By I. Daryl. Immaculata College. 2019.
It should be noted that this symbol may refer to the disease in only some situations quality 80mg tadapox, i tadapox 80 mg overnight delivery. Notifiable diseases bring trade restrictions and a range of necessary disease control measures order tadapox 80 mg. Trypanosomiasis is considered the most important disease of livestock in Africa where it causes severe economic losses purchase tadapox 80mg visa. The disease has the greatest impact on domestic cattle but can also cause serious losses in domestic swine, camels, goats and sheep. Infection of susceptible cattle results in acute or chronic disease which is characterised by intermittent fever, anaemia, occasional diarrhoea and rapid loss of condition and often terminates in death. Although most trypanosomes that cause African animal trypanosomiasis are not known to be zoonotic, some are of zoonotic concern, e. Trypanosoma brucei rhodesiensi and other closely related trypanosomes do infect humans. Non- zoonotic trypanosomes might cause disease in people with certain genetic defects. Causal agent Trypanosomes, protozoan parasites of the genus Trypanosoma that live in the blood, lymph and various tissues of vertebrate hosts. Species affected Many species of domestic and wild animals including cattle, swine, camels, goats and sheep. Cattle are prefered by the tsetse fly and this preference can shield other animals from the effects of trypanosomiasis. Wild animals known to be infected but which are trypanotolerant include greater kudu Tragelaphus strepsiceros, warthog Phacochoerus africanus, bushbuck Tragelaphus scriptus, bush pig Potamochoerus porcus, African buffalo Syncerus caffer, African elephant Loxodonta africana, black rhinoceros Diceros bicornis, lion Panthero leo and leopard Panthera pardus. Geographic distribution Endemic in Africa, primarily occurring in areas inhabited by the tsetse fly. In Africa this falls between latitude 14° N and 29° S - that is from the southern edge of the Sahara desert to Zimbabwe, Angola and Mozambique (‘the tsetse fly belt’) an area of 10 million square miles affecting nearly 40 countries. Despite a century or more of effort to eradicate the tsetse fly, the trypanosomes have persisted across their range except in areas where all vegetation has been removed. The three main species of tsetse flies responsible for transmission are Glossina morsitans, which favours open woodland on savanna; G. Fomites (inanimate objects such as footwear, nets and other equipment) can also mechanically transmit trypanosomes. How is the disease Trypanosomes must first develop within tsetse fly vectors for one to a few transmitted to animals? They are then transmitted through tsetse fly saliva - when flies feed on an animal they inject saliva before sucking blood. Trypanosomes can also be mechanically transmitted by biting flies when these flies transfer blood from one animal to another. How does the disease Tsetse flies or mechanical vectors carrying trypanosomes from one group of spread between groups animals to another. Animals imported from endemic areas can be subclinical carriers and may become ill with the disease when stressed. Recommended action if Contact and seek assistance from appropriate animal health professionals suspected immediately if there is any illness in livestock. Diagnosis The disease should be confirmed by health professionals identifying pathogenic trypanosomes in blood or lymph node smears. Anticoagulated fresh blood, dried thin and/or thick blood smears, and smears of needle lymph node biopsies can be submitted from live animals. Trypanosomes are most likely to be found in the blood by direct examination during the early stages of infection. They are less likely to be detected in chronically ill animals, and are almost never seen in healthy carriers. Xenodiagnosis (looking for the parasite in a previously uninfected vector which is exposed to the host, rather than the host itself) is also a useful technique when attempting to isolate from wildlife. Before collecting or sending any samples from animals with a suspected animal disease, the proper authorities should be contacted. Samples should only be sent under secure conditions and to authorised laboratories to prevent the spread of the disease. Although the trypanosomes that cause African animal trypanosomiasis are not known to be zoonotic, precautions are recommended when handling blood, tissues and infected animals. Various environmental measures can be used to control the vector: Buffer zones: if tsetse fly wetlands occur near villages, a buffer zone, i. Habitat modification/removal: tsetse flies need shady and relatively humid conditions. The distribution and ecology of the different species of tsetse fly are closely linked with vegetation. Any modification in vegetation cover may affect the dynamic behaviour of the tsetse fly populations and the transmission of trypanosomiasis. In extreme circumstances, it may be necessary to remove the