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Fistula ligation would decrease the contamination of the respiratory tract from the stomach menstruation more than 10 days purchase alendronate 70 mg on-line. The typical repair consists of a posterolateral thoracotomy on side opposite aortic arch pregnancy implantation symptoms buy 70 mg alendronate otc. We wait 6-12 weeks to menstrual 2 times a month buy cheap alendronate 35mg on line attempt to pregnancy signs cheap alendronate 35mg fast delivery repair these babies in order to achieve primary esophageal anastomosis. Bolus feeds are given to the babies in temporal synchrony with oral stimulation, to train them into associating feeding with feelings of satiety. Bolus feedings also enlarge the stomach, and potentially distends and elongates the distal esophageal remnant. If unable to achieve primary esophageal continuity and reluctant to do primary esophageal replacement, cervical esophagostomy can be performed. The proximal esophageal pouch brought out on left neck allowing salivary secretions to drain and not be aspirated into the lungs. An esophagostomy automatically buys an eventual esophageal replacement with stomach or colon. A Fogarty balloon catheter is inserted into fistula and passed into the esophagus. The most experienced person should intubate these babies since repeated intubations can damage either the tracheal or esophageal repair. When suctioning of salivary secretions is needed, the tip of the catheter should only reach the posterior pharynx proximal to esophageal anastamosis (shallow suctioning). Some surgeons prefer the patient’s neck to be slightly flexed to decrease the tension on the anastomosis. Other maneuvers to decrease the tension on the anastomosis include mechanical ventilation for 3-5 days, with chin-to-chest position. Notably, there are no data to support that these actually promote anastomotic healing. The drain is left in place until there is fluoroscopic confirmation that the anastomosis is intact and there is no leak. Alternatively, a small orogastric feeding tube can be passed at the time of the operation, and low volume feedings into the stomach. If a leak is seen, feeds are held until another contrast esophagram documents an intact anastomosis (usually 7 days 388 later). If the baby, shows discoordinated oral motor skills, he or she may need evaluation by speech therapy Evaluation for other anomalies should be completed. The wider the gap between the upper and lower esophagus portends higher leak rates. Leaks are documented during esophagrams scheduled at a pre-determined time after repair. In contrast, anastomotic disruptions are symptomatic and present with pneumothorax and/or hydrothorax. The leak from the anastomosis is large enough that the thoracic drain cannot handle the salivary secretions and swallowed air. It requires surgery to make certain that the area is adequately drained, and the lung is able to inflate fully. An attempt a re-doing the repair is usually not done, since the tissues are often friable and contaminated. Any leaks associated with esophageal anastomosis increases the likelihood of a stricture. Esophageal strictures are sually seen 2-6 weeks post-operatively and present with inability to handle secretions, apnea/bradycardia episodes (from oropharyngeal aspirations). The causes of strictures are multifactorial and may include anastomotic tension, local vascular insufficiency, and tissue fragility leading to leak. Baloon dilation is the current standard of care and may be required several times. Surgeons attempt to put intervening tissue or graft(Surgisys) between the tracheal repair and the esophageal anastomosis to prevent this complication. Tracheomalacia is one of the differential diagnoses in children with apenea and bradycardia episodes after definitive surgery. A rigid bronchoscopy in a spontaneously breathing child is required to make the diagnosis of tracheomalacia; the posterior trachea coapts with the anterior trachea during expiration. If tracheomalacia is severe, an aortopexy (aorta is pexed to the underside of the sternum) may be necessary. It is hypothesized that the distal esophageal dissection added to the cephalad pull on the distal esophagus straightens out the gastroesophageal junction, leading to increased reflux in this population. If reflux leads to recurrent aspiration pneumonias, significant apnea, emesis leading to failure to thrive, repeated episodes of anastomotic stricture, a fundoplictaion may be necessary. It is thought that this may be due to the natural disappearance of the right umbilical vein during the course of fetal development. Associated anomalies are rare except for intestinal atresia (10-15%) of cases Risk factors include maternal use of tobacco, salicylates, pseudoephedrine, or phenylpropanolamines during the first trimester. Management in the Delivery Room In the delivery room, an airway if infant in respiratory distress. The intestines should be handled gently making sure that the mesentery is straight. The bowel is placed on top of abdomen without tension to avoid impediment to venous drainage and to avoid inducing bowel edema and injury. The baby should be have his legs placed in a plastic bag (bowel bag) or if this is not 391 available, the bowel should be carefully wrapped in warm saline-soaked gauze. The baby’s position should be optimize position of baby (see above) Operative Decision Making In some institutions, the decision whether a primary fascial closure versus a silo closure is performed is determined the in the operating room. The decision whether the abdominal wall is closed or a silo is placed depends