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Since this is usually a medication side effect discount generic cialis canada impotence grounds for divorce, your doctor will usually lower the strength (dose) or your medications buy 10 mg cialis amex erectile dysfunction causes weight. Sometimes cheapest generic cialis uk impotence questionnaire, though order 2.5 mg cialis free shipping erectile dysfunction natural, when medications are stopped or adjusted, your movement problems can become worse. This way, they can make sure that your health care team is aware and you can get the help you need. Almost all people with Parkinson’s will have changes in the ability to smell, and 1 out of 3 people will have no sense of smell at all. You may also notice changes in taste, as your sense of smell is directly linked to taste. People do not often notice these changes right away as they come on slowly over time. This is caused by dying cells in areas of your brain that control your sense of smell. Also, since you may not be able to smell some dangerous odors, be sure that your smoke detectors are installed and are always in good working order. Nausea refers to an uneasy Nausea usually begins when starting stomach and the feeling that you a new medication. You may also have away on its own with time (even a stomach ache and/or feel bloated. Sometimes nausea can be caused by slow stomach emptying, which is caused by disease affecting nerve cells in the stomach. Taking your medications with meals Please note that that certain nausea (or with a small snack) may help medications used by people without with relieve nausea. Stemetil or can slightly reduce the absorption Maxeran) can make your movement of certain medications, such as problems worse. If your Parkinson’s medications are causing your nausea, your doctor may prescribe domperidone (Motilium) medication. Domperidone blocks the effects of dopamine in your stomach and intestines, without blocking its beneft in your brain. Key points * Usually, it will go away on its own with time (even if you stay on the medication). We still do not understand the You will not usually have a greater exact reasons for Parkinson’s appetite with Parkinson’s. It could be related do feel the urge to binge eat to nausea which is caused by (and gain weight as a result), this your medications. It can also be may happen after starting certain caused by dyskinesia (increased medications (e. That said, weight (Mirapex), ropinirole (Requip) and changes can be seen even if you do the rotigitine patch). Try the following to manage any weight loss: • Try taking your meals during “on” times (when the medication is working well). You will fnd it easier to use utensils and you may also have less diffculty swallowing. While we cannot know what all of these might be, we can certainly try to cover some of the most common topics that people discuss with us in our clinics. Making sense of your Parkinson’s Should I avoid levodopa to prevent dyskinesia or What stage of disease am I in? What does ‘tremor predominant’ and ‘akinetic-rigid’ Can dopamine treatments slow the progression? Does that mean there will be no new treatments to Looking forward and planning for the future slow the progression? Do I have to inform my local motor vehicle licensing Medications & treatments authority? What should I expect from treatment with dopamine Parkinson’s research medications? Do I have to take my medication at the same times Are there any advantages or disadvantages to every day? This means system (that is also used most often) staging is not really very useful for is called Hoehn and Yahr staging. They are mainly based on whether your For these reasons, we do not use symptoms are on one or both sides just one staging system at our clinic. However, your for the different signs and symptoms Parkinson’s as a whole is too complex we see. What does the suggests, people most often ‘tremor predominant’ and ‘akinetic- experience tremor with this type of rigid’ mean? Tremor-predominant Parkinson’s may advance more a Everybody with Parkinson’s is bit slowly than other types. Recognizing this, People with this form of neurologists have tried to divide Parkinson’s tend to see more patients into different subtypes (or slowness, stiffness and trouble groups, or categories) of Parkinson’s. While it may be interesting deal specifcally with you and your to label your Parkinson’s this way, individual issues as they arise. Your ‘honeymoon’ can Your health outlook for the future continue for many years to come. For some, Parkinson’s may advance That said, even after this honeymoon quite quickly. Others may continue period is over, you still may be able for many years before they have any to manage quite well with medication serious challenges or problems. Speak to your health care Most people do very well once team regularly about your Parkinson’s treatment has started. People with balance problems early on in the disease tend to have a Not perfectly. For some people, Parkinson’s in younger people tend a combination of non-motor problems, to have more “on-off