tsetse fly habitat however bush clearing can lead to soil erosion and other ecological disruption. Persistent chemicals are no longer used for environmental reasons and other non-persistent forms of spray are applicable in certain, mostly open, habitats e. Control of Vectors Secondary control methods should employ veterinary interventions and reduce the spread of the parasite by using preventative treatments, treating infected animals and monitoring the number of animals that carry the disease. Vaccination There is currently no vaccine against human or animal trypanosomiasis. Some African cattle and small ruminant breeds have some tolerance to trypanosomiasis. Introduction and development of these breeds may be effective in lessening the impact of trypanosomiasis. However it should be noted that: - Immunity may only be local and therefore ineffective against trypanosomes from a different region. Switching from cattle to poultry farming, for example, can allow animal protein production without losses to trypanosomiasis. In mixed wildlife-livestock systems, tsetse can preferentially feed on wildlife species and this has a dilution effect on livestock attack. If an outbreak is detected early, the parasite might be eradicated by: Movement controls and quarantine periods Euthanasia of infected animals - trypanosomes cannot survive for long periods outside the host and disappear quickly from the carcase after death. Wildlife Wild animals carry trypanosomes and are an important food source for the tsetse fly. Each type of fly derives nourishment from a narrow range of animal species, however, tsetse flies have been shown to be adaptable and will utilise novel hosts in the absence of a favoured host. For this reason, and because of the obvious detriment to the local wildlife, eradication of game hosts is no longer an acceptable method of control. Prevention should be directed towards controlling vector populations or preventing human and livestock access to tsetse habitat and dedicating the land to alternative land use and income generation. Some species such as southern white rhinoceros, which prefers open grassland, can suffer mortality from the disease. Effect on livestock Trypanosomiasis has the greatest impact on domestic cattle but can also cause serious losses in domestic swine, camels, goats and sheep. The cattle of African nomadic communities are at particular risk as they are increasingly driven to utilise higher risk habitats due to agriculture reducing their available range. Although acute cases can be caused by less pathogenic types, in general the disease has a high morbidity rate and is often chronic in susceptible animals. The mortality rate can reach 50-100% within months of exposure, particularly if the animal is exposed to poor nutrition and other stressors. In Africa, tsetse fly transmitted trypanosomiasis is a persistent endemic disease. In South America trypanosomiasis is mechanically transmitted and epizootic outbreaks occur cyclically every few years. Effect on humans African animal trypanosomes are not known to be zoonotic so health impacts are negligible but they are of concern in wildlife tourism areas where rare cases in wildlife can occur. This can have significant negative economic knock-on effects where illness deters visitors.
On Stench of the Mouth * For stench of the mouth caused by a disorder of the stomach generic 80 mg tadapox with amex, let the tips of myrtleberry be ground and cooked in wine until reduced by half and buy 80mg tadapox fast delivery, with the stomach having been purged generic tadapox 80 mg overnight delivery, let the wine be given to drink generic tadapox 80mg mastercard. On Removing Redness of the Face  For removing redness from the face, we put on leeches35 of various colors, which are in reeds, but ﬁrst we wash with wine the place to which they ought to adhere; they are usually placed around the nose and ears on both sides. For Veins in the Face  For veins which appear in the nose or on the face, we apply to the place three parts soap and a fourth part pepper, [all] powdered, and we cure it in the above-mentioned manner. Recipe oliba- num, masticem,f ceram, oleum, picem grecam, galbanum, aloen, absinthium, arthimesiam, peritariam, rutam, saluiam. Terantur herbeh et in- fundatur oleum et misceaturi super ignem, et cum fuerit in suppremo calidum, oleum coletur et iterum igni apponatur, et cum incipietj bullire apponaturk cera, et postea ceteral pulueri[vb]zata et decocta colentur et superponan- tur. Et nota quod loco cancroso folia hedere siluestris satis ualent in uino decocta et superposita. Later we spread around rose oil during the night and she will be freed in a short time. For Black Teeth  For black and badly colored teeth, take walnut shells well cleaned of the interior rind,which is green,36 and we rub the teeth three times a day, and when they have been well rubbed, we wash the mouth with warm wine, and with salt mixed in if desired. On Treating Cancer  We wash a cancer