upon the physiologic ramifications of having the intestines inside. Post-operative Management: Primary Abdominal Closure: the baby is extubated as soon as possible. The baby requires sedation and pain medication about 15 minutes before the reduction. The baby’s ventilator settings may need to be temporarily increased during the reduction due to the sedation and increased abdominal pressure. Apply gentle pressure on the intestines, pushing the intestines about 2-3 cm during each reduction. Keep the silo vertical by securing the bag with another umbilical tape to the top of the bed. If a “giant” omphalocoele (>5 cm), C-section is warranted Incidence of omphalocele is ~ 1 in 6,000-10,000 live births Like gastroschisis, omphaloceles are now most commonly diagnosed prenatally. Unlike gastroschisis, the defect is contained within umbilical cord, unless ruptured. If the sac is not ruptured, carefully wrap herniated viscera in warm saline-soaked Kerlix. If a ruptured omphalocele is present, the initial management is similar to gastroschisis. Place the baby feet first into a “bowel bag” and tie the bag loosely around the axilla. A sepsis work-up should be considered, especially in ruptured omphalocele patients. Administration of intravenous antibiotics such as ampicillin and gentamycin should be considered. This should include a cardiac echocardiogram, renal ultrasound, and chromosomal studies. Operative Considerations If the defect is small (3cm or less), primary closure can be achieved easily. The baby with giant omphalocoele is often able to breathe without support and eat without any problems. If an omphalocele is closed in the early newborn period, specific attention should be paid when the globular liver is placed in the abdomen.

Indeed womens health 4 week fat blaster generic alendronate 70mg without prescription, as we shall see throughout the book pregnancy 0-2 weeks alendronate 35 mg sale, the molecular revolution has already identified mutant genes underlying a great number of diseases menstruation yoga sequence alendronate 70 mg discount, and the entire human genome has been mapped women's health big book of exercises download alendronate 70mg discount. Nevertheless, the functions of the encoded proteins and how mutations induce disease are often still obscure. Because of technologic advances, it is becoming increasingly feasible to link specific molecular abnormalities to disease manifestations and to use this knowledge to design new therapeutic approaches. For these reasons, the study of pathogenesis has never been more exciting scientifically or more relevant to medicine. The morphologic changes refer to the structural alterations in cells or tissues that are either characteristic of the disease or diagnostic of the etiologic process. The practice of diagnostic pathology is devoted to identifying the nature and progression of disease by studying morphologic changes in tissues and chemical alterations in patients. More recently, the limitations of morphology for diagnosing diseases have become increasingly evident, and the field of diagnostic pathology has expanded to encompass molecular biologic and immunologic approaches for analyzing disease states. Nowhere is this more striking than in the study of tumors — breast cancers and tumors of lymphocytes that look morphologically identical may have widely different courses, therapeutic responses, and prognosis. Increasingly, such techniques are being used to extend and even supplant traditional morphologic methods. The nature of the morphologic changes and their distribution in different organs or tissues influence normal function and determine the clinical features (symptoms and signs), course, and prognosis of the disease. Virtually all forms of organ injury start with molecular or structural alterations in cells, a concept first put forth in the nineteenth century by Rudolf Virchow, known as the father of modern pathology. We therefore begin our consideration of pathology with the study of the origins, molecular mechanisms, and structural changes of cell injury. Yet different cells in tissues constantly interact with each other, and an elaborate system of extracellular matrix is necessary for the integrity of organs. Cell-cell and cell-matrix interactions contribute significantly to the response to injury, leading collectively to tissue and organ injury, which are as important as cell injury in defining the morphologic and clinical patterns of disease. Overview: Cellular Responses to Stress and Noxious Stimuli the normal cell is confined to a fairly narrow range of function and structure by its genetic programs of metabolism, differentiation, and specialization; by constraints of neighboring cells; and by the availability of metabolic substrates. It is nevertheless able to handle normal physiologic demands, maintaining a steady state called homeostasis. More severe physiologic stresses and some pathologic stimuli may bring about a number of physiologic and morphologic cellular adaptations, during which new but altered steady states are achieved, preserving the viability of the cell and modulating its function as it responds to such stimuli (Fig. The adaptive response may consist of an increase in the number of cells, called hyperplasia, or an increase in the sizes of individual cells, called hypertrophy. Conversely, atrophy is an adaptive response in which there is a decrease in the size and function of cells. We will return to a detailed discussion of these pathways of cell death later in the chapter. Stresses of different types may induce changes in cells and tissues other than adaptations, cell injury, and death (see Table 1-1). Cells that are exposed to sublethal or chronic stimuli may not be damaged but may show a variety of subcellular alterations. Metabolic derangements in cells may be associated with intracellular accumulations of a number of substances, including proteins, lipids, and carbohydrates. Calcium is often deposited at sites of cell death, resulting in pathologic calcification. Finally, cell aging is also accompanied by characteristic morphologic and functional changes. In this chapter, we discuss first how cells adapt to stresses, and then the causes, mechanisms, and consequences of the various forms of acute cell damage, including cell injury and cell death. We conclude with subcellular alterations induced by sublethal stimuli, intracellular accumulations, pathologic calcification, and cell aging. Cellular Adaptations of Growth and Differentiation Cells respond to increased demand and external stimulation by hyperplasia or hypertrophy, and they respond to reduced supply of nutrients and growth factors by atrophy. In some situations, cells change from one type to another, a process called metaplasia. Some adaptations are induced by direct stimulation of cells by factors produced by the responding cells themselves or by other cells in the environment. Others are due to activation of various cell surface receptors and downstream signaling pathways. Adaptations may be associated with the induction of new protein synthesis by the target cells, as in the response of muscle cells to increased physical demand, and the induction of cellular proliferation, as in responses of the endometrium to estrogens. Adaptations can also involve a switch by cells from producing one type of proteins to another or markedly overproducing one protein; such is the case in cells producing various types of collagens and extracellular matrix proteins in chronic inflammation and fibrosis (Chapter 2 and Chapter 3). The cellular adaptation depicted here is hypertrophy, and the type of cell death is ischemic necrosis. In reversibly injured myocardium, generally effects are only functional, without any readily apparent gross or even microscopic changes. In the example of myocardial hypertrophy, the left ventricular wall is more than 2 cm in thickness (normal is 1 to 1. In the specimen showing necrosis, the transmural light area in the posterolateral left ventricle represents an acute myocardial infarction. All three transverse sections have been stained with triphenyltetrazolium chloride, an enzyme substrate that colors viable myocardium magenta. A, Gross appearance of a normal uterus (right) and a gravid uterus (removed for postpartum bleeding) (left). B, Small spindle-shaped uterine smooth muscle cells from a normal uterus (left) compared with large plump cells in gravid uterus (right). Figure 1-4 Changes in the expression of selected genes and proteins during myocardial hypertrophy. Figure 1-5 A, Atrophy of the brain in an 82-year-old male with atherosclerotic disease. B, Metaplastic transformation of esophageal stratified squamous epithelium (left) to mature columnar epithelium (so-called Barrett metaplasia). With continuing damage, the injury becomes irreversible, at which time the cell cannot recover. Is there a critical biochemical event (the "lethal hit") responsible for the point of no return However, as discussed later, in ischemic tissues such as the myocardium, certain structural changes. There are two types of cell death, necrosis and apoptosis, which differ in their morphology, mechanisms, and roles in disease and physiology (Fig. When damage to membranes is severe, lysosomal enzymes enter the cytoplasm and digest the cell, and cellular contents leak out, resulting in necrosis. Whereas necrosis is always a pathologic process, apoptosis serves many normal functions and is not necessarily associated with cell injury. Although we emphasize the distinctions between necrosis and apoptosis, there may be some overlaps and common mechanisms between these two pathways. In addition, at least some types of stimuli may induce either apoptosis or necrosis, depending on the intensity and duration of the stimulus, the rapidity of the death process, and the biochemical derangements induced in the injured cell. The mechanisms and significance of these two death pathways are discussed later in the chapter. Figure 1-8 Schematic representation of a normal cell and the changes in reversible and irreversible cell injury. Depicted are morphologic changes, which are described in the following pages and shown in electron micrographs in Figure 1-17. Reversible injury is characterized by generalized swelling of the cell and its organelles; blebbing of the plasma membrane; detachment of ribosomes from the endoplasmic reticulum; and clumping of nuclear chromatin. Transition to irreversible injury is characterized by increasing swelling of the cell; swelling and disruption of lysosomes; presence of large amorphous densities in swollen mitochondria; disruption of cellular membranes; and profound nuclear changes. The latter include nuclear codensation (pyknosis), followed by fragmentation (karyorrhexis) and dissolution of the nucleus (karyolysis). Laminated structures (myelin figures) derived from damaged membranes of organelles and the plasma membrane first appear during the reversible stage and become more pronounced in irreversibly damaged cells. Figure 1-9 the sequential ultrastructural changes seen in necrosis (left) and apoptosis (right). In apoptosis, the initial changes consist of nuclear chromatin condensation and fragmentation, followed by cytoplasmic budding and phagocytosis of the extruded apoptotic bodies.

