A = Acetinado CR = Cremoso C = Cintilante. Spinal implants retrieved from 11 patients with scoliosis were examined. All the implants were posterior instrumentation systems made of 316L stainless steel and. Find patient medical information for VITAMIN E on WebMD including its uses, effectiveness, side effects and safety, interactions, user ratings and products that have it. Change Your Brain program references and further reading recommendations, based on more than 600 sources. Search torrents on dozens of torrent sites and torrent trackers. Unblock torrent sites by proxy. PirateBay proxies, RARBG unblocked and more torrent proxies. 9780415405713 0415405718 Adolescent Coping - Advances in Theory, Research and Practice, Erica Frydenberg 9781436756174 1436756170 A Treatise on Copyholds V1. Connections are at the heart of Sinai Health System. We are working to forge stronger connections between patients and caregivers, colleagues and care settings and. The All-Day Energy Diet helps busy, everyday people enjoy more energy, improve their health, and lose weight by restoring their bodies' optimal vitality. Com textura cremosa, cores intensas e alta cobertura, a coleção de batons da Vult oferece mais de 60 cores entre os acabamentos cremosos, cintilantes e acetinados. Study online flashcards and notes for 2012 ITE Question and Answers.pdf including Name American Board of Family Medicine IN-TRAINING EXAMINATION TIME–4 HOURS Read. JESUS FASTENING MOFFETT SHUSTER MORTARS Garbhán Tintorero SOLTAU GAUTHREAUX Yocemento SUSPECTS' PINCKNEY UNPRESERVED DRINKER LEACHMAN JABBING WEAK.
0 Comments
Mc. Kale Memorial Center - Arizona. Wildcats. com. 17. E. Enke Drive. Tucson, AZ 8.
Directions: http: //tinyurl. The opening of Mc. Kale Memorial Center in February of 1. Below is a partial list of minor league baseball players of the minor league affiliates of the Arizona Diamondbacks. News, Arizona Wildcats sports, breaking news, lifestyle, parenting, business, entertainment, weather, jobs, autos and real estate listings from the Arizona Daily Star. Kickoff your Fantasy Football season at Fantrax with the best Commissioner, Salary Cap and Classic Draft leagues around. Wildcat basketball. After playing several games in front of crowds of a few thousand in Bear Down Gym to open the 1. Mc. Kale and literally filled the upscale arena overnight with crowds over 1. Named after the late J. F. It is situated off the UA mall, adjacent to Arizona Stadium and the Hillenbrand Aquatic Center. Mc. Kale houses the offices for the entire athletic department, aside from the football program, and includes a state- of- the- art weight room and the Hall of Champions on the north end of the building. Following the Arizona State game on February 2. University of Arizona athletic department honored head coach Lute Olson with a ceremony to name the Mc. Kale Center floor, . Olson led seven teams to undefeated seasons at home, and Arizona has led the Pac- 1. Part of the attraction for fans is the winning tradition that was quickly established in Mc. Kale. Arizona defeated WAC rival Wyoming, 8. Feb. 1, 1. 97. 3, and went on to win 6. Mc. Kale. Then, from 1. Arizona put together the 1. NCAA history, winning 7. Mc. Kale and making tickets nearly impossible to find. By the time UCLA snapped the string on Jan. Cats, there was rarely an empty seat in Mc. Kale for any game. That tradition keeps growing as Arizona teams continue to win games in front of sell- out crowds. UA has won 7. 4 of its 8. Sean Miller and has an overall record of 5. Mc. Kale, for a winning percentage of . Since the National- Championship season of 1. Arizona has a record of 2. Mc. Kale. The seating capacity has fluctuated through the 4. Mc. Kale opened in 1. Elimination of all bleacher seating dropped the level to 1. After a renovation was completed prior to the 2. The largest crowd in Mc. Kale history was the 1. Arizona face New Mexico on Jan. The largest crowd in the Lute Olson era showed up for the 1. Morgan State (1. 4,6. Arizona's National Championship. Since its initial construction at a cost of $8. Mc. Kale Center has undergone numerous face lifts to keep up with the times. Sophisticated computerized message boards spanning the upper deck on both sides of the court, along with padded press row and officials' tables with computer- drive scoreboards were added in the early 1. The 1. 99. 2 season saw the installation of four huge video replay screens in each corner of the arena. At the conclusion of the 1. The 2. 00. 1- 2. 