wherever it is in the body, and we sprinkle over it a powder made of cumin and green copper. And when it has become necrotic, we foment it as beﬁts a dried-out, aﬄicted place. We anoint it with this oint- ment: Take frankincense, mastic, wax, oil,Greek pitch, galbanum, aloe, worm- wood, mugwort, pellitory-of-the-wall, rue, and sage. Let the herbs be ground and let the oil be poured in and mixed upon the ﬁre, and when it is exceedingly hot, strain the oil and place it again upon the ﬁre, and when it begins to boil let the wax be added. Afterward let the other things, which have been powdered and cooked, be strained and added. The sign of thorough cooking is when a drop placed upon marble stays there and hardens. And note that leaves of wild ivy, cooked in wine and laid upon the cancerous place, work very well. On Fissures of the Lips  There are some women who suﬀer from ﬁssures of the lips, and this on account of the excessive embraces of their lovers and their kisses with their lips rubbing between them. We treat these women with an ointment made of ﬂeawort or with the unguent made from lily. Hiis autem illinimus labia cum melle, et postea picem grecam pulueri- zatam superaspergimus. Secundum magistrum Ferrarium,45 accipe magnam nucem et decoque sub cinere eta nucleum tere, et ﬁssure appone apposito tartaro et sanabitur. Facimuse eis recipere uinum in ore in quo bullieritf zinziber, galangam, et post ablutionem circa dentes puluerem olibani superaspergimus,g et cumh eodem uino facimusi osj abluere hiisk qui habent palatum excorti- catum, et post alumen cum zucchara46 apponamus. Puluis zinziberis, pi- retri, et cynamomi decoquimus in uino et facimus gargarizare, et puluerem horum calidorum apponimus uuule. Pulueres uerod etiame predictos in posterioribus facimus insuﬄare per nares ne tume- scant. Accipe albu- minab ouorum51 et distempera cum aqua in qua coctum sit pulegium et huius- modi herbe [rb] calide et panno nouo linic intinctod bis uel ter in diee uuluef ¶a. On Treatments for Women  Likewise there are other women who suﬀer ﬁssures caused by the air and the wind and similar causes. For these, then, we anoint the lips with honey, and afterward we sprinkle on powdered Greek pitch. And after tartar has been put on, apply [the walnut] to the ﬁssure and it will be healed. On Loosening of the Teeth  There are somewomen in whom the teeth are loosened by the cold. We make them take in their mouth wine in which gin- ger and galangal have been boiled, and after this ablution we sprinkle powder of frankincense around the teeth. And for those who have an excoriated palate, we have the mouth washed with this same wine, and afterward we apply alum with sugar. We cook a powder of ginger, pellitory, and cinnamon in wine and we make them gargle, and we apply a powder of these hot things to the uvula. On Prolapse of the Vagina of Women  In prolapse of the vagina after birth we place a tampon, pressing it so that it does not come out except when she urinates. Also we make the powders mentioned above in later [chapters] be blown through the nostrils lest they become swollen. Take the whites of eggs40 and mix them with water in which pennyroyal and hot herbs of this kind have been cooked, and with a new linen cloth dipped ¶a. Et nota quod prius abluenda est bene cum eademi aqua calida cum qua fuerint ista distemperata. Accipe gallas, rosas, sumac, plantaginem, consolidam maio- rem, bolum armenicum, alumen,a chimoleam, ana unciam. On Treatments for Women in it, place it in the vagina two or three times a day. And note that prior to this the vagina ought to be washed well with the same warm water with which these things were mixed. Having ground it, dis- solve it with rainwater, and with a linen or cotton cloth place it in the vagina in the above-mentioned manner. Let the woman sit in water where there have been cooked marsh mallows and pennyroyal, and she will be freed. For Swelling of the Face  For sudden swelling of the face, a fumigation of hot water alone suﬃces. Ad hoc facimusb ma- turatiuum de malua et maluauisco, absinthio, arthimesia, et auxungia, et cum caputc apparuerit,d contere nucleose et appone. Et sif non rumpitur cum ﬂebo- tomo aperiatur, et exprimeg parum in principio ne subita euacuatione malum ﬁat, et inpone licinium singulis diebus bis uel ter, illinitum cum uitello oui. Istis facimus pannum in uino intinctum in quob bullierint folia mirtilli, uelc ipsa herba ueld ipsi mirtilli. On Treatments for Women On Pain of the Breasts  For pain of the breasts caused by milk, we should mix clay with vinegar and make a plaster; this diminishes the pain and constricts the milk. On Lesions of the Breasts  There are some women who have lesions in the breasts. For this we make a maturative from marsh mallow and mayweed, wormwood, mugwort, and animal grease, and when the head [of the lesion] appears, grind together nuts and apply them. And if it does not rupture let it be opened with a lancet, and press out a little in the beginning lest