periods” and (e. Their blood pressure) may predict a worse medications tend to offer them better outcome. That said, you may want to redo • How do you get around most your fnancial planning, especially if often (long car commutes, public you are still working. If things are more advanced and you Will you need help to care for are not doing so well, keep in mind, them over time? Try to plan for • Will you need more help to what your health needs might be 1 to manage? Do you 119 Finally, all people (including those It may be painful to talk about this, but without Parkinson’s) should spend a it is important. While you will not be bit of time with their family outlining able to foresee all the possible future what they would want if their health scenarios, make sure your loved ones suddenly worsened and they could have a good general idea of what no longer speak for themselves. Especially if Questions to consider: you are alone, write things down in a living will. For this reason, very few Most Parkinson’s medications now patients take name-brand versions. In general, Save the extra money for something there is no advantage in taking name- worthwhile. Herbal These have had a good amount of research to show that they are safe supplements? This might increase relatively harmless, but sometimes your chances for vascular disease there are serious side effects. This effect on homocysteine rule of thumb is: the more expensive can be blocked if you take B vitamins. Do keep in mind that once an ‘alternative’ • Green leafy vegetables therapy has been shown to work, it • Bread (in North America, B is generally no longer considered vitamin is added. A simple over-the-counter multivitamin - use these if you don’t If you are interested in alternative or get many B vitamins in your diet. You can Chinese movement technique) get plenty of Vitamin D from the sun, has been proven to prevent falls from spring to fall. Some studies have spend lots of time indoors, especially found that dance may also have during winter, over-the-counter similar benefts. These classes (usually found online) Senna, or Senokot: The herb, are available in most cities. Speak Senna, treats constipation in to your local Parkinson’s society Parkinson’s very well. There are currently no other herbal supplements, homeopathic medications or alternative treatments that help Parkinson’s. There is simply no evidence taking this will not offer you a high to show that these therapies work. These plants also Parkinson’s disease is a very active do not have carbidopa (see page area of research. At early stages of Parkinson’s, In general, it depends on the type of wearing-off or “off-times” (see treatment you have. For this levodopa, you should notice clear reason, you do not have to take your improvement in your movement and medication on an exact schedule. You can continue to improve tremor (although not always do this, as long as your medication at lower doses). If you do not, then your treatment (or diagnosis) may need to If you do start to notice “off-times”, be changed. This will help The other dopamine medications also prevent any wearing-off, so you can help, but the difference may not be as have better control of your symptoms dramatic. There is no one set rule for this, and it depends on Usually it is best to take pills an how the medications affect you. You will just need to keep in might: mind that its effect may not be as strong this time. Another option to consider is a smart phone application, which can set up reminders for you.

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Visual impairment tends to develop later in Thiel-Behnke corneal dystrophy purchase 5 mg cialis visa best erectile dysfunction vacuum pump, compared to Reis-Bucklers corneal dystrophy 2 buy cialis with mastercard erectile dysfunction treatment new delhi. Episodic pain from recurrent erosions developing in first or second decade generic cialis 2.5mg otc erectile dysfunction protocol + 60 days, abating by third decade of life D purchase cialis erectile dysfunction at 65. Slit-lamp biomicroscopy: bilateral geographic or honeycomb, gray white, axially-distributed opacification involving Bowman layer that spares the peripheral cornea. Immunohistochemistry: Bowman layer deposits are immunopositive for transforming growth factor beta-induced protein (keratoepithelin) 7. Corneal infection from contact lens wear or recurrent erosions - prophylactic antibiotics reduce risk C. Counsel patients regarding risk of transmission to offspring Additional Resources 1. Causative mutations have been identified in two different genes on two different chromosomes a. Foreign body sensation and tearing associated with infrequent epithelial erosion C. Minute intraepithelial cysts, typically bilateral and most densely concentrated in the interpalpebral zone. Confocal microscopy - hyporeflective areas in the basal epithelium ranging from 40 to 150 µm 6. Molecular genetic analysis - Screening of the genes in which causative mutations have been identified may be performed in cases of an atypical phenotype or absence of a