00. A new four- sided scoreboard with video replay screens was installed and hung from the center of the arena. Then, prior to the 2. The new scoreboard features four 1. LED rings. In addition, the renovation addressed amenities and upgrades that include men’s and women’s locker rooms, concessions and restrooms. Mc. Kale's reputation has attracted several major national sports events. It was the site for the NCAA Wrestling West Regionals in 1. NCAA Wrestling Championships in 1. More recently, Mc. Kale was a site for the men's NCAA first and second rounds in 1. In addition, the USA Basketball Team trained in the arena prior to capturing the 1. World Championships, and Arizona played host to the second Pac- 1. Conference tournament in 1. The facility is 4. University's athletic department. With three levels that consist of equipment rooms, a training and rehabilitation center, locker rooms, storage areas, ticket operations, academic services, computer lab facilities and administrative offices, Mc. Kale Center is the primary gathering place for all of UA athletics. Vital Stats - Mc. Kale Center. Mc. Kale Center's Largest Crowds. New Mexico. 1/1. 4/7. Arizona State. 3/4/7. Morgan State. 11/2. Coppin State. 12/1. UCLA1/2. 0/9. 6Mc. Kale Center's Largest Crowds During the Lute Olson Era (1. Morgan State. 11/2. Coppin State. 12/1. UCLA1/2. 0/9. 64. California. 1/3. 0/9. USC3/4/9. 9Yearly Attendance & Record in Mc. Kale Center. Year. Games. Record. Total. Avg. 1. 97. 2- 7. Totals. 63. 85. 25- 1. Full Capacity* Led the Pac- 1. Pac- 1. 2 in attendance% Figure includes three home games during the Pac- 1. Tournament$ Mc. Kale Center opened Feb. NCAA infractions. Actual on- court record was 1. Facility win/loss record and winning percentage reflects those vacated victories. Catfish - Wikipedia. Catfish (or catfishes; order.
Siluriformes or Nematognathi) are a diverse group of ray- finnedfish. Named for their prominent barbels, which resemble a cat's whiskers, catfish range in size and behavior from the three largest species, the Mekong giant catfish from Southeast Asia, the wels catfish of Eurasia and the Pira. There are armour- plated types and there are also naked types, neither having scales. Despite their name, not all catfish have prominent barbel. Members of the Siluriformes order are defined by features of the skull and swimbladder. Catfish are of considerable commercial importance; many of the larger species are farmed or fished for food. Many of the smaller species, particularly the genus Corydoras, are important in the aquarium hobby. Many catfish are nocturnal. Catfish have inhabited all continents at one time or another. They are the only ostariophysans that have entered freshwater habitats in Madagascar, Australia, and New Guinea. However, the European stock of American catfishes has not achieved the dimensions of these fish in their native waters, and have only increased the ecological pressure on native European fauna. Walking catfish have also been introduced in the freshwaters of Florida, with the voracious catfish becoming a major alien pest there. Flathead catfish, Pylodictis olivaris, is also a North American pest on Atlantic slope drainages. In general, they are negatively buoyant, which means that they will usually sink rather than float due to a reduced gas bladder and a heavy, bony head. Some have a mouth that can expand to a large size and contains no incisiform teeth; catfish generally feed through suction or gulping rather than biting and cutting prey. Catfish also have a maxilla reduced to a support for barbels; this means that they are unable to protrude their mouths as other fish such as carp. Catfish barbels always come as pairs. Many larger catfish also have chemoreceptors across their entire bodies, which means they . Like other ostariophysans, they are characterized by the presence of a Weberian apparatus. In some species, the mucus- covered skin is used in cutaneous respiration, where the fish breathes through its skin. In loricarioids and in the Asian genus Sisor, the armor is primarily made up of one or more rows of free dermal plates. Similar plates are found in large specimens of Lithodoras. These plates may be supported by vertebralprocesses, as in scoloplacids and in Sisor, but the processes never fuse to the plates or form any external armor. By contrast, in the subfamily Doumeinae (family Amphiliidae) and in hoplomyzontines (Aspredinidae), the armor is formed solely by expanded vertebral processes that form plates. Finally, the lateral armor of doradids, Sisor, and hoplomyzontines consists of hypertrophied lateral lineossicles with dorsal and ventral lamina. As a defense, these spines may be locked into place so that they stick outwards, which can inflict severe wounds. These juveniles can be readily placed in their families, particularly those with highly derived fin or body shapes; in some cases identification of the genus is possible. As far as known for most catfish, features that are often characteristic of species such as mouth and fin positions, fin