by a sudden evacuation it becomes bad, and each day apply a piece of lint twice or three times smeared with egg yolk. For this cleans every ﬁstula and makes it become necrotic, as long as it is not between any bones. On Foul-Smelling Sweat  There are some women who have sweat that stinks beyond measure. For these we prepare a cloth dipped in wine in which there have been boiled leaves of bilberry, or the herb itself or the bilberries themselves. Accipe pulegium, policariam, quatuor frondes lauri, et bullianta in aqua, et facias eam sedere in aqua ista, et postb fac de omni- bus fumigium. On Treatments for Women On Swelling of the Vagina  For swelling of the vagina. Take pennyroyal, ﬂeabane, and four fronds of laurel, and boil them in water, and you should make her sit in this water, and afterward make a fumigation from all these [herbs]. For Antlike Itching and Itch-Mites  For antlike itches and itch-mites wherever they might be in the body, especially in the face and on the forehead, we mix grain with wine, and with a powder of frankincense applied in the manner of a plaster, we place it on the [aﬄicted] spot. On Pain of the Eyes  For pain of the eyes, take marsh mallow, the herb of violets, tips of bramble, dried roses, vervain, and sermountain. OnW eboftheEye  If there is a web in the eye, take conch and frankincense and burn them. Take two parts of aloe, and as much frank- incense and plaster of Paris as of the aloe; pulverize them ﬁnely and prepare them with fresh animal grease and anoint the place. On Cancer of the Nose  For cancer of the nose, take lungwort, sage, Greek tar, wild garlic, and ‘‘blacking,’’ that is, earth of the countryside,45 and pulverize them all equally.
Invasive alien species and novel pathogens and parasites have many parallels in their biology safe tadapox 80 mg, the risks they pose buy tadapox 80 mg otc, and in the measures required to prevent their establishment and control cheap tadapox 80 mg fast delivery. Prevention of their introduction is preferable to subsequent control quality tadapox 80 mg, and wetland management practices aimed at prevention of any of these can provide additional benefits and protection from all. In: Global biodiversity mechanisms: a thematic review of recent developments and future evidence needs. Rinderpest and peste des petits ruminants: Virus plagues of large and small ruminants (Biology of Animal Infections). Healthy wetlands, healthy people: a review of wetlands and human health interactions. Secretariat of the Ramsar Convention on Wetlands, Gland, Switzerland, & The World Health Organization, Geneva, Switzerland. Guidance on how to incorporate disease management into management plans for wetlands. Case studies: descriptions and photos of wetland managers’ experiences responding to disease problems. Common Eider Somateria mollissima mortality in the spring and winter of 1999/2000 in the Wadden Sea. Snail fever integrated control and prevention project in Tongxing Village of Wucheng Township, Yongxiu County of Jiangxi Province, P. Training for live wild bird avian influenza surveillance in the Dagona Wetlands of Northern Nigeria However, a risk assessment approach can be used to quantify and/or qualify risks and so help the wetland manager to identify an appropriate course of management actions. Understanding diseases of wildlife and domestic stock, and their public health implications, within wetlands requires a multidisciplinary approach. Advisory groups reflecting a diverse range of knowledge and understanding for specific or general issues, can significantly improve risk assessments and advise on best courses of actions that safeguard both livestock interests and wildlife protection appreciating that these may sometimes seem to be at odds. This is illustrated by the use of advisory groups to deal with highly pathogenic avian influenza H5N1 where it is important to appreciate human health issues, poultry trade and economic issues, alongside factors relating to wildlife such as the behaviour and movements of migratory birds. To ensure the principles and specific actions for disease management and control are embedded within the management practices at a wetland site, they should be written into management plans and updated, as and when, disease risks change. Disease control in endemic disease situations depends upon engagement of all key stakeholders together with their sustained participation and cooperation. Disease control in outbreak situations is similarly dependent on stakeholder engagement but also requires preparedness for a rapid response. Appropriate contingency planning helps to reduce response times and promotes the likelihood of an effective resolution. It is sensible to build a degree of flexibility into contingency plans as unexpected local conditions may be important in determining the action to take. Following implementation of contingency plans, they should be critically reviewed and updated. Clearly defined roles and responsibilities are