (130/80 mm Hg for people with diabetes mellitus or chronic kidney disease), whenever possible. Two classes of drugs are available as flrst-line therapy: diuretics and beta-blockers. Nursing Interventions Increasing Knowledge • Emphasize the concept of controlling hypertension (with lifestyle changes and medications) rather than curing it. Hypertension (and Hypertensive Crisis) 379 • Arrange a consultation with a dietitian to help develop a plan for improving nutrient intake or for weight loss. Gerontologic Considerations Compliance with the therapeutic program may be more difflcult for elderly people. The medication regimen can be difflcult to remember, and the expense can be a problem. Monotherapy (treatment with a single agent), if appropriate, may simplify the medication regimen and make it less expensive. H • Provide continued education and encouragement to enable patients to formulate an acceptable plan that helps them live with their hypertension and adhere to the treatment plan. Monitoring and Managing Potential Complications • Assess all body systems when patient returns for follow-up care to detect any evidence of vascular damage. Evaluation Expected Patient Outcomes • Maintains adequate tissue perfusion • Complies with self-care program • Experiences no complications For more information, see Chapter 32 in Smeltzer, S. Hyperthyroidism (Graves’ Disease) 381 Hyperthyroidism (Graves’ Disease) Hyperthyroidism is the second most common endocrine disorder, and Graves’ disease is the most common type. It results from an excessive output of thyroid hormones due to abnormal stimulation of the thyroid gland by circulating immunoglobulins. The disorder affects women eight times more frequently than men and peaks between the second and fourth decades of life. It may appear after an emotional shock, stress, or infection, but the exact signiflcance of these relationships is not understood. Other common causes include thyroiditis H and excessive ingestion of thyroid hormone (eg, from the treatment of hypothyroidism). Clinical Manifestations Hyperthyroidism presents a characteristic group of signs and symptoms (thyrotoxicosis). Assessment and Diagnostic Findings • Thyroid gland is enlarged; it is soft and may pulsate; a thrill may be felt and a bruit heard over thyroid arteries. H Gerontologic Considerations Elderly patients commonly present with vague and nonspeciflc signs and symptoms. The only presenting manifestations may be anorexia and weight loss, absence of ocular signs, or isolated atrial flbrillation. Use of radioactive iodine is generally recommended for treatment of thyrotoxicosis rather than surgery unless an enlarged thyroid gland is pressing on the airway. Thyrotoxicosis must be controlled by medications before radioactive iodine is used because radiation may precipitate thyroid storm, which has a mortality rate of 10% in the elderly.
Praziquantel is the drug of choice buy 50mg minocin with mastercard virus mask, with recommended dosage of 75 mg/kg per day order minocin 50 mg with visa bacteria joke, divided into 3 doses over 2 days (Pachucki et al 50 mg minocin overnight delivery antibiotic 7244 93. Geographical distribution Human paragonimiasis occurs in three endemic focal areas: Asia (P. Tere have been some reports of the disease in the United States of America during the past 15 years because of the increase in immigrants. Severity of chronic morbidity The chronic phase might embrace pulmonary manifestations such as cough, expectoration of discoloured sputum, haemoptysis and chest radiographic abnormalities. Flukes occasionally invade and reside in the pleural space without parenchymal lung involvement. Extra-pulmonary locations of the adult worms result in more severe manifestations, especially when the brain is involved. Extra-pulmonary paragonimiasis is rarely seen in humans because the worms migrate to the lungs, but cysts can develop in the brain and abdominal adhesions resulting from infection have been reported. Table 1 shows the number of cerebral infections in patients infected with paragonimiasis. Chronic illness fraction No reports could be found on chronic illness cases, but column 3 in Table 1 depicts an estimation of cases that might result in chronic infection. Increase in human illness potential Tere are many reports that show the increasing risk of