family history. Diffuse punctate epithelial keratopathy from various causes such as contact lens induced keratopathy C. Bandage contact lenses for management of ocular irritation associated with epithelial erosions C. Note: epithelial changes would be expected to recur following any of the following procedures. Therefore, they should be reserved for the management of associated subepithelial fibrosis or scarring a. Discuss implications of corneal epithelial adherence in terms of contact lens wear and refractive surgery B. Counsel patients regarding risk of transmission to offspring Additional Resources 1. Initial reports of individuals with Italian ancestry but more common in other populations (Korea and Japan) 3. Often present with atypical phenotype (asymmetric, late onset, primary involvement of the posterior corneal stroma) B. Decreased vision may result from stromal haze and epithelial surface irregularity c. Onset in the early second decade with superficial granular deposits that subsequently appear as crumb like anterior stromal opacities that broaden into a disciform appearance in the teens ii. Begins as superficial small whitish dots, which later develop small spokes or thorns iii. Most patients also develop spiky anterior to midstromal star or spider-shaped deposits iv. Refractile lines (lattice lines) seen best by retroillumination, starting centrally and spreading centrifugally, sparing the far periphery iii. Decreased vision may result from lattice lines, stromal haze (ground-glass appearance) or epithelial irregularity c. Recurrent erosions and visual symptoms are common starting in the first decade but significant visual disturbance does not develop typically until the third or fourth decades iii. Significant phenotypic variability, with thicker and more posteriorly located lattice lines ii. Masson trichome stain of corneal button to reveal bright red eosinophilic hyaline deposits c. Penetrating or deep anterior lamellar keratoplasty for reduction of visual acuity 3. Anterior lamellar keratoplasty if only anterior stroma is involved with dystrophy V. Bacterial keratitis following superficial keratectomy, phototherapeutic keratectomy, or therapeutic contact lens B. Corneal scarring following superficial keratectomy or phototherapeutic keratectomy C. Accumulation of non-sulfated keratan sulfate in endoplasmic reticulum of keratocytes and endothelial cells, and extracellular stroma. Focal, gray-white superficial fleck-like stromal opacities with indefinite edges, progress to involve full stromal thickness and corneal periphery 3. Alcian blue or Hale colloidal iron stain on pathology specimens delineates macular mucopolysaccharides and staining of endothelium 3. As opposed to stromal dystrophies, Descemet membrane and endothelium are primarily involved, as evidenced by guttae and Descemet thickening 4. Penetrating keratoplasty or deep anterior lamellar keratoplasty for reduction of visual acuity 3. Anterior lamellar keratoplasty if only anterior stroma is involved with dystrophy V. Some families with involvement of consecutive generations (autosomal dominant inheritance) have been reported. Abnormal production and thickening of basement membrane-like material on the posterior non banded portion of Descemet membrane b. Onset of symptoms in the fourth decade or later, but the early variant starts in first decade 3. Photophobia, pain and tearing in later stages associated with epithelial edema and bullae formation D. Nodular excrescences of Descemet membrane that start centrally and spread peripherally b. Stromal edema begins posteriorly, progresses to Descemet folds, then to mid- and anterior-stromal edema, with progressive increases in corneal thickness b. Topical hyperosmotic agents (5% sodium chloride) - used primarily for epithelial edema a. Cool setting applied to cornea may increase evaporation and temporarily improve vision 3. Bandage soft contact lens may be useful in the treatment of painful erosions and ruptured bullae, and may improve blurring due to corneal irregularity from microcystic edema or bullae in the visual axis B. Penetrating keratoplasty (in the presence of corneal opacification or irregular astigmatism), with cataract extraction as indicated c. In presence of cataract, assess cornea for signs of decompensation including pachymetry and endothelial cell count d. Cataract extraction could lead to corneal decompensation and patients should be informed of this risk prior to surgery 2. Complications of treatment (See Endothelial keratoplasty and Penetrating keratoplasty) 1. Limit use of topical agents (See Endothelial keratoplasty and Penetrating keratoplasty) V. Epithelial breakdown resulting in secondary stromal scarring and risk of infectious corneal ulcer E. Stress education of disease process as well as implications of penetrating keratoplasty and endothelial keratoplasty B. Awareness of symptoms that may represent worsening of disease Additional Resources 1. Mutations in genes on two different chromosomes are responsible for causing posterior polymorphous corneal dystrophy B. Family history may or may