required to ensure effective management which can deliver a range of benefits to stakeholders. Risk assessments are valuable tools for animal health planning and serve to identify problems/hazards and their likely impact thus guiding wetland management practices. Good local, national and regional surveillance data are needed for robust risk assessments. Multidisciplinary advisory groups provide a broad range of benefits for disease prevention and control. Their role is to review epidemiological and other disease control information, inputting to the activation of agreed contingency plans and advising the appropriate decision makers on future contingency planning. Contingency plans aim to consider possible emergency disease management scenarios and to integrate rapid cost effective response actions that allow the disease to be prevented and/or controlled. Risk assessments should be based on the best available data, which may be quantitative or qualitative. Quantitative assessment of risks associated with wildlife diseases is often difficult due to complex disease dynamics and absence of robust biological data. Qualitative assessments of risk are more usual, within which, risks may be described as “extreme”, “high”, “medium” or “low” or a simple scoring system may be employed. Risk assessments should be revised in the light of new data or changing circumstances. Site assessment: site-specific Framework (Ramsar information on stressor and Convention Secretariat environment. Problem or hazard Risk management/risk reduction identification Manage inputs/alter practices. Useful key information relating to potential disease problems includes: Species known or likely to be affected. Human activities contributing to potential problems or hazards in and around the site (e. Identification of the adverse effects and/or extent of the problem For each problem or hazard identified, the effect and extent of the potential impact needs to be evaluated and described. This process can be difficult in view of the scarcity of information relating to wetland disease epidemiology, however, the following sections help to provide a general framework for making these evaluations: What sort of effects may occur and to what extent? For example: The most obvious consequences may be direct mortalities or morbidities of varying scales. If the disease is zoonotic then measures may have to be put in place to reduce human exposure. For example: Range of species potentially affected (including domestic animals, wildlife and humans). Threatened species (present in low numbers and/or fragmented populations) may be at particular risk from disease. When and for how long is the problem likely to occur For example: Disease risks may be seasonal and the range of wild or domestic species present may vary accordingly (e. There may be relatively predictable times of increased risk due to human and livestock activities. For example, during times of livestock movements, when people or vehicular access to the site is greater or when there is application of fertilizer which may contain potentially infected manure. For example: Wetlands tend to be connected so potential for aquatic spread of toxins or pathogens needs to be assessed. Species are likely to be unevenly distributed within a site due to different habitat preferences and daily behavioural patterns (feeding, roosting, resting, bathing/drinking). Some species will be present in dense flocks or herds, some in loose aggregations, and others as small groups or individuals, and different species may mix with one another to varying degrees. For infectious diseases it is worth appreciating how infection may be moved into and out of a wetland into surrounding areas by animal movements. For example, waterbirds may feed on adjacent agricultural fields and fish-eating birds like cormorants may commute between wetlands, rivers, farmed fishponds and coastal areas. Some wildlife species will remain far from human habitation whilst others are attracted as it offers benefits such as food sources, shelter, nesting and safety from predators. Risk management is the practice of identifying, documenting and implementing measures to reduce risks and their associated consequences. Although risks can rarely, if ever, be totally eliminated the aim is to implement actions that reduce the risks to an acceptable level. These following sections illustrate the types of practical risk management practices that can be implemented at wetland sites: ►Section 3. Risk communication is the route for stakeholders (everybody that could be affected) and risk analysts to exchange information and outlooks on risks. Stakeholders should be consulted throughout each process to ensure ownership of decisions. Public health communication may require knowledge of points of contact and a strategy to disclose information. Risk analysis as a component of animal disease emergency preparedness planning, Chapter 3. In: Manual on the preparation of national animal disease emergency preparedness plans. Revue scientifique et technique (International Office of Epizootics), 29 (2): 329-350. Guidance on responding to the continued spread of highly pathogenic avian influenza.
