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An important physical sign of portal hypertension in a patient of cirrhosis of liver is: a) Gynecomastia generic nitroglycerin 2.5 mg otc. Key: e Ref: Portal Hypertension (Page 957) Davidson’s Principles and Practice of Medicine discount nitroglycerin 2.5 mg with amex. A forty year old diabetic man presents with history of sudden onset of pain in right loin which radiates towards right iliac fossa. Key: e Ref: Acute Pyelonephritis (Page 470) Davidson’s Principles and Practice of Medicine. In a patient with history of haematemesis, the clinical feature which suggests that peptic ulcer is the underlying cause is: a) Ascites. Key: d Ref: Peptic Ulcer (Page 885-890) Davidson’s Principles and Practice of Medicine. Which o the following features suggests that she has irritable bowel syndrome: a) Anaemia. Key: b Ref: Irritable Bowel Syndrome (Page 920) Davidson’s Principles and Practice of Medicine. Key: b Ref: Chronic Hepatitis B Infection (Page 370, 371) Clinical Medicine Kumar and Clark 40. Which of the following serum electrolyte level is most likely to be low: a) Calcium. A young boy presents in outdoor with history of sudden painful swelling of joints after minor trauma since childhood. Key: d Ref: Haemophilia (Page 1057) Davidson’s Principles and Practice of Medicine. In a patient with history of jaundice, pruritis and clay-colored stools, which of the following enzyme level is expected to be markedly elevated: a) Alkaline aminotransferase. Key: b Ref: Cholestatic Jaundice (Page 946) Davidson’s Principles and Practice of Medicine. A patient presents with history of intermittent fever, abdominal pain and headache. Key: b Ref: Antimalarials (Page 211) Davidson’s Principles and Practice of Medicine. When such a science is applied to a dynamic human being that is being continuously run with food – Thiruvalluvar, The Kural 1072. Human When one enters the medical college the first thing that body is not only non-linear,it follows the holistic rules of happens is that the person is made to forget his/her the universe. All these make the present the present educational system; even as early as entry to medical science a square plug in a round hole. In the practice of bedside medicine, progress and if we want to progress in medical science however, common sense is not just common but it is we have to think deeply of changing our mind set and commoner than what one thinks it is. The statistical science follow the new science of chaos-of non-linearity and of medicine can, at best, manage to size up cohorts of holism. It is basically status quoists wanting the comfort of the existing the past experience of the doctor with his clinical acumen order. We are usually afraid of change and what it might that helps him at that point in time. But life itself is ceaseless change till decision one way or the other based on his own death. Unfortunately, that is what medicine, sold as the gold standard in medical research, is presumed in the science of medicine. The British claim The art of medicine is the one that makes the patient’s that it was Archie Cochrane that introduced the term and day. No amount of science and technology will ever be they claim that the first such study was undertaken by able to replace that humane human being, the doctor their Medical Research Council in 1940 of the role of that alone could put to rest the universal anxiety that is streptomycin in tuberculosis and on the role of the part of all illnesses since every disease presents through whooping cough vaccine. In reality even mathematics randomisation so that precisely framed questions can be becomes shaky. Randomised Controlled removed from reality and when it is closer to reality it is Clinical Trials. However, in our enthusiasm, we have and after modern medicine do not show much to write extrapolated those designs for the study of treatment of home about, either! David When one has a control population the same must be Eddy of Stanford University, a cardiac surgeon turned identical to the study cohort for the results to be reliable. To cap it, we research, has invented a new soft ware tool that has can only measure a few phenotypic features of both the thousands of differential equations to test the efficacy of groups for comparison. These, by any stretch of what we do in medical science arena in a virtual field, named imagination, could be taken to match the two groups.