not be present as many affected individuals are asymptomatic 2. Blurred vision and painful bullae may be present in the minority of patients with corneal edema C. Isolated and/or grouped endothelial vesicles - often appear in clusters with surrounding gray halo b. Stromal edema may develop, necessitating penetrating or endothelial keratoplasty in 20% to 25% of those affected 3. Patients undergoing penetrating or endothelial keratoplasty have good prognosis with no recurrence of disease in the graft 4. Hair dryer - cool setting applied tangentially to cornea may increase evaporation and temporarily improve vision iii. Penetrating keratoplasty (in the setting of visually significant coexistent corneal steepening), with cataract extraction as indicated (See Penetrating keratoplasty) b. In presence of cataract, assess likelihood of corneal decompensation with pachymetry and endothelial cell count prior to cataract surgery 2. Complications of penetrating or endothelial keratoplasty (See Penetrating keratoplasty) (See Endothelial keratoplasty) B. Prevention and management (See Anterior stromal puncture) (See Penetrating keratoplasty) (See Endothelial keratoplasty) 1. Prophylactic topical antibiotics while treating with bandage contact lenses or stromal puncture 2. Epithelial breakdown resulting in secondary stromal scarring and risk of infectious corneal ulcer E. Education of disease process, implications of penetrating keratoplasty and endothelial keratoplasty B. Awareness of symptoms that may represent worsening of disease Additional Resources 1. Classification of posterior polymorphous corneal dystrophy as a corneal ectatic disorder following confirmation of associated significant corneal steepening.

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It is also important in the early moments of the triadic encounter for the interpreter to attend to other concerns cialis 2.5mg overnight delivery erectile dysfunction lubricant, such as arranging the spatial configuration of the parties in the encounter cialis 10mg without a prescription erectile dysfunction causes and treatment, addressing any discomfort a patient or provider may have about the presence of an interpreter order cialis in united states online erectile dysfunction drugs research, or assessing the linguistic style of the patient cialis 2.5 mg on line erectile dysfunction johannesburg, keeping in mind at all times the goal of establishing a direct relationship between the two main parties. The most basic task of the interpreter is to transmit information accurately and completely. Therefore, interpreters must operate under a dual commitment: (1) to understand fully the message in the source language, and 2) to retain the essential elements of the communication in their conversion into the target language. Interpreters whose linguistic proficiency (in terms of breadth and depth) in both languages is very high and who have a solid working knowledge of the subject matter are more likely to be able to make the conversions from one language to another without needing to ask for much clarification Those whose linguistic proficiency is limited can use appropriate strategies to ensure that they themselves understand the message before they make the conversion and that all the pertinent information has been transmitted. In the interest of accuracy and completeness, interpreters must be able to manage the flow of communication so that important information is not lost or miscommunicated. Interpreters may also have to attend to the dynamics of the interpersonal interaction between provider and patient, for example when tension or conflict arises. The introduction of a third party into the medical encounter generates dynamics that are inherent in triadic interactions. A primary characteristic of a triadic, as opposed to a dyadic, relationship is the potential for the formation of an alliance between two of the three parties. Because the interpreter is the party to whom both provider and patient can relate most directly, both have a propensity to want to form an alliance with the interpreter. The provider and patient often exhibit this tendency by directing their remarks to the interpreter rather than to each other, which leads to the ‘tell the patient/doctor’ form of communication. Thus, the interpreter must work at encouraging the parties to address each other directly, both verbally and nonverbally. The natural tendency of both providers and patients is to perceive interpreters as an extension of either their own world or the other, rather than as partners in their own right, with their own role responsibilities and obligations. For patients, the desire to form an alliance with the interpreter is heightened because they are likely to perceive the interpreter as understanding not only their language but also their culture. This perceived cultural affinity often leads patients to act as if the interpreter were there as their friend and advocate. For providers, the danger lies in assuming that the interpreter is part of their world and therefore expecting that the interpreter can