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Large vitreous floaters are They can be differentiated from asteroid hyalosis also found after hemorrhage in the vitreous women's health and wellness issues purchase alendronate 70mg overnight delivery. They are composed of calcium-conscintillans taining phospholipids and represent asteroid hyalosis (asteroid bodies) menopause no period buy generic alendronate 70 mg on line. They produce little Laterality Unilateral Bilateral symptoms and occur often unilaterally womens health supplements generic 35mg alendronate mastercard. Asteroid Composition CalciumCholesterol crystals containing bodies are adherent to women's health for over 50 discount alendronate 70 mg otc the vitreous structure. The opacities may vary in size and are symptom-free before the eye usually unaffected by gravity. They seldom affect State of Gel Fluid the vision, but may cause difficulty in fundus vitreous examination. Asteroid bodies causing impairment Attachments Adherent Free of vision may be dealt with bimanual vitrectomy. The ocular features include proptosis, ophthalmoplegia, retinal hemorrhages, cotton-wool spots, exudates and perivasculitis. The vitreous opacities are classically linear with footplate attachments to the retina and posterior lens surface. The intravitreal amyloid deposits can be removed by vitrectomy with guarded prognosis. Diseases of the Vitreous 275 Degeneration and Detachment of Vitreous Vitreous gets degenerated when its gel structure is disrupted. As one gets older the hyaluronic acid concentration decreases, depriving the collagen fibers of their support. Besides senile vitreous degeneration, ocular trauma, high myopia, proliferative diabetic retinopathy and chorioretinitis may also cause vitreous degeneration and fluidity. The condition is diagnosed by the presence of freefloating opacities in the vitreous on slit-lamp examination or ophthalmoscopy. The eye with fluid vitreous runs a risk of complications if intraocular surgery is undertaken. They originate from the endothelial cells posterior vitreous from the internal limiting of the capillaries or from hyalocytes. This causes collagen meshthin tissue may cover the inner retinal surface, the work to collapse and move forward, a phenoepiretinal membrane. It is coagulation or cryopexy of retina is indicated if a characterized by a persistent hyaloid system break is detected. A two monthly follow-up is desirable Hemorrhage into the vitreous cavity may occur to assess the progress in clearance of the vitreous due to various causes, the important ones are as hemorrhage. If the blood does not absorb within follows: six months and the patient has visual acuity less 1. The cyst has to be removed by pars plana vitrectomy Clinical Features (See video). The vitreous hemorrhage may be found either in the subhyaloid space or in the vitreous cavity or, Prepapillary Vascular Loops sometimes, in both. The subhyaloid blood moves with gravity and appears boat-shaped because it Prepapillary vascular loops are normal retinal remains unclotted for a long time. When blood in vessels, mainly arterial, that extend in Bergmeister’s the vitreous cavity clots, it becomes a white opaque papilla before returning to the optic disk. Sudden onset of floaters, diminution of vision or near complete loss of vision are the common symptoms. All cases of vitreous hemorrhage should be carefully examined using an indirect ophthalmoscope. Complications Recurrent vitreous hemorrhages may lead to degeneration of vitreous, tractional retinal detachment, hemolytic or ghost cell glaucoma and hemosiderosis bulbi. Treatment Some of the cases of vitreous hemorrhage show significant improvement by bed rest, eye patching Fig. Diseases of Vitreous and fibroglial tissue emanating from the optic nerve Vitreoretinal Interface. Vitreoretinal loops may cause vitreous hemorrhage and branch Disorders: Diagnosis and Management. In fact, the retina is a part of the brain and develops from the optic vesicle, an outgrowth from the forebrain. The outer wall of the vesicle forms the retinal pigment epithelium and the inner, the neurosensory retina. The retina, a thin transparent membrane, lies between the choroid and the hyaloid membrane of vitreous. It extends from the optic