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Indirect hernias are Patients complain of symptoms of dyspepsia (see ear- repaired by surgical removal of the herniation sac from lier in this chapter) particularly heartburn generic nitroglycerin 2.5 mg with visa, a retroster- the spermatic cord best nitroglycerin 2.5 mg. If the internal ring is enlarged it is nal burning pain aggravated by bending or lying down. For other hernias, the principle is to Effortless regurgitation of food and acid (waterbrash) excise the sac and obliterate the opening either by sutur- into the mouth may occur. Gastrooesophageal reflux disease Management Definition Patients are managed as for dyspepsia, i. Chapter 4: Disorders of the oesophagus 157 Older patients and those with suspicious features should diameter of 10–15 mm. It may be axial/sliding, r Patients should be advised to lose weight if obese, and paraesophageal/rolling or mixed. Prevalence r The most effective relief is provided by proton pump Increases with age, very common in elderly patients (up inhibitors; however, many patients have adequate to 70%). This can eventually shorten the oesoph- terprevious upper gastrointestinal tract surgery. Symptoms may result from pressure on the heart latation to stretch the stricture to achieve a luminal orlungs. Oesophagus Gastro-oesophageal Herniated Diaphragm junction stomach Stomach Sliding (axial) hernia 90% Para-Oesophageal (rolling) hernia 10% Disrupts normal anti-reflux mechanisms Anti-reflux mechanisms intact Figure 4. Patients with a slid- Patients may present with a lump in the throat and dys- ing hernia may present with symptoms of dyspepsia due phagiawithregurgitationofundigestedfoodsomehours to gastro-oesophageal reflux. Endoscopic techniques may be used in elderly Investigations patients, with a large dependent pouch, who are unfit Chest X-ray may reveal a gas bubble above the di- for surgery. Endoscopycanestablishtheextent Plummer–Vinson syndrome and severity of inflammation and exclude oesophageal Definition carcinoma. Plummer–Vinson syndrome or Paterson–Brown–Kelly syndrome is an unusual combination of iron deficiency Management anaemia and dysphagia. In fundoplication (open or laparo- the upper oesophagus with the formation of a post- scopic) the gastric fundus is mobilised and wrapped cricoid web. Thereisahighriskofupper patients) to reduce the risk of strangulation and other oesophageal or pharyngeal malignancy. Surgery consists of ex- cisionoftheperitonealsac,reductionoftheherniaand closure of the defect. Webs are dilated endoscopically to relieve obstruction, iron deficiency anaemia is treated. Pharyngeal pouch Definition Achalasia A false diverticulum arising at the junction of the oe- sophagus and the pharynx. Definition Achalasia is a disordered contraction of the oesophagus Aetiology/pathophysiology of neuromuscular origin. In co-ordinationbetweenthecontractionofthepharynx andrelaxationoftheupperoesophagealsphinctercauses Aetiology the pharyngeal mucosa to herniate posteriorly between Degeneration is seen in the vagus nerve associated with the upper and lower fibres of the inferior constrictor adecrease in ganglionic cells in the Auerbach’s nerve muscle (Killian’s dehiscence). Chagas’ disease in Chapter 4: Disorders of the oesophagus 159 South America is very similar where infection by Try- oesophageal sphincter. Surgical intervention is indicated panosoma cruzi causes destruction of the myenteric in those who fail to respond; a 10–12 cm incision is made plexus. Gastro-oesophageal reflux is a The neuromuscular damage causes disordered motility complication with both procedures. On manom- etry there is aperistalsis and incomplete relaxation of Diffuse oesophageal spasm the lower oesophageal sphincter in response to swallow- ing. The gastrooesophageal sphincter classically remains Definition tightly closed and there is dilation of the oesophagus. Aetiology/pathophysiology Clinical features There is a generalised abnormality of the oesopha- Patients present with progressive dysphagia, regurgita- gus with resultant hypermotility leading to painful oe- tionandnocturnalaspiration. Clinical features Complications Painisretrosternalandrangesfrommildtoseverecolicky Patients may aspirate and develop respiratory symp- spasms that occur spontaneously or on swallowing. Achalasia may predispose to oesophageal car- cinoma even after successful treatment (incidence of Investigations 5–10%). Barium swallow may show a corkscrew appearance due to contracted muscle (nutcracker oesophagus). Manom- Investigations etry can be used to identify the diseased segment and is r Achest X-ray may reveal a fluid level behind the heart. There may be Management superficial mucosal erosions with a very narrow pas- Calcium channel blockers can reduce the amplitude sage of barium (rat’s tail) into the stomach through of the contractions. Surgical intervention with open or tho- r 24-hour pH and manometry studies can differentiate racoscopic myotomy is considered in refractory cases. The myotomy should extend the entire length of the r Upper gastrointestinal endoscopy is performed to ex- involved segment of oesophagus and through the lower clude a tumour.