and should take on other functions, such as obtaining a medical history. On the other hand, when providers assume that interpreters are extensions of the patient’s world, they tend to dismiss the importance of their role and ascribe inferior status to their work. As professionals in their own right, in the interpreter-mediated encounter interpreters owe their allegiance to the therapeutic relationship and its goals of quality health care. Their commitment is to support the other two parties in their respective domains of expertise – the provider as the technical expert with the knowledge and skills in medicine and health care, and the patient as the expert on his or her symptoms, beliefs, and needs. The provider offers informed opinions and options, while the patient remains the ultimate decision maker in terms of treatment. The role of the interpreter is not to take control of the substance of the messages but rather to manage the process of communication. The responsibility of the interpreter in the closing moments of the clinical encounter is to encourage the provider, when necessary, to provide follow-up instructions that the patient understands and will therefore be likely to follow. In addition, the role of the interpreter is to make sure that the patient is connected to the services required (including additional interpreter services) and to promote patient self-sufficiency, taking into consideration the social context of the patient. Cultural Interface Language is not the only element at work in the interaction between providers and patients who speak different languages. The meaning inherent in the messages conveyed is rooted in culturally based beliefs, values, and assumptions. According to the linguists Whorf (1978) and Sapir (1956), language is an expression of culture and the way in which culture organizes reality. The interpreter, therefore, has the task not only of knowing the words that are being used but of understanding the underlying, culturally based propositions that give them meaning in the context in which they are spoken. Interpreting in the health care arena requires the interpreter to understand the ways in which culturally based beliefs affect the presentation, course, and outcomes of illness as well as perceptions of wellness and treatment. If provider and patient share similar assumptions about medicine and its positivistic, scientific principles, it is more likely that the interaction will go as smoothly as if they were speaking the same language. In such a case, the interpreter simply has to make the conversion from one linguistic system into the other; the layers of meaning will automatically be understood. As the dissimilarities between providers’ and patients’ assumptions increase, however, literal interpretations become inadequate, even dangerous. In such cases, to convey the intent of the message accurately and completely, the interpreter may have to articulate the hidden assumptions or unstated propositions contained within the discourse. Here the role of the interpreter is to assist in uncovering these hidden assumptions and, in doing so, to empower both patient and provider with a broader understanding of each other’s culture. Another major cultural linguistic problem occurs when a speaker uses ‘untranslatable’ words. For example, the concept of bacteria, a living physical organism that is not visible to the naked eye, is a concept that has no equivalent in many rural, non-literate societies. To get the concept across, the interpreter may have to work with the provider to find ways to transmit the essential information underlying this concept. Interpreters, therefore, have the task of identifying those occasions when unshared cultural assumptions create barriers to understanding or message equivalence. Their role in such situations is not to ‘give the answer’ but rather to help both provider and patient to investigate the intercultural interface that may be creating the communication problem. Cultural patterns, after all, are generalized abstractions that do not define the individual nor predict what an individual believes or does. They are simply hypotheses that may be more likely to occur in a member of that culture than in someone who is not a member (Avery, 1992). Ethical Behavior The role of interpreter, on the surface, appears to be straightforward and uncomplicated. The interpreter is present to convert a message uttered in one language into another. Professional interpreters, however, understand the profound complexities of what appears to be a simple task. In fact, even in the simplest of encounters, the interpreter may need to recognize and address a series of dilemmas. In face-to-face, interpreter-assisted, medical encounters, the very presence of the interpreter changes the power dynamic of the original dyadic relationship between patient and provider. In a very significant way, the interpreter holds tremendous power, often being the only one present in the encounter who understands both languages involved. In addition, the interpreter enters the interaction as an independent entity