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This concept of deconstructing the abilities of a professional into parts antibiotic prophylaxis for dental procedures roxithromycin 150 mg buy on line, called competencies, was first described over 60 years ago as a way to focus on the outcome of an education program. Competency-based medical education refers to an "outcomes-based approach to the design, implementation, assessment, and evaluation of medical education programs, using an organizing framework of competencies. The term competent refers to "possessing the required abilities in all domains in a certain context at a defined stage of medical education or practice. Focus on outcomes: this includes ensuring that every graduate is prepared for practice and that they are competent in all domains of their intended practice. Emphasis on abilities: Curriculum is organized around competencies or abilities rather than long lists of knowledge objectives. The terms competence and competency can be confusing when one considers the spectrum of performance of a given practitioner. An intern may be competent (has the ability) to insert the nasogastric tube (the competency), but may not be an expert at the procedure. In addition, one may be competent at one point in time, but not maintain competence, or can be competent to perform a task in one setting but not another. One might also be competent under ideal circumstances without pressure or stress, but not maintain the same level of competence in urgent or emergent situations. The deconstruction of the work of a physician to six core competencies (patient care, medical knowledge, professionalism, interpersonal and communication skills, systems-based practice, and practice-based learning and improvement) occurred after considering 84 potential physician competencies in 13 categories. Two of the competencies (Systems-Based Practice and Practice-Based Learning and Improvement) can be difficult to understand based on their name alone, especially for individuals who have not used those terms in other settings. Examples of how the work of an anesthesiologist can be described by competencies are provided in Table 9-9. Key structural elements of the Anesthesiology Program Requirements are listed in Box 9-4. The widespread adoption of the competency model was accompanied by a proliferation of assessment tools to assess resident achievement of the competencies. In phase 2, programs integrated competencies into their curriculum and assessment. In phase 3, programs were to use resident performance data as a means for program improvement. Chapter 9: Teaching Anesthesia 219 whether the six general competencies can be measured independently of one another in a reliable and valid manner. Instead, the available assessment tools related to several different competencies. For example, one large study examined global evaluations from more than 1300 residents in 92 specialties. The two factors were described as "medical knowledge, patient care and systems-based care" and "interpersonal communication skills and professionalism. Second, the behavior of a learner in a workplace-based assessment, such as direct observation, may be influenced by their knowledge of being observed and may not necessarily reflect their actual behavior. In health care, the model has been adapted to describe both physician and nursing skills acquisition. For individuals to progress to the expert stage, they need supervision, training, and opportunities for deliberate professional practice. Miller, a widely respected medical education researcher, acknowledged that "no single assessment method can provide all the data required for judgment of anything so complex as the delivery of professional services by a successful physician. Finally, another implication is that if a learner does a skill appropriately and successfully, that level of skill has been attained and can be applied to all practice settings. An example of a patient care milestone for various levels of anesthesia residents is shown in Table 9-12. Each rotation should have specific goals and learning objectives, as well as teaching and assessment methods and educational resources. As a resident advances through training, the rotations should become progressively more challenging. The resident should also assume progressive responsibility for patient care and be appropriately supervised during the entire training period.

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After her delivery virus island walkthrough order roxithromycin without a prescription, she breastfed for 6 months, and during this time she had scant and irregular vaginal bleeding. After stopping breastfeeding 6 months ago, she notes the absence of menses, but instead has monthly painful cramping, which seems to be getting worse. She remarks that prior to her pregnancy, she had normal, regular menses, which were not too heavy or painful. She and her husband would like to have another child, and have been having unprotected intercourse for the past 6 months without achieving a pregnancy. You perform a physical examination, which is normal other than a slightly enlarged, tender uterus. Inform your patient that unfortunately, she is "barren" and will not be able to carry a pregnancy again What obstetrical complication might you be concerned about for your patient in her next pregnancy Placenta accreta An 18-year-old young woman presents to your office with a complaint of amenorrhea. She notes that she has never had a menstrual period, but that she has mild cyclic abdominal bloating. Pelvic examination reveals normal appearing external genitalia, and a shortened vagina ending in a blind pouch. Which of the following tests would be your first step in determining the diagnosis Diagnostic laparoscopy You perform a bedside ultrasound and find normal appearing bilateral ovaries as well as an absent uterus and fallopian tubes. Vignette 3 A 15-year-old female adolescent presents to your office with primary amenorrhea. She has noticed that she has not developed breasts or pubic hair like her friends at school have, and this is frustrating to her. Physical examination confirms the absence of secondary sex characteristics, and auscultation of the chest reveals Vignette 2 A 32-year-old G1P1001 woman presents to your office with the chief complaint of amenorrhea since her most recent vaginal delivery 1 year ago. She notes that she had an uncomplicated pregnancy, followed by 288 Clinical Vignettes · 289 a harsh systolic murmur. Pelvic examination reveals normal appearing female external genitalia and a normal vagina, with a palpable uterus on bimanual examination. Serum estradiol Suddenly you remember from medical school that there are