shapes, and barbel lengths show little difference between juveniles and adults. For many species, pigmentation pattern is also similar in juveniles and adults. Thus, juvenile catfishes generally resemble and develop smoothly into their adult form without distinct juvenile specializations. Exceptions to this are the ariid catfishes, where the young retain yolk sacs late into juvenile stages, and many pimelodids, which may have elongated barbels and fin filaments or coloration patterns. Some Goonch in the Kali river grow large enough to attack humans and water buffalo. Catfish have one of the greatest ranges in size within a single order of bony fish. Mythology and literature record wels catfish of astounding proportions, yet to be proven scientifically. The average size of the species is about 1. However, they are known to exceed 2. In July 2. 00. 9, a catfish weighing 8. River Ebro, Spain, by an 1. British schoolgirl. The largest flathead catfish, Pylodictis olivaris, ever caught was in Independence, Kansas, weighing 5. These records pale in comparison to a giant Mekong catfish caught in northern Thailand on 1 May 2. Among the most recent crappie tracking studies, this study lends insight to where are crappies. Catfish guide for the Albino Cory, Corydoras paleatus, Albino Paleatus Cory profile, Armored Catfish information and pictures, habitat, diet, and care, breeding. Many athletes have a large part of their daily diets that consist of fish and seafood. The reason is obviously quite simple - protein. Exploit the following guide on. Bluegill Characteristics. A deep, slab-sided sunfish with a small mouth. The upper jaw does not reach the front of the eye when the mouth is closed. This is the largest giant Mekong catfish caught since Thai officials started keeping records in 1. Wade was of the opinion that the offending fish must have been significantly larger than this to have taken an 1. Pira. They can occasionally grow to 4. There are also reports in the region of deaths from being swallowed by these fish. Internal anatomy. Most of the internal organs are located near the head. In many catfish, the humeral process is a bony process extending backward from the pectoral girdle immediately above the base of the pectoral fin. It lies beneath the skin where its outline may be determined by dissecting the skin or probing with a needle. Many catfish have a tapetum lucidum which may help enhance photon capture and increase low- light sensitivity. Double cones, though present in most teleosts, are absent from catfish. They are typically paired, multi- chambered, and connected with the sperm duct, and have been reported to play a glandular and a storage function. Seminal vesicle secretion may include steroids and steroid glucuronides, with hormonal and pheromonal functions, but it appears to be primarily constituted of mucoproteins, acid mucopolysaccharides, and phospholipids. In the first type, the oocytes are released directly into the coelomic cavity and then eliminated. In the second type, the oocytes are conveyed to the exterior through the oviduct. They are also able to determine the distance of the sound's origin and from what direction it originated. List from Thewebsiteofeverything of fish beginning with A. Includes articles, facts and pictures.Catfish are able to produce a variety of sounds for communication that can be classified into two groups: drumming sounds and stridulation sounds. In these fishes, sonic muscles insert on the ramus Mulleri, also known as the elastic spring. The sonic muscles pull the elastic spring forward and extend the swimbladder. When the muscles relax, the tension in the spring quickly returns the swimbladder to its original position, which produces the sound. Many species in the catfish family possess an enhanced first pectoral fin ray, called the spine, which can be moved by large abductor and adductor muscles. The base of the catfishes’ spines has a sequence of ridges, and the spine normally slides within a groove on the fish’s pelvic girdle during routine movement; but, pressing the ridges on the spine against the pelvic girdle groove creates a series of short pulses. In some catfishes, pectoral fins are longer in males than in females of similar length, and differences in the characteristic of the sounds produced were also observed. During courtship behavior in three species of Corydoras catfishes, all males actively produced stridulation sounds before egg fertilization, and the species’ songs were different in pulse number and sound duration. According to a study by Kaatz, sounds for disturbance (e. Due to these constraints, some fish may not even be able to produce a specific sound. In several different species of catfish, aggressive sound production occurs during cover site defense or during threats from other fish. More specifically, in long- whiskered catfishes, drumming sounds are used as a threatening signal and stridulations are used as a defense signal. Kaatz investigated 8. Farm- Raised Catfish. Catfish are easy to farm in warm climates, leading to inexpensive and safe food at local grocers. About 6. 