Morphological characteristics order tadapox 80mg visa, pathophysiology buy tadapox 80mg on-line, and relative prevalence of each of the causes of anemia generic 80 mg tadapox mastercard. The classification of anemia into hypoproliferative and hyperproliferative categories and the utility of the reticulocyte count/index buy 80mg tadapox free shipping. The potential usefulness of the white blood cell count and red blood cell count when attempting to determine the cause of anemia. History-taking skills: Students should be able to obtain, document, and present an age-appropriate medical history, that differentiates among etiologies of disease, including: • Constitutional and systemic symptoms (e. Physical exam skills: Students should be able to perform a physical exam to establish the diagnosis and severity of disease, including: • Pallor (e. Laboratory interpretation: Students should be able to recommend when to order diagnostic and laboratory tests and be able to interpret them, both prior to and after initiating treatment based on the differential diagnosis including consideration of test cost and performance characteristics as well as patient preferences. Laboratory and diagnostic tests should include, when appropriate: • Hemoglobin and hematocrit. Communication skills: Students should be able to: • Communicate the diagnosis, treatment plan, and subsequent follow-up to patients. Basic procedural skills: Students should be able to perform and interpret: • Stool occult blood testing. Management skills: Students should be able to develop an appropriate evaluation and treatment plan for patients that includes: • Evaluating for underlying disease processes, given that anemia is not a disease per se, but rather a common finding that requires further delineation in order to identify the underlying cause. Demonstrate commitment to using risk-benefit, cost-benefit, and evidence- based considerations in the selection of diagnostic and therapeutic interventions for anemia. Appreciate the impact anemia has on a patient’s quality of life, well-being, ability to work, and the family. Recognize the importance of and demonstrate a commitment to the utilization of other healthcare professions in the treatment of anemia. It has an important differential diagnosis, and the initial decision-making must be made on the basis of clinical findings. As such, it is an excellent training condition for teaching decision-making based on careful collection and interpretation of basic clinical data. There is emerging data on test utility, especially as regards expensive spinal imaging, which facilitates teaching rational, cost-effective test ordering. Moreover, its requirement for skillful management, patient education, and support facilitate the teaching of these competencies. The symptoms, signs, and typical clinical course of the various causes of back pain including: • Ligamentous/muscle strain (nonspecific musculoskeletal back pain). The role of diagnostic studies in the evaluation of the back pain there indications, limitations, cost: • Plain radiography. Response to therapy of the various etiologies, with understanding of the roles of: • Bed rest. History-taking skills: Students should be able to obtain, document, and present an age-appropriate medical history, that differentiates among etiologies of disease, including: • Cancer history. Physical exam skills: Students should be able to perform a physical exam to establish the diagnosis and severity of disease, including: • Examination of the spine. Laboratory interpretation: Students should be able to recommend when to order diagnostic and laboratory tests and be able to interpret them, both prior to and after initiating treatment based on the differential diagnosis, including consideration of test cost and performance characteristics as well as patient preferences. Communication skills: Students should be able to: • Communicate the diagnosis, treatment plan, and subsequent follow-up to patients. Management skills: Students should able to develop an appropriate evaluation and treatment plan for patients that includes: • Patient education about the typical course of back pain. Demonstrate commitment to using risk-benefit, cost-benefit, and evidence- based considerations in the selection diagnostic and therapeutic interventions for back pain. Recognize the importance of patient preferences when selecting among diagnostic and therapeutic options for back pain. Appreciate the importance of active patient involvement in the treatment of back pain. Appreciate the impact back pain has on a patient’s quality of life, well-being, ability to work, and the family. Recognize the importance of and demonstrate a commitment to the utilization of other healthcare professionals in the treatment of back pain. The ability