disk to the anterior end of the choroid where it has a serrated termination known as ora serrata. The retina comprises photoreceptor cells, a relay layer of bipolar cells and ganglion cells and their axons that run into the central nervous system. Microscopically, the retina from without inwards is made up of following ten layers (Fig. Diseases of the Retina 279 the rods and cones are the end organs of vision and are photosensitive (Fig. There are well-developed vertical fibers of Muller which have supportive as well as nutritive functions. The internal limiting membrane separates the retinal nerve fiber layer from the vitreous, while the external limiting membrane is perforated by the rods and cones. At the posterior pole there is a circular area which appears darker than the surrounding retina—macula lutea. It is approximately 2 disk diameters away from the temporal margin of the optic disk and about 1 mm below the horizontal meridian. The fovea centralis is a highly differentiated spot where only cones are present and the other layers of the retina are almost absent (Fig. The blood supply of inner layers of retina comes from the central retinal artery and its branches. Since by diffusion from the choriocapillaris as well as neurosensory retina is a delicate and loosely by the retinal vascular system. The venous drainage of inner layers of the retina is through attached membrane, it is prone for separation or the retinal veins that do not exactly follow the detachment. The retina fails to develop in the mmatory, degenerative, infiltrative and neoplastic region due to non-closure of the optic fissure. The myelination of the optic nerve progresses from the brain towards the periphery and stops at the Hyperemia of the Retina lamina cribrosa. It is usually completed shortly Hyperemia of the retina may occur due to either after birth. However, occasionally some of the inflammatory lesions of retina and choroid or nerve fibers near the optic disk become myelinated venous obstruction. The venous hyperemia is that on ophthalmoscopic examination appear as characterized by dilatation and tortuosity of the white patches with feathery margins covering the veins and seen in central retinal vein occlusion, retinal vessels and are termed as opaque nerve fibers papilledema, congestive cardiac failure and or medullated nerve fibers (Fig. Congenital Pigmentation of the Retina Anemia of the Retina It is not rare to see small, oval, gray or black polygonal spots in the retina lying below the Anemia of the retina is commonly found in central vessels which are labeled as congenital pigmentation retinal artery occlusion, quinine poisoning and of the retina. They occur due to abnormal heaping spasm of the retinal arteries due to toxemia of of the retinal pigment epithelium. It can be a local expression of profuse Diseases of the Retina 281 hemorrhage, severe anemia and arteriosclerosis. Fluoreswhite-centered hemorrhages (Roth’s spots) are the cein angiography demonstrates abnormal permecharacteristic features. Cystoid show constriction in hyperoxemia (oxygen macular edema may develop following ocular concentration in the blood is high) and dilatation surgeries like cataract extraction (Irvine-Gass in hypoxemia. It is Edema of the Retina less frequent following extracapsular lens the retinal edema may be diffuse or localized. The extraction than the intracapsular cataract extracdiffuse retinal edema renders the bright red retina tion. A macular reflex and edema of the macula with multiple star may be found in hypertensive retinopathy and cystoid spaces giving a honeycomb appearance papilledema. The shows an area of hyperfluorescence giving a central vision is usually diminished and later flower-petal appearance in the late phase of pigmentary changes appear at the macula causing angiogram (Fig. Coats’ disease or exudative retinopathy of Coats is an uncommon uniocular condition mostly Retinal Hemorrhages found in young males. It is characterized by telangiectatic blood vessels, multiple small the retinal hemorrhages are either intraretinal aneurysms and varying amount of yellowish(within the tissue) or preretinal. The hemorrhages white exudates and hemorrhages near or temporal assume a characteristic appearance according to to the fovea.