0% of U. S. Several walking catfish (Clariidae) and shark catfish (Pangasiidae) species are heavily cultured in Africa and Asia. Exports of one particular shark catfish species from Vietnam, Pangasius bocourti, has met with pressures from the U. S. In 2. 00. 3, The United States Congress passed a law preventing the imported fish from being labeled as catfish. Other catfish commonly found in the aquarium trade are banjo catfish, talking catfish, and long- whiskered catfish. Catfish as food. Judgments as to the quality and flavor vary, with some food critics considering catfish excellent to eat, while others dismiss them as watery and lacking in flavor. Migrants from Europe and Africa to the United States brought along this tradition, and in the Southern United States, catfish is an extremely popular food. The most commonly eaten species in the United States are the channel catfish and the blue catfish, both of which are common in the wild and increasingly widely farmed. Farm- raised catfish became such a staple of the diet of the United States that on 2. June 1. 98. 7, President Ronald Reagan established National Catfish Day to recognize . In Europe it is often cooked in similar ways to carp, but in the United States it is popularly crumbed with cornmeal and fried. The same dish can also be called as lele penyet (squashed catfish) if the fish is lightly squashed along with sambal in the stone mortar. The pecel/pecak version present the fish in separate plate while the stone mortar is solely for sambal (Lele is the Indonesian word for catfish.)In Malaysia catfish, called . Catfish, locally known as thedu oretta in Malayalam, is popular in the Indian state Kerala. In Hungary catfish is often cooked in paprika sauce (Harcsapaprik. It is traditionally served with pasta smothered with curd cheese (t. It is particularly cooked in a delicacy popularly known as . Many catfish species have “stings” (actually non- venomous in most cases) embedded behind their fins; thus precautions must be taken when handling them. Taxonomy. This is supported by molecular evidence. Some place Gymnotiformes as a sub- order of Siluriformes, however this is not as widely accepted. Recently updated. Author- Eileen C. First in a 1. 4- part series describing the Freshwater Fishes of New York. Some Catfishes Of New York. Mention the word catfish or bullhead and most people think - ugly! I think - survivor! While catfish thrive and enjoy clean, pristine water, if the water is too warm, too murky, or does not have enough oxygen to support other fish species, chances are you may find a member of the catfish family present. As a group, catfish are among the hardiest fishes living under some of the worst conditions. What other fish can survive for days and even weeks in a dried up pond by burying itself in the wet mud? It is no accident that catfish can survive in such adverse conditions. Catfish have evolved to tolerate muddy, low water situations. Under low oxygen levels, certain catfish such as brown bullheads can breathe through their skin and even use their air bladder as an emergency lung by gulping surface air. Highly adaptable, catfish are found in a wider range of habitats than most other freshwater fish. They are generally warmwater fish that live in ponds, lakes, or quiet, slow moving streams and rivers, but they are also present in many cool Adirondack lakes. Catfish are distinctive and easily recognized. Adults are almost always medium- sized, averaging eight to 1. However, channel catfish can reach over 2. Catfish have broad, flat heads, eight whiskers (called barbels), no scales, and strong, serrated spines at the front of three of their fins. While they may not win any beauty contest, their odd features are actually part of their adaptations to their environment. Catfish are nocturnal - feeding most actively at night. Locating food in such dim light could be difficult; however, one of their most noticeable features - the barbels on their face - act as taste and touch sensors that help locate food along the bottom. Catfish have a very diverse diet, generally eating any object they can get their mouths around. Their major foods are insects, crustaceans and fish. Catfish also possess a unique defense mechanism similar to a porcupine. They have three sharp spines located on their bodies: one at the front of the dorsal fin (on its back), and one on each of the two pectoral fins (just behind the head, on