with individual beliefs and feelings. Both the patient and the provider have to be able to trust that the interpreter will not abuse this power. They need to trust that the interpreter will transmit faithfully what it is they have to convey to each other and not the interpreter’s own thoughts. They also need to trust that the interpreter will uphold the private and confidential nature of the clinician-patient relationship. A code of ethics provides guidelines and standards to follow, creating consistency and lessening arbitrariness in the choices interpreters make in solving the dilemmas they face (Gonzalez et. Too often educational and training programs are developed without clearly articulated connections to performance expectations in the field. These standards of practice were developed by practitioners with years of experience in the field who are also responsible for on-the-job training and supervision. As such, they reflect a comprehensive view of the basic skills and knowledge required on the job. Used as guideposts, these standards can serve as the foundation of course and/or training objectives. Standards of practice can serve as pre-selected criteria against which the performance of students, trainees, or practitioners in the field can be evaluated. Both students and instructors can use the indicators as a formative evaluation tool in the academic or training setting to provide ongoing feedback on the skills students need to work on, the areas in which they have achieved mastery, and the tasks they still need to learn or improve. As an outcome measure, these standards can be used to determine whether or not a student has achieved mastery of the required skills. At the workplace, they can be used both to assess the level of competency at the point of entry and as a supervisory tool to provide ongoing feedback. Interpreters can also use these standards to continue to monitor and assess their own performance individually. These standards offer health care providers with a comprehensive overview of what to expect from interpreters. Since these standards represent a comprehensive articulation of the basic skills and knowledge a competent interpreter must master, they can also be used as a basis for a performance-based portion of a certification examination. For example, the certification candidate could be placed in a role play designed to include both a routine interpreting interaction and an unanticipated problem. The role play would require the interpreter to demonstrate in an integrated way the application of various skills to address the situation in an appropriate, professional manner. The members of the Subcommittee on Standards of Practice recognize that this document represents a first step in what needs to be an ongoing, developmental process. It is expected that by simultaneously setting clear, high standards of performance and creating rigorous training and academic programs, a marked increase in the quality of interpreting in the health care arena will follow. This increase in quality will in turn lead to a full recognition of competent, professional interpreters, who will be accorded the status and compensation commensurate with the critical nature of their work; and it will also create the demand for higher-level training and academic programs. Does not attempt to hold a to find out the provider’s goals for the pre-conference, even when encounter and other relevant possible background information B. Gives introduction missing and succinctly to provider and patient one or more components as follows: Gives name Indicates language of interpretation Checks on whether either provider or patient has worked with interpreter before Explains role, emphasizing:  Goal of ensuring effective provider- patient communication  Confidentiality  Accuracy and completeness (i. Does not fulfill this minimum cannot be held and/or a full requirement introduction made, at a minimum asks provider to state briefly the goal of the encounter and informs patient and provider that the interpreter is obliged to transmit everything that is said in the encounter to the other party and, therefore, that if either party wishes something to be kept in confidence from the other, it should not be said in the presence of the interpreter D. Shows uneasiness in role from the beginning establishing and asserting the interpreter’s role E. Arranges spatial configuration to support direct communication place the interpreter at the center between provider and patient of communication or otherwise disrupt direct communication D.