other medical predispositions that Turner patients have, and you order all of the following tests except: a. The patient notes that what bothers her most is her lack of breasts and absent pubic hair. Estrogen alone Five years later, at age 20, your patient returns to your clinic for an infertility consultation. She has had surgical repair of her aortic coarctation, and has been on oral contraceptive pills for the last 2 years for hormone replacement. She is followed by an internist who reports that all other systems (hepatic, renal, etc. Stop the birth control pills because they are preventing spontaneous conception c. In vitro fertilization She reports that she eats a healthful diet and has been running approximately 15 miles per week with her cross-country team for the past year. She states that running is her "passion" and sometimes she puts in a few extra miles to blow off stress from her classes. Physical examination reveals a thin, athletic female with normal breast development and normal secondary sex characteristics. Pelvic examination reveals normal external genitalia and on bimanual examination, you palpate a small, anteverted uterus with no adnexal masses. What findings would you expect to see on laboratory testing in a patient with premature ovarian failure No further testing is necessary What therapy would you first initiate with this patient Vignette 4 A 19-year-old female college freshman presents with amenorrhea for the past 8 months. She states that she had normal menarche at age 12, and initially had irregular menses for the first few cycles, but they became regular quickly, and had been normal until 8 months ago. She denies sexual activity, has had no sexually transmitted infections, and is otherwise healthy with no past medical problems or surgeries. Iatrogenic amenorrhea A Answers contraindicated) given immunosuppressive medications needed for the success of the transplant; this is not currently an available therapy for women with Müllerian agenesis. Intrauterine adhesions caused by prior obstetric procedures (typically dilation and curettage) obstruct the uterine cavity and cause cyclic pain and (in some cases) secondary amenorrhea. Vignette 2 Question 2 Answer A: the correct answer is to offer surgical management with hysteroscopy to resect the scar tissue within her uterine cavity, which would allow the patient relief from her cyclic pain (by releasing the obstructed menstruation), and additionally would assist her in attaining a more hospitable uterine cavity for future pregnancy. Inducing a withdrawal bleed with Provera would not improve her obstructed flow or increase her fertility.

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Assessment of incidence of severe sepsis in Sweden using different ways of abstracting International Classification of Diseases codes: difficulties with methods and interpretation of results antibiotic resistance risk factors generic 150 mg roxithromycin with mastercard. Stage migration and new diagnostic techniques as a source of misleading statistics for survival in cancer. Declining case fatality rates for severe sepsis: good data bring good news with ambiguous implications. Hospitalizations, costs, and outcomes of severe sepsis in the United States 2003 to 2007. Association of diagnostic coding with trends in hospitalizations and mortality of patients with pneumonia, 2003­2009. The implications of long-term acute care hospital transfer practices for measures of in-hospital mortality and length of stay. Mortality related to severe sepsis and septic shock among critically ill patients in Australia and New Zealand, 2000­2012. Chapter 3 Epidemiology of Sepsis: Current Data and Predictions for the Future Bashar Staitieh and Greg S. Martin Introduction the history of sepsis is deeply intertwined with advancements in the study of infectious diseases. Modern discussions of sepsis have focused on the importance of early recognition and treatment of the disease. In this chapter, we will focus on the epidemiology of sepsis in the light of its changing patterns over time across the globe. Incidence and Outcome of Sepsis the consensus definition of sepsis has enabled investigators to study the incidence of the disease through time in different settings. Surveys have been conducted in many, if not most, developed and undeveloped nations and offer a few general points to review before delving into specific cohorts (Table 3. Furthermore, large studies of administrative data sets that rely on coding for surrogates of sepsis. One notable attempt to study the epidemiology of sepsis specifically in an academic setting was undertaken by Sands et al. In a study of eight academic medical centers in a prospective observational trial, the 3 Epidemiology of Sepsis: Current Data and Predictions for the Future 27 authors found an incidence of sepsis of 2. Census data and estimated the incidence of severe sepsis in the United States at 300 cases per 100,000 people (studies of cohorts outside the United States have often found a lower incidence, as discussed below). Several studies have attempted to ascertain the prevalence of sepsis within intensive care units generally. More recently, another study of sepsis trends in the United States by Kumar et al. Mortality rate decreased from 39% to 27% and hospital length-of-stay decreased 28 B. Many other studies from across the world (some discussed below) have found similar evidence of increasing incidence of sepsis over time as mortality rates continue to decrease. Many explanations have been offered for these findings, notably the increasing use of immunosuppressive medications for organ transplantation and chemotherapy, as well as changes in coding rates of organ dysfunction over time. In any case, these trends are expected to continue for the foreseeable future, particularly in industrialized nations. While administrative databases do carry the caveats described above, one recent study by Stevenson et al. Despite that, wide variability exists depending on the method used to study the incidence of sepsis, as shown in a study by Gaieski et al. Additionally, as billing codes and quality improvement data are increasingly used to identify sepsis, septic shock, and its mortality, incentives to record or not record these data increase. An attempt to validate the use of administrative data in epidemiologic studies of sepsis was published by Iwashyna et al. The authors conclude that 3 Epidemiology of Sepsis: Current Data and Predictions for the Future 29 Angus implementation is a reasonable but imperfect method for identifying patients with severe sepsis. The improvement in mortality rates over time may be due in part to the development of bundled care plans for septic patients.