to distinguish chest pain caused by an acute coronary syndrome (unstable angina or acute myocardial infarction) from other cardiac, gastrointestinal, pulmonary, musculoskeletal or psychogenic etiologies is an important training problem for third-year medical students. Symptoms and signs of chest pain that may be due to an acute coronary syndrome such as unstable angina or acute myocardial infarction. Symptoms and signs of chest pain due to other cardiac causes such as: • Atypical or variant angina (coronary vasospasm, Prinzmetal angina). Symptoms and signs of chest pain due to musculoskeletal causes such as: • Costochondritis. Symptoms and signs of chest pain due to psychogenic causes such as: • Panic disorders. Factors that may be responsible for provoking or exacerbating symptoms of ischemic chest pain by: • Increasing myocardial oxygen demand. Physiologic basis and/or scientific evidence supporting each type of treatment, intervention or procedure commonly used in the management of patients who present with chest pain. Role of a critical pathway or practice guideline in delivering high quality, cost- effective care for patients presenting with symptoms of chest pain in the outpatient clinic, emergency room or hospital. History-taking skills: Students should be able to obtain, document, and present an appropriately complete medical history that differentiates among the common etiologies of chest pain. Physical exam skills: Students should be able to perform a focused physical exam that includes the following elements: • Accurate measurement of arterial blood pressure and recognition of the typical blood pressure findings that occur in patients with aortic stenosis, aortic insufficiency, and pulsus paradoxus. When a heart murmur is present, students should be able to: o Identify timing (systolic vs. Laboratory interpretation: Students should be able to recommend when to order diagnostic and laboratory tests and be able to interpret them, both prior to and after initiating treatment based on the differential diagnosis, including consideration of test cost and performance characteristics as well as patient preferences. Test interpretation should take into account: • Important differential diagnostic considerations including the “must not miss” diagnoses. Communication skills: Students should be able to: • Communicate the diagnosis, prognosis and treatment plan to patients and their families. Management skills: Students should be able to develop an appropriate evaluation and treatment plan for patients that includes: • Identification of the indications, contraindications, mechanisms of action, adverse reactions, significant interactions, and relative costs of the following medications: o Anti-platelet agents (aspirin, clopidogrel). Understand the emotional impact of a diagnosis of coronary artery disease and its potential effect on lifestyle (work performance, sexual functioning, etc). Recognize the importance of early detection and modification of risk factors that may contribute to the development of atherosclerosis. Demonstrate commitment to using risk-benefit, cost-benefit, and evidence- based considerations in the selection of diagnostic and therapeutic interventions for chest pain. Recognize the importance and demonstrate a commitment to the utilization of other healthcare professions in the treatment of chest pain. There are several common etiologies for cough of which a third year medical student should be aware, as well as more clinically concerning etiologies. A proper understanding of the pathophysiology, diagnosis, and treatment of cough is an important learning objective. Symptoms, signs, pathophysiology, differential diagnosis, and typical clinical course of the most common causes cough: • Acute cough: o Viral tracheitis. History-taking skills: Students should be able to obtain, document, and present an age-appropriate medical history that differentiates among the etiologies of disease, including: • Onset. Physical exam skills: Students should be able to perform a physical exam to establish the diagnosis and severity of disease, including: • Accurately determining respiratory rate and level of respiratory distress. Differential diagnosis: Students should be able to generate a prioritorized differential diagnosis recognizing history, physical exam, and laboratory findings that suggest a specific etiology of cough. Laboratory interpretations: Students should be able to recommend when to order diagnostic and laboratory tests and be able to interpret them, both prior to and after initiating treatment based on the differential diagnosis, including consideration of test cost and performance characteristics as well as patient preferences. Laboratory and diagnostic tests should include, when appropriate: • Chest radiograph. Communication skills: Students should be able to: • Counsel and educate patients about environmental contributors to their disease, pneumococcal and influenza immunizations, and smoking cessation.