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Describe the indications 20 mg cialis with amex list all erectile dysfunction drugs, contraindications cialis 2.5mg low price erectile dysfunction doctor brisbane, side effects and complications of the methods order cialis 10 mg with amex erectile dysfunction with diabetes. Contents • Magnitude of the problem • Maternal morbidity and mortality generic cialis 10 mg line erectile dysfunction natural, under five morbidity mortality. Types of impairment, disability, handicap • Assessment of Postpolio Residual Paralysis • Rehabilitation at individual level • Community based rehabilitation – Practical exercise: Post Polio residual paralysis assessment. Plan and investigate an epidemic of a communicable disease in a hospital/ community setting, and institute control measures. Describe the important features of the Workman Compensation Act and provision of health services and health insurance to industrial workers. Contents – Working environment, health hazards of industrial and agricultural workers – Common occupational lung diseases – Common occupational skin diseases and cancers – Industrial Toxic Substances – Principles of prevention of Occupational diseases – Legal status in relation to Workman Compensation Act – Employees’ State Insurance Act – Practical exercise - visit to a factory 12. Describe the organization of health services at all levels and the School Health Programme. Contents – Planning and organizational set up of health services in India – Primary Health Care – Health Theam at District Hospital, Community Health Primary Health Centre – School Health – Management of health resources – Voluntary and international agencies in health care – Natural and manmade disasters and disaster management 13. Contents – Need of health economics – Methods of economic analyses in health Community Medicine 75 14. Contents • The students will observe counselling being done in the various situations. Attending the Mobile clinic at slum areas to learn about the patterns of morbidity, care of patients and referrals at primary level. Clinico-psycho-social review:L Each student will be allotted a case in the community to take history and do a complete physical examination and reach a diagnosis. This will be followed by a visit to the patient’s family to determine the psycho - social aspects of the disease and the effects on the patient and family. The student will also have to advise appropriate intervention, Individual presentation. Participating in the immunization, health education activities and special exercises like survey. To study the family structure and health status of the individual members with special reference to: (a) Nutritional status (b) Immunization status (c) General Health status (d) Environmental status (e) Socio-Economic status (f) Family Welfare Planning status 3. To assess the knowledge, attitude, behaviour and practices regarding health and disease. To identify the communication and decision making process in the family, and utilization of health services by the families. To counsel the family in solving their health problems and to educate the families to improve their health and family welfare. Methodology The whole class is divided into two (2) batches and each batch will have two faculty supervisors during field visits as well as in briefing. Each batch visits the allotted families along with preceptors once a week and discuss the findings with faculty supervisor next week. The students will also maintain a record of their family visits and present the family’s case history book at the end of the posting. Community Medicine 77 Evaluation Students will be evaluated in the following manner: Total Marks: 50 1. Describe the important statistical data of Ballabgarh project and to compare them with the National figures. Conduct an epidemiological study, plan and execute an intervention programme in a rural community. Describe the model of health care delivery in rural areas and the National Health Programmes. Management of patients at the secondary level: A list of diseases which are seen commonly in Ballabgarh is provided (Appendix). Theaching by faculty members from the above specialties from Wednesday to Saturday. Demonstration of the procedures mentioned above, and if possible, the student will carry out these procedures under the supervision of the faculty member and the Senior Resident. These are pulmonary tuberculosis, antenatal case, antenatal high risk case, and protein energy malnutrition in a child. Information to be collected for each condition: Pulmonary Tuberculosis: Index case - occupation, literacy & social status Social & environmental factors and their contribution to the disease Steps taken by the patient for his own treatment Preventive measures for other family members Condition of the patient at the time of visit Health education Antenatal Case: Literacy of the family and the woman Customs - social or religious during pregnancy, delivery and lactation Dietary habits - particularly restrictions during pregnancy Knowledge, attitude & practices regarding antenatal care High risk pregnancy - identification Health education / Family Planning advice Protein Energy Malnutrition: Socio-economic status of the family Infant feeding & weaning practices Social customs regarding diet for children Environmental factors contributing to malnutrition Knowledge, attitude & practices about nutrition & steps taken for the management of child Community Medicine 79 3. The statistics to be known are: Birth Rate Death Rate Infant Mortality Rate Maternal Mortality Rate Eligible Couple Protection