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The Complete Works of William Shakespeare
AMA surg journal
U. Wash ancient philosophy lecture notes
Sheffield "ask a philosopher site"
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CNN's Cold War

Why is the Red Sea red?

Normally the Red Sea is an intense blue-green; occasionally, however, it is populated by extensive blooms of the algae Trichodesmium erythraeum, which, upon dying off, turn the sea a reddish brown colour. 
                                       encyclopedia brittanica



the diaries and letters of Rutherford B Hayes
reflections of Krishnamurti
Message of Pope John Paul II to youth
Lonergan Discussion
cardiac exam note demeanor and mood of patient completely examine all systems cardiac auscultation recognition of pitch important concentrate on segments of the heart sound S1 mitral and triscuspid normally split loud in mitral stenosis S2 aortic pulmonic fixed split S2 indicative of increased right ventricular flow i.e. left to right shunt with increased flow S3 pericardial knock occurring in early diastole may indicate left ventricular dysfunction S4 may indicate right ventricular dysfunction Clicks are always systolic have brief duration and are high pitched congenital and aortic valve stenosis mitral and tricuspid valve stenosis pulmonary hypertension murmurs may be systolic diastolic or continuous systolic ejection diamond shaped aortic stenosis r 2nd ics, apex, rad both carotid pulmonic stenosis l 2nd ics, little radiation IHSS increased with Valsalva, left sternal border holosystolic regurgitant or shunt mitral regurg apex rad axilla tricuspid regurg left sternal border and over liver VSD left sternal border dims with increase pulmonary hypertension diastolic stenosis mitral stenosis low pitched early diastolic apical tricuspid stenosislow pitched quiet left sternal border 4th and 5th ICS regurgitant aortic regurg blowing high pitched lower left sternal edge to apex Austin Flint murmur (mid diastolic rumble with aortic regurg) pulmonic regurg left ICS Graham Steele murmur due to valve stretch in pulmonary htn continuous pda 2nd left ICS medial clavicle arteriovenous fistula over lesion coarctation of aorta or p.a. various fistulas and aortopulmonary window pericardial friction rub cerebral ischemia or infarction The sudden onset of focal sensory loss, weakness, or speech disorder particularly in older people with hypertension diabetes hypercholesterolemia heart disease history of cigarette smoking. Cerebellar hemorrhage commonly begins with an occipital headache followed by nausea, vomiting, lightheadedness or vertigo, and ataxia of gait hypertension urgencies - may be reversed in several hours emergencies- in one hour post op hypertensive urgency has been defined as >190/100 children and pregnant females more apt to develop htn encephalopathy with hypertension check BP in all limbs, think aortic aneurysm, mi, cva, check retina nicardipine is a titratable intravenous calcium channel blocker approved for tx of htn emergencies Labetalol is a combined blocker of the alpha and beta adrenergic receptors given intravenously drug is that it is also effective as an oral antihypertensive agent initial intravenous bolus of 0.25 mg/Kg, followed by larger boluses (0.5 mg/Kg) every 15 minutes until the BP is controlled or a total dose 3.25 mg/Kg has been given. Esmolol a beta-adrenergic blocking agent that has an extremely brief elimination half-life (<10 minutes). available for intravenous use both as a bolus and as an infusion. It is of particular value for some dysrhythmias and used in hypertensive crises. dosage is 0.5-1 mg/Kg followed by an infusion at 50-200 mcg/Kg/min. Clonidine (0.1 mg PO q 20 min.) has been used for the treatment of hypertensive crises in hypertensive urgencies This medication has been widely studied. In a random, double blind study, comparing the effects of oral nifedipine versus oral clonidine in 51 patients, clonidine was found to produce a more gradual decrease in BP than nifedipine Sedation was observed in those patients taking clonidine. choice for those patients in whom BP control within a few hours is desired. have iv fluids ready just in case. captopril leptospirosis Leptospirosis caused by a family of spirochetes with numerous serogroups and serotypes clinically distinct syndromes: anicteric leptospirosis and icteric leptospirosis. anicteric leptospirosis meningitis septicemic phase characterized by abrupt onset with fever, malaise, headache, myalgia, and