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The humani- ties must be made integral to the life of the medical student and the physi- cian nitroglycerin 6.5mg free shipping. In actual practice safe 6.5 mg nitroglycerin, medical students and physicians must see how the medical humanities support the physician’s virtuous response to actual patients. The next essay locates concerns regarding humanism and the virtue of the physician in the context of Roman Catholic perspectives on medical morality. In “Agape and Ethics: Some Refections on Medical Morals from a Catholic Christian Perspective,” Pellegrino reviews the recent Roman Catholic dialogue with “the dominant cultural ideas of the time” and the competing accounts of morality and ethics which this has produced. He selects for his focus what he terms an agapeistic ethic: a virtue-based ethic which afrms charity as the principle that should structure the relation- ship between physicians and patients. With charity taken as the ordering principle of discernment in moral choice, Pellegrino places the general concerns of the humanities and the liberal arts within the more concrete focus of a particular Roman Catholic understanding. In this fashion, he gives content to the meaning of the virtuous and humane physician. He suggests as well the importance of the tie between Christian belief and vir- tuous practice. This section ends with an essay that locates the previous discussions in terms of the challenge of bringing bioethics to speak to the pressing issues of normative ethics: “Bioethics at Century’s Turn: Can Normative Ethics Be Retrieved? The default position in bioethics and health care policy tends to be procedural rather than substantive, because substance divides and en- © 2008 University of Notre Dame Press An Introduction genders dispute. Quoting Gilbert Meilaender, Pellegrino concludes that bioethics has “lost its soul. The last subsection is a brace of papers exploring the Hippocratic tra- dition and its capacity to inform a bioethics for the future. The frst essay, “Toward an Expanded Medical Ethics: The Hippocratic Ethic Revisited,” begins by recognizing that “Good physicians are by the nature of their vocation called upon to practice their art within a framework of high moral sensitivity. For two millennia this sensitivity was provided by the oath and the other ethical writings of the Hippocratic corpus. No code has been more infuential in heightening the moral refexes of ordinary indi- viduals. Every subsequent medical code is essentially a footnote to the Hippocratic precepts, which even to this day remain the paradigm of how good physicians should behave. This Hippocratic ideal he shows to lie at the heart of the Hippocratic com- mitment to protecting the vulnerability of the patient. Pellegrino then ex- amines the shortcomings of the Hippocratic Oath and its ethos in the service of pointing to the possibility of “the elaboration of a fuller and more comprehensive medical ethic suited to our profession as it nears the twenty-frst century. Through a study directed primarily to the Oath, Pellegrino dis- plays its limitations, while yet recognizing its importance for the history of medical ethics. As he appreciates, the Hippocratic tradition, despite its past infuence, must be reappropriated through a moral philosophy of medicine that takes account of “the moral heterogeneity of modern societies and the cosmopolitan character of scientifc medicine. That is, Pellegrino argues that medicine’s internal morality must be understood through a moral philosophy internal to medicine and prior to medical ethics. Only such a moral philosophy of medicine, when adequately de- veloped, so Pellegrino claims, will be able to meet the challenges of the fu- ture. Pellegrino and the Future This volume both refects a cultural crisis or rupture and indicates possible responses to the challenges this brings. This collection of essays recognizes medicine’s break from its sense of possessing tradition, a sense of continuity repeatedly re-achieved over the centuries by means of an af- frmation of that period’s understanding of the Hippocratic ethos. Pel- legrino attempts to fnd a surrogate ethos and sense of professionalism in the face of rapid cultural change by reaching to the humanities and a phil- osophically recast bioethics. These essays of Pellegrino show a deep ap- preciation for the search for orientation in the face of post-modernity’s cacophony and the constant presence of the moral concerns integral to the physician-patient relationship. It recognizes as well that bioethics at- tempted to claim hegemony over medical ethics, though bioethics itself failed to realize a unifed normative undertaking. Though bioethics arose to give guidance in a cultural vacuum consequent upon the secularization of American society and the marginalization of the traditional authority of physicians, bioethics has nevertheless failed to provide, much less jus- tify, a canonical moral perspective that can supply the guidance sought. Again, he locates bioethics within a vision of the human enterprise, a core contribution of the humanities. He then places all of this within a philosophy of medicine that takes seriously that which is essen- tial to the calling of physicians. It ofers an interesting proposal for rethinking the nature of the philosophy of medicine and its ofce in grounding and directing not just the medical humanities and bioethics, but medical eth- ics and medical professionalism. Pellegrino has shaped the development of the philosophy of medi- cine, the medical humanities, bioethics, and medical ethics. The past would not have been the same in the absence of his scholarship and per- sonal engagement.

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