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The objective is to menstruation through history purchase alendronate 35mg visa introduce students to menopause 52 years old alendronate 70mg fast delivery the method of collating the clinical features of common surgical problems women's health clinic macquarie fields buy alendronate 70mg overnight delivery, utilizing the deductions so obtained to breast cancer recurrence alendronate 70mg otc determine relevant investigatory and treatment procedures in the management of surgical disease. Intermediate Surgery Posting the aims are: to consolidate the knowledge which the student had obtained in the course of the Junior Surgery Posting and to enhance his skill in the correlative application of pathology, clinical and investigative diagnosis and the treatment of general diseases General Surgery & Urology Instructional Topics the face, mouth and tongue the Neck. Senior Surgery Posting in Major Surgical Specialties this posting is designed to enable the student absorb the biological concept as it is applicable to the clinical management of surgical diseases in the sub-specialties of General Surgery, Urology, Orthopaedic Surgery, Paediatric Surgery, Dentistry, Plastic and Reconstructive Surgery, Thoracic and Vascular Surgery as well as in Neurosurgery. Senior Surgery Posting Instructional Topics Orthopaedics: Fractures and dislocations, Infections of Bones and Joints, Bone Tumours, Congenital disorders of musculo-skeletal system, Rheumatic disorders of the musculoskeletal system, Amputation and limb substitution, Re-implantation of the extremities, Multiple injured patient (at the Site; Removal; Transit to Hospital; Triage, Blood Conservation & Replacement; Rehabilitation), the Hand, Infections of the musculo-skeletal system in the tropics Paediatric Surgery: Paediatric Surgery, Respiratory Distress, Congenital Disorders in Neonates and Children, Acute Abdomen in Children, Neoplasm in Children, Surgical Care in Sickle Cell Disease, Early Diagnosis of Congenital Lesions. Plastic and Reconstructive Surgery: Diagnosis and Management of Burns, Pathological Processes of the Epidermis, Malignant Tumours of Fibrous Tissue, Cancer of the Skin, Superficial Lumps, Principles of Skin Grafting and Skin Transportation, Alternatives to Skin Cover. Thoracic and Vascular Surgery: Disorder of the Lymphatic System, Disorders of the Veins, Pulmonary Embolism, Surgery of the Arteries, Aneurysms, Thrombo-Obliterative Disease of the Aorta and its branches, Surgical Disorders of the Lungs, Pleura and Chest Wall, 43 Bronchoscopy, Thoracic Trauma, Lung Abscess, Bronchiectasis, the Pleura and Empyema, Surgical Treatment of Pulmonary Tuberculosis, Tumours of the Respiratory System, Thoracic Outlet Syndrome, Congenital Disorders of the Chest Wall, Surgical Disease of the Mediastinum, Cardiac Surgery, Cardiac Catheterisation, Cardio-respiratory Arrest: Prevention, Diagnosis and Management, Congenital Anomalies of the Heart and Great Vessels, Acquired Disorders and Cardiac Valvular Disease, Cardiac Neoplasms, Cardiac Pacemakers, Assisted Circulation. Neurosurgery: Diagnostic Techniques in Neurosurgery, Spontaneous Intracranial Haemorrhage, Cranio-cerebral Trauma, Intracranial Infections, Intracranial Tumours, Spinal Disc Disorders, Spinal Infections, Spinal Tumours, Spinal Trauma, Peripheral Nerve Injury, Congenital Disorders in Neurosurgery, Neurosurgical Relief of Pain, Neurosurgical Treatment of Epilepsy, Principles of Stereotactic Neurosurgery. Senior Surgery Posting (Specialties Posting) During this period, the student will be expected to acquire knowledge and relevant basic skills in the diagnosis, investigation and treatment of conditions and diseases in the specialties of anaesthesia, ophthalmology and otorhinolaryngology. For a period of eight weeks, he will perform duties as a Junior House Surgeon” in the care of patients in the wards and as a junior Casualty Officer” in the reception and care of surgical emergencies. It is a period for the student to consolidate fully the knowledge and skill he has acquired in surgical training to enable him emerge into the profession as a confident and competent house surgeon. During the specialties posting in Surgery, the student would be expected to acquire skills in the following procedures. Anaesthesia Introduction to Anaesthesia including the Roles of the Anaesthetist in Resuscitation, Operative Management, Intensive Care and Pain Management Pre-operative Assessment, Preparation and Pre-medication. During the course of training in Ophthalmology, the student would be expected to acquire skills in the following procedures. Obstetrics and Gynaecology Objectives At the conclusion of his programme in Obstetrics & Gynaecology, the medical student would have acquired knowledge, skills and attitudes which would enable him to: Appreciate the principles and practice of the speciality of obstetrics and gynaecology on the basis of the biology of human pregnancy, labour and puerperium. Instructional Topics in Gynaecology Applied Anatomy of the Female Genital Tract Ovarian structure and function. Course Content Introduction to Paediatrics (a) Lecture/Tutorials