nonpurulent conjunctivitis hepatosplenomegaly, lymphadenopathy, rashes. This septicemic phase usually lasts three to seven days followed by immune phase, characterized by a lower temperature and the development of meningeal signs. Renal disease proteinuria pyuria microscopical hematuria mild-to-moderate azotemia severe renal dysfunction is rare. Icteric leptospirosis hyperbilirubinemia, hepatic dysfunction, renal failure, pulmonary infiltrates, and cardiac dysfunction. fatal myocarditis has been found. Magnesium should now be considered as a rational agent for the prevention and treatment of eclamptic seizures. The Collaborative Eclampsia Trial indicates that it is the drug of choice for treating eclamptic seizures, and the study by Lucas et al. shows that it is also the drug of choice for prophylaxis. An important question is, Who should receive prophylactic therapy? The indication for therapy in the study by Lucas et al. was a blood pressure of more than 140/90 mm Hg during labor nutrition major nutritional diseases marasmus - deficiency of all nutrients kwashiorkor - deficiency primarily of protein xerophthalmia - deficiency of retinol ( Vitamin A ) drying (xerosis) of conjunctiva keratomalacia night blindness in early vitamin A deficiency leading cause of blindness in young in developing countries seen in marasmus and kwashiorkor rickets - vitamin D (ergocalciferol, cholecalciferol) deficiency and dependency restlessness, and developmental delay bone growth defect, bowing, osteomalacia in adults vitamin A toxicity headache nausea diplopia cns manifestations pellagra - niacin (nicotinic acid) deficiency may complicate INH therapy use of corn protein (maize) scarlet stomatitis, glossitis, dermatitis, diarrhea, cns aberrations beriberi - thiamine (B1) deficiency thiamine pyrophosphate alpha keto acid decarboxylation (CHO metabolism) polished rice (devoid of the husks) fatigue, irritability, sleep disturbances memory disorder precordial pain dry beriberi peripheral neuropathy cerebral beriberi Wernicke-Korsakoff syndrome (acute hemorrhagic polioencephalitis) wet beribery tachycardia leading to cardiogenic shock infantile beriberi aphonia, cardiac failure, breastfed infants of thiamine deficient mothers pyridoxine deficiency or excess vitamine b 12 deficiency taste and smell-zinc deficiency lips gums teeth tongue and buccal mucosa B complex deficiency scurvy bones and joints rickets - see above scurvy - vitamin c deficiency (collagen formation) gingivitis, teeth loosening, poor wound healing conjunctival hemorrhage, ecchymoses, petechiae, lassitude, weakness, irritability, weight loss. ddx adult - arthritis, gingivitis, hemorrhagic diseases osteomalacia- vitamin D deficiency, rickets osteoporosis- calcium deficiency drug-nutrition interactions tyramine-a component of cheese and potent vasoconstictor which may cause hypertensive crisis in those on monoamine oxidase inhibitors. otitis media The most common bacterial pathogens in acute otitis media are Streptococcus pneumoniae Haemophilus in-fluenzae ( the pathogens most frequently associated with sinusitis and pneumonia) Additional bacterial pathogens include Moraxella catarrhalis Strep. pyogenes Staph-ylococcus aureus gram-negative enteric bacteria and anaerobes viruses have been identified as the sole infective agent in only 6 percent of the middle-ear aspirates obtained from children with acute otitis media, viruses may promote bacterial superinfection by impairing eustachian-tube function and other host defenses, such as the respiratory epithelial-cell barrier. pulsus paradoxus is a fall in systolic bp greater than 10 with inspiration obstructive pulmonary disease constrictive pericarditis cardiac tamponade restrictive cardiomyopathy poisoning always suspect ingestion in children with unusual presentations arrhythmia altered mental status elderly-drug mistakes hospitalized-drug errors occupational or environmental exposures for altered mental status, or respiratory depression naloxone glucose thiamine ipecac 15 mg/kg up to 15 to 30 mls note contraindications antidotes (rough overview) naloxone for opioid overdose atropine for organophosphate toxicity methylene blue for methemoglobinemia acetylcysteine for acetaminophen poisoning digibind dig FAB for digitalis glycoside ingestions presentations CNS stimulation sedate with diazepam or barbiturate seisures diazepam 5-10 mgs adult (slow push) 0.1-0.2 mg per kg for child (slow push) phenobarbital 100 - 200mgs im or iv for adults 4-7 mg/kg for children