illness potential in endemic regions. Many cases of eating roast crabs in the feld amongst schoolchildren have been reported, as well as frequent consumption of seasoned crabs by adult villagers, and papaya salad with crushed raw crab (Stanford University, no date; Song et al. Kung Plah, Kung Ten (raw crayfsh salad) and Nam Prik Poo (crab sauce) are popular and widely consumed dishes in Tailand. Kinagang, which is semi-cooked fresh-water mountainous crabs, are eaten as an appreciated dish in the Philippines. All these data show the increasing risk of the disease in regions where eating crab is a part of the culture. When live crabs are crushed during preparation, the metacercariae may contaminate the fngers or utensils of the kitchen staf. Accidental transfer of infective cysts can occur via food preparers who handle raw seafood and subsequently contaminate cooking utensils and other foods (Yokogawa, 1965). Consumption of animals that feed on crustaceans can also transmit the parasite, such as eating raw boar meat. Food preparation techniques such as pickling and salting do not neutralize the causative agent. In some countries, crabs are soaked in wine for 3–5 minutes, and so called “drunken crabs” are eaten by people or cats and dogs; hence it is an important risk factor for transmission of the disease (Yokogawa, 1965). In addition, raw or undercooked meat of paratenic hosts such as boar, bear, wild pig or rat, where juvenile worms can survive in the muscles for years, is also an important source of human infection. Trade relevance Paragonimiasis is a neglected disease that has received relatively little attention from public health authorities. Interest in Paragonimus species outside endemic areas is increasing because of the risk of infection through consumption of crustaceans traded far from their point of origin in today’s globalized food supply. Impact on economically vulnerable populations In many countries endemic for paragonimiasis, it is very difcult to change the habits of consuming raw or semi-cooked crabs and crayfsh. Unfortunately, in some poor countries involved with this disease, intersectoral collaboration between governmental sectors, such as agriculture, aquaculture, public health and education and fnance, is weak and this can cause an increase in the disease rate. Boil before eating: paragonimiasis afer eating raw crayfsh in the Mississippi River Basin. Global burden of human food-borne trematodiasis: a systematic review and meta-analysis. Food-borne trematodiases in Southeast Asia epidemiology, pathology, clinical manifestation and control. General information The genus Sarcocystis consists of obligate intracellular protozoan parasites with a two-host life cycle described as a prey-predator, herbivore-carnivore or intermediate-defnitive host relationship. Humans can serve as intermediate hosts for some species of Sarcocystis and as defnitive hosts for other species. Care must be taken to understand these roles and the potential sources of infection for each. In the intermediate host, sarcocysts develop in skeletal muscles, tongue, oesophagus, diaphragm and cardiac muscle, and occasionally in spinal cord and brain (Fayer, 2004a, b). Mature sarcocysts of diferent species vary in size from microscopic to macroscopic, and in the structure of the wall that surrounds 100s to 1000s of crescent-shaped bodies called bradyzoites. Afer fesh (meat) from the intermediate host is eaten by the carnivore defnitive host the sarcocyst wall is digested, bradyzoites are liberated and enter cells in the intestine. Each bradyzoite develops into a sexual stage and afer fertilization the oocyst stage is formed. Mature oocysts (containing two sporocysts each with four sporozoites) are excreted in the faeces and contaminate the environment. When a susceptible intermediate host ingests the oocysts in water or food they pass to the small intestine, where the sporozoites are released. Sporozoites penetrate the gut epithelium and enter endothelial cells in blood vessels throughout the body giving rise to several generations of asexual stages. The number of asexual generations and their primary sites of development difer for each species of Sarcocystis. Maturation varies with the species and can take 2 months or more until bradyzoites form and sarcocysts become infectious for the defnitive host.