these are aimed at providing the student with basic knowledge of the discipline for general practice. These lectures cover a wide range of selected topics in Paediatrics to include general principles and practice Paediatrics, preventive Paediatrics, growth and development (from infancy to adolescence) including growth condition monitoring and pathological states in paediatrics in all systems. A student is expected to clerk and if possible present, at least 6 cases per posting. The student, on Ward Round Day, should present the patient he/she clerked to the Consultant, and follow up the patient’s progress till discharge. They also must pay visits to the Under-Fives Clinic, where they are individually expected to perform such functions as: Immunization procedures Assessment of nutritional status of children Anthropometry, and giving nutritional advice to mothers Conduct seminars on environmental and social factors related to child health Acquire competence in the rudiments of prevention and management of physical handicap in children as well as rudiments of management and competent referral of children who have significant variations in intelligence. Instructional Topics in Primary Care Poisons and Accidents Kerosene ingestion Household accidents – Burns. Diseases of the Respiratory System Acute infections of the respiratory tract Chronic respiratory conditions: o Bronchial asthma o Pulmonary tuberculosis. Disease of the Genitourinary Tract Developmental and structural anomalies of the genitourinary tract Urinary tract infections. Diseases of the Central Nervous System Acute infections: meningitis, encephalitis, etc Hydrocephalus: causes and complications. Mental Health General Objectives Every medical school should aim at the establishment of a Department of Psychiatry or Mental Health and have attached to it a separate ward facility for short term care of acute psychiatric patients. Such facilities help to give students the general orientation to psychiatric care, liaison practice and inter-relatedness of disciplines, and it stimulates appropriate faculty development. Departments of Psychiatry should play an active role in the teaching, research and development of communication skills and interpersonal relationships especially of the doctor-patient relationship and in the provision of Mental Health Services at the Primary Health Care level. Departments of Psychiatry should also establish links with long stay psychiatric institutions in the locality, so as to offer students exposure to the full range of mental health services. About eight (8) weeks are actually required to teach psychiatry in medical school. Students should have had a course in Medical Psychology (or Behavioural sciences) in preclinical years. Exposure during Training Students should participate in clerking, physical and mental status examinations, psychological testing and laboratory investigation of patients. Students should see a range of patients including those typically managed in primary care, general hospital, and community based clinics as well as those treated in psychiatric facilities. They should have the opportunities of visiting long stay psychiatric institutions and institutions for persons with intellectual disability and other disadvantaged children. Students should participate in the clinical management and community based care of patients. Course Objectives the acquisition of appropriate attitudes is of primary importance. It is important that the objective of imparting these attitudes is in the teacher’s mind throughout his interaction with students. However, each school should have a clear plan that ensures that the necessary attitudes have been acquired by the time the students graduate. It is important that students develop appropriate attitudes to psychiatry as a medical discipline. These attitudes will be encouraged particularly during the teaching of psychiatry but it is important that they are not negated during the teaching of other subjects. Psychiatric symptoms and syndromes, and their treatment, are to be taught and learned in the context of an integrated biological, psychological and social approach. They include the skills of: o “active listening”, empathy, non-verbal communication, o opening, controlling and closing an interview, o Information gathering skills, taking a history of patient’s complaints and a life history, conducting a physical examination, assessing the functioning of the patient’s family and assessing the patient’s family’s ability to contribute to the patients’ care 54 o Information evaluation skills Select the crucial pieces of information for making a diagnostic formulation and undertake a differential diagnosis Make a personality assessment Evaluate the role of personal and social factors in the patient’s behaviour Formulate a plan of management which includes the points at which referral to a specialist will be appropriate. The contributions of the following: Hippocrates, Paracelsius, Philippe, Adeoye Lambo etc. Disturbances of motor functions, disorders of thinking, disturbances of perception, disturbances of cognition. Abuse, dependence, induced psychosis and intoxication; Psychological