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Therefore virus hitting kids purchase roxithromycin 150 mg on-line, persistent abnormal bleeding, even in the setting of normal imaging warrants a tissue diagnosis for women 45 and those at risk for malignancy regardless of age. These levels can also be followed postoperatively to assess the effectiveness of treatment. An up-to-date Pap smear should also be obtained in women with abnormal bleeding although only 30% to 40% of patients with endometrial cancer will have an abnormal Pap smear. These cytology reports are particularly concerning when atypical endometrial cells are found. A pelvic ultrasound should also be performed to look for fibroids, adenomyosis, polyps, and endometrial hyperplasia. As a result of these early symptoms, most endometrial cancers are diagnosed at an early stage (Table 29-3). Pelvic pain, pelvic mass, and weight loss are seen in women who present with more advanced disease. The clinician should look for signs of metastatic disease, including pleural effusion, ascites, hepatosplenomegaly, general lymphadenopathy, and abdominal masses. In more advanced stages of the disease, the cervical os may be patulous, and the cervix may be firm and expanded. The adnexae should be carefully examined for evidence of extrauterine metastasis and/or coexistent ovarian carcinoma. This may include menorrhagia, metrorrhagia, menometrorrhagia, postcoital spotting, or even oligomenorrhea. The differential diagnosis for premenopausal bleeding includes uterine fibroids, endometrial polyps, adenomyosis, endometrial hyperplasia, ovarian cysts, and thyroid dysfunction. Note that endometrial cancer is 386 · Blueprints Obstetrics & Gynecology pelvic washings, pelvic and para-aortic lymph node resection, and complete resection of visible tumor for all stages of the disease (Table 29-7). Exceptions to complete surgical staging are young women with grade I endometrioid carcinoma who desire future fertility or women with a high-mortality risk related to surgery. When practical and feasible, referral to a gynecologic oncologist is recommended in order to facilitate the most appropriate treatment modality. These patients and those with other poor prognostic factors such as large tumor mass (. Postmenopausal women with an endometrial stripe less than or equal to 4 mm are unlikely to have endometrial hyperplasia or cancer. Likewise, even if another potential source for bleeding is identified, the endometrium must still be sampled. This system relies on pathologic confirmation of the extent of spread of the disease (Table 29-6). The presence of certain high-risk features (Table 29-8) confers a higher risk of recurrence and lower survival rates. If without evidence for recurrent disease, the patient can likely be followed annually. Treatment options for recurrent disease are radiotherapy (if not previously radiated), chemotherapy, or highdose progestin therapy (Table 29-7). These therapies, typically megestrol (Megace) or medroxyprogesterone (Provera), have been used with a 30% response rate and minimal side effects. However, at this time, it is usually reserved for those patients whose cancer was well differentiated and minimally invasive. Type I endometrial cancers can be caused by prolonged exposure to exogenous or endogenous estrogen in the absence of progesterone. Other types have poorer prognosis, including papillary serous and clear cell carcinomas. Endometrioid cancer is diagnosed at a median age of 61 with 25% of patients being diagnosed premenopausally and 75% postmenopausally. The major risk factors for type I endometrial cancer include unopposed estrogen exposure, endometrial hyperplasia, obesity, chronic anovulation, nulliparity, and late menopause. Currently, there are no cost-effective screening tools for endometrial cancer; however, because of abnormal bleeding, most women are diagnosed early with 75% of lesions being at stage I at the time of diagnosis. Advanced or recurrent disease can be treated with chemotherapy or high-dose progestin therapy. Overall 5-year survival rate is 65% with 85% to 100% of recurrences occurring in the first 3 years after treatment.

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