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By W. Dolok. Green Mountain College.

However buy rizatriptan 10 mg low price, before advances in the underlying science of health discount rizatriptan 10 mg on-line, medicine lacked effective tools cheap 10mg rizatriptan, and religious explanations for disease dominated rizatriptan 10mg sale. As early communi- ties consolidated people more closely buy rizatriptan 10mg with mastercard, severe epidemics of plague, smallpox, and syphilis occurred. The bubonic plague and its coinfections, measles and smallpox, were the most devastating of the epidemic diseases. Starting in the lower Volga it spread to Italy and Egypt in 1347 on merchant ships carrying rats and feas infected with the plague bacillus, Yesinia pestis. The disease apparently was unknown in the New World prior to the appearance of the Spanish and Portuguese conquistadors. Cortez was routed in battle in 1520 but was ultimately victorious as smallpox killed more than 25% of the Aztecs over the next year. He reported that 1000 persons per day died in Tlaxcala, with ultimately 150,000 total dead. At the least, it was appreciated that the skin lesions and scabs could transmit the disease. It was known that survivors of the infection were immune to reinfection after further exposure. The practice of inoculation, or variolation, whereby people were intentionally exposed to smallpox was practiced in China, Africa, and India centuries before the R1 practice would be adopted in Europe and the Americas. Syphilis became epidemic in the 1490s as a highly contagious vene- real disease in Spain, Italy, and France. One theory proposes that it began as a tropical disease transmitted by direct (nonsexual) contact. After the frst accounts of syphilis, it was reported to spread rapidly through Europe and then North America. In keeping with the hypothesis that syphilis was a recently emerged disease, mortality from syphilis was high in these early epidemics. In his treatise Airs, Water and Places, Hippocrates dismissed supernatural explanations of disease and instead attributed illness to characteristics of the climate, soil, water, mode of life, and nutrition surrounding the patient. Galen combined his practical experience caring for gladiators with experiments, including vivisections of animals, to study the anatomy and physiology of man. It was over a thousand years before Andreas Vesalius (1514–1564), who based his work on dissections of humans, was able to correct Galen’s errors in anatomy. Plague was rec- ognized to be contagious; however, the control measures focused primarily on quarantine and disposal of the bodies and the possessions (presumably contaminated) of the victims. Although it was observed that large numbers of rats appeared during an epidemic of plague, the role of rats and their feas was not appreciated. Given that leprosy progresses slowly, quarantine of cases late in disease likely had little effect on the epidemic spread. In the Middle Ages lepers were literally stricken from society as leprosy became increasingly equated with sin. Some R1 even required lepers to stand in a dug grave and receive the “Mass of Sepa- © Jones and Bartlett Publishers. I forbid you to leave your house unless dressed in your recognizable garb and also shod. I forbid you to wash your hands or to launder anything or to drink at any stream or fountain, unless using your own barrel or dipper. I forbid you to enter any tavern; and if you wish for wine, whether you buy it or it is given to you, have it funneled into your keg. I command you, if accosted by anyone while traveling on a road, to set yourself downwind of them before you answer. I forbid you, wherever you go, to touch the rim or the rope of a well without donning your gloves. Fracastoro (1478–1553) was much more than just an author of the popular poem on syphilis. Although revolutionary, Fracastoro did not realize that the seeds of a disease were microbes, and he held to ancient beliefs that they were infuenced by planetary conjugation particularly “nostra trium superiorum, Saturni, Iovis et Martis” (our three most distant bodies: Saturn, Jupiter, and Mars).