and biological theories of substance use. Psychodrama Principles of psychiatric care in non-psychiatric settings and in the community. Community Health and Primary Health Care For effective functioning, the training of medical under-graduates must be community based, community oriented and integrated on problem solving basis, bringing together, as much as possible, all disciplines in the field of Medicine. Aims and Objectives the overall aims of the undergraduate training in Community Health must be: To introduce to the students the concept of community health and its relevance in the health care delivery system of Nigeria. Social Medicine, International Health, Family life and 4th Year Reproductive Health, Clinical Dietetics, Group Dynamics, Integrated Primary Health Care posting, Seminars and Tutorials. Introduction to Primary Health Care Concept: Objectives To introduce the students to the objectives, concepts, and organization of primary health care, within the global social movement of “Health for all by the year 2000” History of Primary Health Care Objectives of Primary Health Care Components of Primary Health Care Organisation of primary Health Care Implementation machinery for Primary Health Care Introduction to Demography Sources of population data Sources of health and vital statistics Measurement of health and disease 58 Measurement of fertility and mortality Standardization of vital rates Population dynamics, structure and growth Interaction between medical action and population Health and population growth Principles and Methods in Health Promotion and Health Education the identification of Living Needs Planning Health Education for Individuals, Groups and Communities the Principles of Communication Selection and Production of Appropriate Audiovisual Aids Field Activities Objectives: To introduce the students to the community and sensitize them to community health needs problems whilst also displaying to them the ecological interplay between man and his total environment. Specific Learning Objectives of the Field Activities Identify and interview the important people in the community. Second Year Teaching Programme Principles of Epidemiology History and Definition of Epidemiology Spectrum of Health and Disease. School Health Administration Objectives of School Health Administration Components of School Health Programmes the Healthful School Environment Schools and the Community Health System Inferential Biostatistics Introduction to probability theory and inductive statistics; Statistical significance of a difference; Tests of significance o Normal Distribution o Z-test o Students t-test o Binomial test o Chi Square test. Public Health Nutrition Nutrition and Health Epidemiology and Control of Common Nutritional Problems in Nigeria Infection and Nutrition Nutritional Values of Common Nigerian foodstuff Food Policy, Hygiene and Toxicology Nutritional Requirements during Pregnancy, Lactation, Infancy and Childhood Through Adolescence and Relationship to Disease Conditions Assessment of Nutritional Status Nutrition Education Health Economics Sources of Health Care Funding National Health Care Financing National Health Insurance Scheme 61 Epidemiology of Zoonosis Definition and types of Zoonosis Prevention and Control of Common Zoonoses Rabies, Brucellosis, Anthrax, etc. Fourth Year Teaching Programme Social Medicine History of Social Medicine; the underprivileged members of society; Classification and causes of Disabilities; Programmes for Persons with Disabilities; Social Welfare Services in Nigeria and other countries. International Health Origins and Development of International Health; the World Health Organization; International Health Regulations; Other Government and Non-governmental Organisations involved with international Health. Objective To introduce the students to the concept of Primary Health Care and to instill in them the technical and managerial skills, attitude and knowledge to operate at the primary health care level. Course Content Each student on qualification must have: A thorough understanding of the principles and concepts of primary health care and how to apply them in the provision of the services. These include stating the skills to perform the tasks required at community and health centre levels and the staff required to carry them out. During the period, students shall be required to gain experience in the following areas: Family Health (Maternal and Child Health/Family Planning) Immunization against common communicable diseases Health Management General Medical practice (Curative medical services) Community Mobilization and Health Education Environmental Health provision of potable water and hygienic disposal of all wastes Promotion of Nutrition, including Agricultural Extension Activities. Family Medicine the aim of the course in General Medical Practice/Family Medicine is to make the medical students aware that a properly trained doctor is basically equipped to initiate appropriate and effective management of human ailments irrespective of which ever specialty the patient would eventually end up in.

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