Course and Curriculum of M D Medicine 105 Vital signs should be immediately recorded in the case sheet as soon as a resident examines a patient order minocin 50mg without prescription virus komputer. Resident should work up the patient in detail and be ready with the preliminary necessary investigations reports for the evening discussion with the consultant on call buy 50 mg minocin with amex antibiotics for uti and bladder infections. After clinical round generic 50 mg minocin fast delivery virus hitting schools, resident should plan out the investigation for the next day in advance, fill up the forms of the investigations and put them in the staff’s record book, after having apprised her. Responsibility of patients should be handed over to the doctor on call personally before returning for the day. No change is permissible unless it is by a mutual consent and in such event senior resident/consultant should be duly informed. The resident on duty for the admission day should know in detail about all sick patients in the wards, and relevant problems of all other patients, so that he could face an emergent situation effectively. In morning, detailed over (written and verbal) should be given to the next resident on duty. The doctor on duty should be available in the ward throughout the duty hours, except during meal times when he is preferably covered by a colleague or intern especially if any patient is critical. In case of New Admission/Transfer this is done usually with the knowledge of senior resident on call. If patient is sick the doctor on call should accompany the patient from the casualty or another ward. Patients in critical condition should be meticulously monitored round the clock and records maintained. Treatment alterations should be done by doctor on duty in consultation with the Senior Resident, and Consultant, if necessary. Discharge of the Patient Patient should be informed about his/her discharge about 24 hours in advance. It should be noted that this document is carried by the patient wherever he/she goes for consultation, or following up hence, incomplete or incorrect information should be avoided. Investigations should be properly written, giving dates and numbers of various pathological and radiological tests. Complete details of dietary advice (preferably with a diet chart), mobilization plan, and instructions regarding activity or exercise should be written, names of drugs, and dosage should be legibly written, giving the timing and duration of treatment. Discharge summary made by Junior Resident should be carefully checked and corrected by the Senior Resident and/or consultant. In Case of Death In case it is anticipated that a particular patient may not survive, relatives must be informed about the critical condition of the patient beforehand. In the event of death of a patient inform the nearest available relative and explain the nature of illness. Face sheet notes and must be filled up and the sister-in-charge should be requested to send the body to the Mortuary from where the patient’s relatives can collect the body. No death certificate is given to their relatives of the medico-legal from the wards. In case Autopsy is Required Autopsy should be attempted for all patients who have died in this hospital especially so if patient died of undiagnosed illness, unexpected deaths and in conditions where the diagnosis may have a bearing in the health of the relatives/hospital staff. The Junior Residents of Pathology on Course and Curriculum of M D Medicine 107 duty should be informed by page or written call, after checking their duty roster. Senior Resident and consultant of the medical unit should be informed about the autopsy. Resident should try to organize and expedite the process to ensure good compliance by the relatives. Bedside Procedure Various bedside procedures like pleural tap, ascetic tap, liver biopsy, and bone marrow examination etc. Rule out contraindications like low platelet count, prolonged prothrombin time, etc. Plan the procedure during routine working hours, unless it is an emergency special containers for collecting the material should be ensured before starting the procedure. Explain the procedure with its complications to the patient and his/her relative and obtain written consent on a proper form. Dispatch sample(s) in appropriately labeled containers with complete investigations forms, check if the payment for the investigation has already been made to the appropriate laboratories during the recommended hours. Make a brief note on case sheet with the date, time, nature or procedure and immediate complications, if any. Monitor the patient and watch for complication(s) Write the reports of the procedure performed with lab Ref. Academic Activities During Junior Residency, post Graduates is not only expected to provide proper patient care, he/she is also supposed to acquire academic knowledge and skills in the field of Internal Medicine. Case Discussions this is held twice a week with the unit consultants at a predetermined convenient time. Radiology Conference this is held in the radiology department once a week separately for each unit where all the radiological investigations of the admitted patients are discussed in detail. Mortality Conference this is held in the doctor’s duty rooms/seminar rooms once a week for each unit where the details of the patients who died the previous week are discussed. The objective of this activity is to understand the management of critically ill patients, identify administrative and personal lacunae and lapses if any, and provide future guidelines for similar patients. One resident prepares a 40 min discussion on an allotted topic under the guidance of a preceptor. Two departments (one surgical and one medical) present, for 30 min each an interesting case/procedure with brief review of literature. Faculty member from department of pathology follows up the discussion with the final diagnosis. Other Research Activities A resident is free to involve himself/herself with other ongoing research activities with any consultant of the department.