the sides of the belly). These spines can be locked into a position perpendicular to the catfish's body, making it difficult for other fish to eat them. Despite this unusual defense, however, catfish are eaten by bass, walleye, other catfish, snapping turtles, and fish- eating water birds. Reproduction (spawning) takes place in late spring and early summer. Like many fish, the catfish constructs a nest and the female deposits the eggs. The male (sometimes aided by the female) builds a saucer- shaped nest or excavates a tunnel near some kind of protective cover. But unlike other fish such as yellow perch, trout and pike who simply lay the eggs and leave, adult catfish will guard the eggs and schooling young for several weeks. By chasing away potential predators, catfish are ensuring better survival for their young. Catfish, especially bullheads, are popular sportfish. They are plentiful, easy to catch, very tasty, and can be fished all year long in New York State. Catfish are among the few fish available for early spring fishing. Simple techniques, such as fishing on the bottom with worms or live cutup baitfish, are very productive. In New York State, there are two major catfish groups: the first includes the larger species such as the channel catfish, white catfish, brown bullhead, yellow bullhead, and black bullhead - the important food or sportfish members of New York State's catfish family. The second group is composed of the small catfishes called madtoms and stonecat and will not be discussed in this article. Persons interested in finding out more about any member of the catfish family can refer to the book, . Lavett Smith. The brown bullhead is the most common catfish in New York State and is found in nearly all waters and all areas of the State. Often, when New Yorkers see or eat catfish, it is a brown bullhead. The brown bullhead is a medium sized fish - averaging about eight to 1. It has the typical catfish appearance of a broad, flat head and dark barbels around the face. Its square tail and mottled side coloration distinguishes it from other members of the catfish family. The brown bullhead is generally dark brown above and yellow to white on its belly, but as is the case with most fishes, its color may vary with its surroundings. Brown bullheads are probably the most adaptable member of the catfish family and live in a wide variety of habitats. They exemplify the hardiness of catfishes in general, tolerating both high water temperatures and low oxygen levels. They are present in many cool Adirondack lakes and often abundant in warm water ponds, lakes, and larger, slow moving streams. They occur in areas with or without aquatic vegetation and can be found over both muddy and gravelly bottoms. Spawning takes place in May or June when the water temperature approaches 7. Fahrenheit. The entire process can take as much as several weeks, with one or both parents remaining for the whole time. Bullhead nests are usually found in a shaded spot near a log, but sometimes they will nest inside objects such as an auto tire nailed to a boat dock. Brown bullheads are delicious to eat and a favorite of many. During the spring, anglers can catch them by the bucketful and large bullhead feeds are popular especially in New York State's Great Lakes counties. New York State's yellow bullhead is much less common than the brown bullhead. It can be found in the extreme western tributaries of Lake Erie, the Genesee River system, bays and tributaries along Lake Ontario, in Oneida Lake, the Mohawk and Mid- Hudson River system, lower Hudson river tributaries, and the St. Lawrence River. While it is most often mistaken for the brown bullhead, a yellow bullhead can be distinguished by its white chin barbels. In addition, the yellow bullhead has a somewhat smaller (eight to 1. Yellow bullheads prefer the waters of ponds, streams, and small brooks, with some vegetation and clear water. They spawn slightly earlier than other bullheads - usually in late May or June. Nests are often built under a stream bank or near the protection of large stones or stumps. Yellow bullheads are less tolerant of harmful conditions than their cousins the brown bullheads. They do not tolerate turbid or muddy waters well and removal of stumps, logs, or vegetation - needed for spawning cover - will cause a decrease in their numbers. Like other catfish, yellow bullheads make a tasty meal. However, because of their more limited range, they are not often caught by anglers. Averaging eight to ten inches long, the black bullhead is the smallest of New York State's bullheads. It is even tougher than the brown bullhead and can withstand extremely high water temperatures and silty conditions. Black bullheads are uncommon in the State, restricted to the upper Genesee