phenytoin CNS depression intubation, narcan cerebral edema, in sedative, CO lead and other CNS depressants 20%mannitol 5 to 10 mls per kilogram dexamethasone 1mg per meter squared BSA iv drip renal failure-dialysis hepatic failure eliminators urine alkalinization in salicylate poisoning sodium bicarbonate 2 to 3 m3qs per kg hemodialysis, peritoneal dialysis, hemoperfusion, lipid dialysis not effective in digitalis glycosides, or tricyclic antidepressants (large vol of dist) chelating agents in metal poisoning toxidromes anticholinergic dry, hot and red fixed dilated pupils mad anticholinesterase inhibition wet fasciculations constricted pupils cholinergic wet fasciculations constricted pupils extrapyramidal opisthotonous, torticollis, oculogyric crisis hemoglobinopathies headache, coma, cherry red skin, cyanosis, chocolate blood metal fume fever dry headache fatique nausea, respiratory distress narcotic pupils pinpoint, lethargy coma sympathomimetic excitation, seizures,tachycardia sympathomimetic withdrawal anticholinergic atropine aminita antihistamines anticholinesterase inhibition, organophosphates cholinergic betel nut pilocarpine alcohol poisoning ethanol fluids with glucose, consider hypoglycemic course, dialysis for levels over 300 isoproanol (rubbing alc) fluids and glucose watch electrolytes, support methanol antifreeze, solvents, varnish ethanol and glucose, bicarb, consider acidotic course amphetamines heart block psychosis antihistamines arrhythmias arsenic antimony chelate with penicillamine throat constriction burning atopine is a belladonna alkaloid belladonna, scopolamine, atropine, physostigmine (if severe) hot and dry dilated pupils benzene V FIB benzodiazepines, flumazenil bismuth dimercaprol beta blockers pacing glucagon 3-5 mgs iv in adults calcium channel blockers calcium chloride, atropine polyarthritis Serologic studies should be obtained antinuclear and antistreptococcal antibodies antibodies to Borrelia burgdorferi in the case Lyme disease is endemic rheumatic fever carditis, chorea, migratory polyarthritis, erythema marginatum, subcutaneous nodules significant familial susceptibility age 4 to 18 for first attack a history also is a risk factor for recurrence, especially if not treated (50%) in strep A disease may cause heart failure Systemic Lupus Erythematosis rare in children, 80% in women of childbearing years The detection of antinuclear antibodies is a sensitive screening test for SLE Polyarthritis and dermatitis- most common clinical manifestations of SLE and the most common presenting symptoms However, any symptom or sign of the disease may be its first manifestation, and a single one, such as arthritis, thrombocytopenia, or pericarditis, may persist or recur for months or years before the diagnosis can be confirmed by the appearance of other features. Chronic fatigue disturbances of cognition or affect, anxiety and depression, are frequently described by patients as early symptoms. Isolated major involvement of the kidney or central nervous system is unusual. ---------------------------------------------------------------------------------------------------------------- Pneumococci are a major cause of pneumonia, empyema, otitis media, septic arthritis, septicemia, and meningitis. In their landmark 1954 article, (7) Godman and Churg concluded that Wegener's granulomatosis, Churg-Strauss syndrome, and the "microscopic form of periarteritis" (microscopic polyangiitis) are closely related and distinct from polyarteritis nodosa. As will be discussed later, this conclusion is supported by recent immunologic observations Rapid diagnosis of ANCA-associated small-vessel vasculitis is critically important, because life-threatening injury to organs often develops quickly and is mitigated dramatically by immunosuppressive treatment. Human monocytic ehrlichiosis, which is recognized primarily in the south central and southeastern United States, is an acute febrile illness characterized by headache and myalgia and usually accompanied by leukopenia, thrombocytopenia, and elevated levels of hepatic aminotransferases. (4) Central nervous system manifestations or nonspecific rashes develop in 15 to 30 percent of patients. Humans acquire E. chaffeensis from the bite of the Lone Star tick, Amblyomma americanum, (5) and deer may be an important reservoir host. (6) E. chaffeensis may also infect dogs. hemolytic disease of infectious origin subacute bacterial endocarditis babesiosis
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