Rate Immunization Coverage 4. Decision whether to survey the entire population or a sample using the usual sampling techniques. Data collected is analysed and presented to the faculty of community medicine for discussion. The final report (typed two copies) is to be submitted within 1 week of completion of the posting. The main objectives of these visits are to make you realise the vast gap between theory and practice of primary health care. This will be based on the – field exercise – visits made – presentation of domiciliary visits 2. End posting assessment Clinical assessment will be taken by the faculty involved in teaching. Emphasis will be on: history taking total management (hospital & domiciliary) of the patient demonstration of the procedures taught (if feasible) Community Medicine Presentation of field exercise Viva Voce on the activities that you have observed and participated in during the posting One question on each area will be asked. Internship Programme in Community Medicine During one year of internship, the interns are posted for 3 months at Comprehensive Rural Health Services Project at Ballabgarh (Haryana) – 36 kms. In this fully residential posting, the distribution of posting is as under: (a) Six weeks posting at Ballabgarh Hospital ( a 60 bedded, secondary care level hospital) : This posting aims to train the interns in managing common health problems at secondary level. The interns are trained to manage common health problems at the primary level under the ambit of primary health care. The aim of the training is to train the candidates to diagnose and manage common skin diseases. Diagnose and manage common skin diseases, sexually transmitted diseases and leprosy. To diagnose and manage common medical emergencies related to skin diseases, leprosy and sexually transmitted diseases. To familiarize them with the common laboratory diagnostic skills which help in the confirmation of diagnosis. To train them for preventive measures at individual and community levels against communicable skin diseases including sexually transmitted diseases and leprosy. Clinical examination and description of cutaneous findings in a systematic way in dermatology, sexually transmitted diseases and leprosy. To have a broad idea and approach to manage common skin diseases, sexually transmitted diseases and leprosy. To develop skills to do day-to- day common laboratory tests and their interpretation which help in the diagnosis. Ineffective dermatoses: Pyoderma, tuberculosis and leishmaniasis- Etiology, Clinical features, Diagnosis and Treatment. Infective dermatoses: Viral and fungal infections- Etiology, Clinical features, Diagnosis and Treatment. Infestations: Scabies and pediculosis – Etiology, Clinical features, Diagnosis and Treatment. Melanin synthesis: Disorders of pigmentation (Vitiligo, Chloasma / Melasma)- Etiology, Clinical features, Diagnosis and Treatment. Allergic disorders: Atopic dermatitis and contact dermatitis – Etiology, Clinical features, Diagnosis and Treatment. Drug eruptions, urticaria, erythema multiforme, Steven’s johnson syndrome and toxic epidermal necrolysis – Etiology, Clinical features, Diagnosis and Treatment. Vesiculo-bullous diseases: Pemphigus, Pemphigoid, Dermatitis herpetiformis – Etiology, Clinical features, Diagnosis and Treatment. Epidermopoisis, Psoriasis, Lichen planus and Pityriasis rosea – Etiology, Clinical features, Diagnosis and Treatment. Pathogenesis, Classification and clinical features of leprosy, Reactions in leprosy. Gonococcal and Non-gonococcal infections – Etiology, Clinical features, Diagnosis and Treatment. Syndromic approach to the diagnosis and management of sexually transmitted diseases. Hereditary disorders: Ichthyosis, Albimism, Epidermolysis bullosa, Melanocytic naevi, Freckles and other naevi – Etiology, Clinical features, Diagnosis and Treatment. They have the clinical teaching and demonstrations of all the common skin diseases sexually transmitted diseases, leprosy and common skin emergencies during this period. They also have about a week’s orientation clinical posting during their 3rd semester training period to familiarize them with the history taking, clinical examination and cutaneous lesions. Clinical Assessment: The students go through an assessment at the end of their clinical postings. Elicit a detailed history, perform a thorough physical examination including mental status 4. Correlate the clinical symptoms and physical signs to make a provisional anatomical, physiological, etiopathological diagnosis along with the functional disability and suggest relevant investigation. Professionally present and discuss the principles involved in the management of the patient, initiate first line management and outline short-term and long term management. Manage acute medical emergencies like acute myocardial infarction, acute pulmonary oedema, acute anaphylactic and hypovolumic shock, status asthmaticus, tension pneumothorax, status epilepticus, hyperpyrexia, haemoptysis, gastro-intestinal bleeding, diabetic coma, electric shock, drowning, snake bites, common poisoning etc.