River drainage, a few locations in the Lake Ontario drainage, and in the St. Lawrence tributaries. In appearance, black bullheads closely resemble brown bullheads and are difficult to tell apart, especially when young. Perhaps the biggest difference between the two is that black bullheads usually lack the color mottling found on the sides of brown bullheads. Like the brown bullhead, the black bullhead is usually not found in cold, clear water, preferring the silty water areas of ponds, sluggish creeks and rivers. It does not live in the same areas as brown or yellow bullheads, but sometimes will replace those species if the habitat worsens. The black bullhead has reproductive habits similar to other bullheads. It spawns near aquatic vegetation in the spring and early summer. Black bullheads are not actively pursued by anglers in New York State. Their small size and restricted range make them a less popular game fish. The channel catfish is the largest of New York State's catfish and is a formidable sportfish. Channel cats reach trophy size of 2. Yet despite their attributes, relatively few New York State anglers seek them. Channel catfish can be found in a number of the State's larger waters, including Lake Erie, Niagara River, Lake Ontario, St. Lawrence River, Finger Lakes, Canal system, Oneida Lake, and Lake Champlain. They can be distinguished from other members of the catfish family by their large size and deeply forked tail. Young and most adult channel catfish have many small black spots along their sides, but these often disappear on the larger, older fish. Channel catfish differ from their cousins the bullheads in that they prefer the clearer waters of large lakes and streams. Often, they are found in currents over gravel or stony bottoms, such as areas below power dams. Channel cats are tolerant of adverse conditions such as low oxygen levels and warm waters, but to a lesser degree than bullheads. Channel catfish also differ from the bullheads in their nest building technique. Rather than make a depression in the bottom, channel catfish make a tunnel. The tunnels are usually built under logs or in other protected areas where the water is clear. The male guards the eggs and young. Channel catfish are most active just before sunrise and sunset. Due to their larger size and clearer habitat, adult channel cats may eat more live fish than bullheads and have even been found to have birds in their stomachs. Channel cats play an important role as a food fish in the United States. They are raised for food on huge catfish farms in several southern states. Their unique ability to quickly turn food into flesh makes them perfect for this purpose. The culture and sale of catfish fillets are becoming a major agricultural industry. Southern catfish fillets are found in many New York State supermarkets. The white catfish is the least common member of New York State's catfish family. It has a very restricted range, occurring only in the lower Hudson River and a few inland lakes. SESSION TITLE: Allergy and Airway Poster Discussions. SESSION TYPE: Original Investigation Poster Discussion. PRESENTED ON: Wednesday, October 28, 2015 at 08:45 AM. Causes of Acute Renal Failure. Acute renal failure can result from decreased renal perfusion without cellular injury; an ischemic, toxic, or obstructive insult to the. Practice Board Questions Although calcium (gluconate or chloride) in. The cookies contain no personally identifiable information and have no effect once you leave the Medscape site.
Fischer Question Link - USMLE Forumbrain. X Digital Learning System. Study Session of Knowledge. Base: Practice Exam 1. Record # 1. Question/Fact: A 3. Polish man comes to the clinic for painful calves after walking long distances and for discoloration of the fingers with changes in temperature. He says his symptoms started two months ago, and he gets no relief from the ibuprofen. He has previously been healthy. He currently smokes a pack a day and drinks socially. He has no history of drug abuse. On physical examination, his blood pressure is 1. Hg, heart rate is 6. Examination of the hands reveals distal digital ischemia and trophic changes in the nails of both hands. Radial pulses are absent bilaterally, but all other pulses are present. His right calf shows evidence of a superficial thrombophlebitis. Laboratory studies show: white cell count 9,6. MCV 8. 9 . The rheumatoid factor and ANA are negative. Which of the following should be done next for this patient?