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The copyright owners grant third parties the right to use the Internal Medicine Milestones on a non-exclusive basis for educational purposes purchase rizatriptan 10mg with mastercard. He/she is demonstrating a learning trajectory that anticipates the achievement of competency for unsupervised practice that includes the delivery of safe buy 10 mg rizatriptan amex, effective cheap rizatriptan 10 mg with mastercard, patient-centered cheap rizatriptan 10mg without a prescription, timely rizatriptan 10mg, efficient and equitable care. The copyright owners grant third parties the right to use the Internal Medicine Milestones on a non-exclusive basis for educational purposes. An improvement plan is in place to facilitate achievement of competence appropriate to the level of training. Copyright (c) 2012 The Accreditation Council for Graduate Medical Education and The American Board of Internal Medicine. The copyright owners grant third parties the right to use the Internal Medicine Milestones on a non-exclusive basis for educational purposes. The Milestones provide a framework for the assessment of the development of the resident physician in key dimensions of the elements of physician competency in a specialty or subspecialty. They neither represent the entirety of the dimensions of the six domains of physician competency, nor are they designed to be relevant in any other context. They are descriptors and targets for resident performance as a resident moves from entry into residency through graduation. For each reporting period, review and reporting will involve selecting the level of milestones that best describes a resident’s current performance level in relation to milestones, using evidence from multiple methods, such as direct observation, multi-source feedback, tests, and record reviews, etc. Selection of a level implies that the resident substantially demonstrates the milestones in that level, as well as those in lower levels (See the diagram on page v). A general interpretation of levels for emergency medicine is below: Level 1: The resident demonstrates milestones expected of an incoming resident. Level 2: The resident is advancing and demonstrates additional milestones, but is not yet performing at a mid-residency level. Level 3: The resident continues to advance and demonstrate additional milestones; the resident demonstrates the majority of milestones targeted for residency in this sub-competency. Level 4: The resident has advanced so that he or she now substantially demonstrates the milestones targeted for residency. Level 5: The resident has advanced beyond performance targets set for residency and is demonstrating “aspirational” goals which might describe the performance of someone who has been in practice for several years. Answers to Frequently Asked Questions about Milestones are available on the Milestones web page: http://www. For each reporting period, a resident’s performance on the milestones for each sub-competency will be indicated by:  selecting the level of milestones that best describes the resident’s performance in relation to the milestones or  selecting the “Has not Achieved Level 1” response option Selecting a response box in the middle of a Selecting a response box on the line in between levels level implies that milestones in that level and indicates that milestones in lower levels have been in lower levels have been substantially substantially demonstrated as well as some milestones demonstrated. The copyright owners grant third parties the right to use the Emergency Medicine Milestones on a non-exclusive basis for educational purposes. The copyright owners grant third parties the right to use the Emergency Medicine Milestones on a non-exclusive basis for educational purposes. The copyright owners grant third parties the right to use the Emergency Medicine Milestones on a non-exclusive basis for educational purposes. The copyright owners grant third parties the right to use the Emergency Medicine Milestones on a non-exclusive basis for educational purposes. Has not Achieved Level 1 Level 2 Level 3 Level 4 Level 5 Level 1 Knows the different Applies medical knowledge Considers array of drug Selects the appropriate Participates in developing classifications of pharmacologic for selection of therapy for treatment. The copyright owners grant third parties the right to use the Emergency Medicine Milestones on a non-exclusive basis for educational purposes. The copyright owners grant third parties the right to use the Emergency Medicine Milestones on a non-exclusive basis for educational purposes. The copyright owners grant third parties the right to use the Emergency Medicine Milestones on a non-exclusive basis for educational purposes. The copyright owners grant third parties the right to use the Emergency Medicine Milestones on a non-exclusive basis for educational purposes. Has not Achieved Level 1 Level 2 Level 3 Level 4 Level 5 Level 1 Identifies pertinent Performs patient assessment, Determines a backup Performs indicated Teaches procedural anatomy and physiology obtains informed consent and strategy if initial attempts procedures on any patients competency and corrects for a specific procedure ensures monitoring equipment is to perform a procedure are with challenging features mistakes in place in accordance with unsuccessful (e. The copyright owners grant third parties the right to use the Emergency Medicine Milestones on a non-exclusive basis for educational purposes. The copyright owners grant third parties the right to use the Emergency Medicine Milestones on a non-exclusive basis for educational purposes. Has not Achieved Level 1 Level 2 Level 3 Level 4 Level 5 Level 1 Discusses with the patient Knows the indications, Knows the indications, Performs procedural Develops pain indications, contraindications contraindications, contraindications, potential sedation providing management and possible complications of potential complications complications and appropriate doses effective sedation protocols/care plans local anesthesia and appropriate doses of of medications used for procedural with the least risk of analgesic/sedative sedation complications and Performs local anesthesia using medications minimal recovery time appropriate doses of local Performs patient assessment and through selective anesthetic and appropriate Knows the anatomic discusses with the patient the most dosing, route and technique to provide skin to landmarks, indications, appropriate analgesic/sedative choice of medications sub-dermal anesthesia for contraindications, medication and administers in the procedures potential complications most appropriate dose and route and appropriate doses of local anesthetics used for Performs pre-sedation assessment, regional anesthesia obtains informed consent and orders appropriate choice and dose of medications for procedural sedation Obtains informed consent and correctly performs regional anesthesia Ensures appropriate monitoring of patients during procedural sedation Comments: Suggested Evaluation Methods: Procedural competency forms, checklist assessment of procedure and simulation lab performance, global ratings, patient survey, chart review Copyright (c) 2012 The Accreditation Council for Graduate Medical Education and The American Board of Emergency Medicine. The copyright owners grant third parties the right to use the Emergency Medicine Milestones on a non-exclusive basis for educational purposes. The copyright owners grant third parties the right to use the Emergency Medicine Milestones on a non-exclusive basis for educational purposes.

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