(A) Heparin(B) Prednisone(C) Arterial bypass(D) Cyclophosphamide(E) Abstention from tobacco. Answer: (E) Abstention from tobacco. Explanation: This patient has thromboangiitis obliterans (Buerger's disease), which is an inflammatory occlusive disorder involving small and medium- sized arteries and veins in the distal and upper extremities. The prevalence is highest in men of Eastern European descent under the age of 4. Although the cause is unknown, there is a definite relationship to cigarette smoking and an increased incidence of HLA- B5 and - A9 antigens in patients with this disorder. Clinical features of thromboangiitis obliterans often include a triad of claudication of the affected extremity, Raynaud's phenomenon, and migratory superficial thrombophlebitis. Claudication is confined to the lower calves and feet or forearms and hands because this disorder primarily affects the distal vessels. Hand examination can reveal severe digital ischemia, trophic nail changes, ulceration, and gangrene at the tips of the fingers. Brachial and popliteal pulses are usually present, but radial, ulnar, and/or tibial pulses may be absent. Smooth, tapering, segmental lesions in the distal vessels are present on angiography. The diagnosis can be confirmed by excisional biopsy of an involved vessel. There is no specific treatment, except abstention from tobacco. The prognosis is worse in those who continue to smoke, but results are relatively good in those who stop. C- ANCA antibodies are usually found in Wegener's granulomatosis. Arterial bypass may be indicated in disease confined to larger vessels. The hand abnormalities effectively exclude peripheral vascular disease. If these measures fail, amputation may be required. Cyclophosphamide and prednisone do not help. Again, the management is to stop smoking.==============Topic: Rheumatology. Record # 2. Question/Fact: A 2. Crohn's disease presents to your office with recurrent abdominal pain and diarrhea. She has been taking mesalamine 4 grams per day for the last year. Last fall, after developing diarrhea and pain, she was placed on prednisone 6. She had a complete remission and, after a 3- month tapering of the prednisone, suffered a relapse. Prednisone was restarted 2 months ago at 6. She is having 6 to 8 water stools per day, crampy pain, and some weight loss. What would be the best next step?(A) Restart the prednisone and plan to maintain the dose at 4. B) Restart the prednisone with 6- mercaptopurine and plan on prednisone taper in 2 months(C) Stop the prednisone and add cyclosporine(D) Admit to the hospital and give high- dose intravenous steroids to induce remission(E) Stop the mesalamine and add methotrexate. Answer: (B) Restart the prednisone with 6- mercaptopurine and plan on prednisone taper in 2 months. Explanation: Prednisone is effective in treating active Crohn's disease for short durations (3- 6 months). Long- term use for maintenance is not indicated. Mercaptopurine and azathioprine are steroid- sparing medications used to limit the need for prednisone. Prednisone, like other corticosteroids, has numerous side effects and should only be used for treating active flares of disease, not maintenance of remission. Cyclosporine and methotrexate have limited roles in the management of Crohn's disease. Topic: Gastroenterology. Record # 3. Question/Fact: A 6. At the time of presentation, he appears to be in moderate distress from the leg pain. The patient states that his symptoms started two days ago. The patient also has frequent urination and increased thirst. He states that he has felt weak for the past few months. Physical examination reveals a tender, erythematous, and swollen right calf. Learning Objectives. This is a beginning to intermediate level course. After completing this course, mental health professionals will be able to. Primary care rationale: This is an example of primary care nursing, in which the RN is the principal or primary person to manage and coordinate the client's care. The following represent additions to UpToDate from the past six months that were considered by the editors and authors to be of particular interest. Hypertension. Norvasc ® is indicated for the treatment of hypertension, to lower blood pressure. Lowering blood pressure reduces the risk of fatal and nonfatal. He also has 2+ pitting edema in all extremities. Blood pressure is 1. Hg, and temperature is 1. F. Venous ultrasound is positive for lower extremity deep vein thrombosis. Laboratory studies reveal: White cell count 1. K 4. 0 m. Eq/L; BUN 2. L; creatinine 1. 7 mg/d. L. The PT/PTT are normal. Total bilirubin 0. L, AST 2. 8 U/L, albumin l. L, cholesterol 3. L; triglycerides 4. L. Urine dipstick shows protein 3+, hemoglobin 1+, white cells 1+; 2. What is the next step in the treatment of this patient?(A) Renal biopsy(B) Plasmapheresis(C) Anticoagulation(D) Cyclophosphamide(E) Prednisone. Answer: (C) Anticoagulation. Explanation: This patient has nephrotic syndrome based on the presence of edema, hyperproteinuria, hypoproteinemia, and hyperlipidemia. Such patients are predisposed to developing a hypercoagulable state secondary to the renal losses of proteins C and S and antithrombin III, as well as increased platelet activation. Patients with evidence of venous thrombosis should be anticoagulated for at least 6 months. Recurrent thrombosis and renal vein thrombosis warrant lifelong anticoagulation. Although he may need a renal biopsy, he needs to have his thrombus treated first as the . The same is true of using cyclophosphamide and prednisone. This patient most likely has membranous glomerulonephritis simply because he is an adult with nephrotic syndrome, and this is the most common cause in adults. Colonoscopy should also be done in a patient like this because there is a strong association of glomerulonephritis with solid tumors, such as colon and breast cancer. Topic: Nephrology. Record # 4. Question/Fact: A 4. Vietnam, who had been a bus driver in Thailand, presents to the emergency department after having shortness of breath while playing soccer with his son this morning. Over the last several months, he has been having several episodes of shortness of breath. Several of the episodes were associated with chest pain. He denies any significant medical history. He has a 2. 5- pack- year use of tobacco, and he has a sedentary lifestyle. His father had a myocardial infarction at the age of 5. His heart rate is 7. Hg, and respiratory rate is 1. His examination shows mild jugulovenous distention with a collapsing carotid arterial pulse. His cardiac examination reveals a point of maximal impulse that is displaced laterally and inferiorly and a mild diastolic blowing murmur at the base while he sits up. His sensory examination shows loss of vibration sense in all extremities, and an abnormal Romberg test. EKG shows normal sinus rhythm with left axis deviation and ST- segment depression and T- wave inversion in leads I, a. VL, V5, and V6. The chest x- ray shows an enlarged heart with dilatation of the proximal aorta. The CBC, chemistries, and cardiac enzymes are negative. The echocardiogram shows an ejection fraction of 6. What is the next best step in the management of this patient?(A) Treat with digitalis(B) Exercise stress test(C) Cardiac catheterization(D) VDRL and lumbar puncture, followed by penicillin therapy(E) Aortic valve replacement. Answer: (D) VDRL and lumbar puncture, followed by penicillin therapy. Explanation: This patient has a murmur of aortic regurgitation (AR) and an abnormal neurological examination, suggesting syphilis. Therefore, this patient needs a VDRL and a lumbar puncture. Syphilis of the aorta involves the intima of the coronary arteries and may narrow the coronary ostia, leading to myocardial ischemia. There is also destruction of the medial muscle layers of the aorta, leading to aortic dilation. Myocardial ischemia in AR happens because oxygen requirements are elevated secondary to left ventricular (LV) dilatation and elevated LV systolic wall tension. Coronary blood flow is normally during diastole when the diastolic arterial pressure is subnormal. This leads to decreased coronary perfusion pressure. Nifedipine or ACE inhibitors are only used once the patient develops severe AR. Digoxin is of very limited use at any time. An exercise stress test is not indicated because of the baseline EKG abnormalities. You normally detect the presence of ischemia on a stress test by looking for the development of ST- segment depression. This patient already has baseline ST- segment depression. A thallium or sestamibi scan would be required in a case like this. If you were investigating for ischemia, surgical treatment does not restore normal LV function. Patients with AR and normal LV function are followed until surgery is indicated. This is when the patient has LV dysfunction but before the development of symptomatic congestive failure. Valve replacement is also indicated in asymptomatic patients when the ejection fraction falls to < 5. LV end- diastolic volume is > 5. L/m. 2. Although catheterization may be useful before surgery, it would not be done before a specific diagnosis of syphilitic aortitis has been confirmed and treatment with penicillin has been given. Topic: Cardiology. Record # 5. Question/Fact: A 4. Her mother has a seizure disorder for which takes an antiseizure medication. She also has a history of alcohol abuse in the remote past. For the past several weeks, her mother has been complaining of difficulty sleeping and anxiety. The patient is stuporous and unresponsive to verbal stimuli. Her blood pressure is 1. Hg, heart rate is 5. The pupils are pinpoint, and there is horizontal nystagmus. Asterixis is present. |
Details
AuthorWrite something about yourself. No need to be fancy, just an overview. Archives
November 2017
Categories |