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Which of the following organisms accounts for Answers to Questions 39–40 the majority of septic arthritis cases in young and middle-age adults? Which of the following statements about Answers to Questions 1–3 amniotic fluid bilirubin measured by scanning spectrophotometry is true? Baseline correction is not required if a scanning from 350 to 600 nm generic atorlip-5 5 mg visa, then drawing a baseline using spectrophotometer is used the points at 365 nm and 550 nm buy discount atorlip-5 5mg. Chloroform extraction is necessary only when absorbance (ΔA) of hemoglobin at 410 nm and meconium is present bilirubin at 450 nm are determined by subtracting the D. In normal amniotic fluid, bilirubin increases absorbance of the baseline from the respective peaks. Rh antibody titer of the mother with increasing gestational age because fetal urine B. Lecithin/sphingomyelin (L/S) ratio contributes more to amniotic fluid volume as the C. B Respiratory distress syndrome develops when processes/L/S ratio/2 surfactants are insufficient to prevent collapse of the infant’s alveoli during expiration. Tests measuring pulmonary phospholipid surfactants are the most specific and sensitive indicators of respiratory distress syndrome. Most of the surfactants in the amniotic fluid are present in the form of lamellar bodies. These can be counted using an electronic cell counter at the settings for enumerating platelets. Which of the following statements regarding Answers to Questions 4–6 the L/S ratio is true? Sphingomyelin levels increase during the third constant throughout gestation and serves as an trimester, causing the L/S ratio to fall slightly internal reference. Meconium contains less lecithin during the last 2 weeks of gestation than amniotic fluid and will usually decrease the D. Which of the following conditions is most likely its presence indicates fetal lung maturity. Centrifugation at 1,000 × g for 10 minutes 3:1 more closely correlates with fetal lung maturity D. Centrifuge speed is below expected levels should be the minimum required to spin down cells C. Samples that cannot levels than expected for the time of gestation be measured immediately should be refrigerated D. Samples are stable for up to 3 days at 2 days following delivery, stillbirth, or abortion 2°C–8°C and for months when frozen at –20°C or lower. Meconium and blood may also introduce Body fluids/Correlate clinical and laboratory data/ errors when measuring the L/S ratio. Blood has Chorionic gonadotropin/2 an L/S ratio of approximately 2:1 and will falsely raise the L/S ratio when fetal lungs are immature and depress the L/S ratio when fetal lungs are mature. In ectopic pregnancy, the expected increase between consecutive days is below normal. Which of the following statements regarding Answers to Questions 7–10 pregnancy testing is true? Because monoclonal antibodies are Body fluids/Apply principles of basic laboratory derived from mouse hybridomas, rare false positives procedures/Pregnancy test/2 may occur in patients who have antimouse Ig 8. Although the test can detect lower levels physician who suspected a molar pregnancy. Serum is preferred over urine because sample was diluted 10-fold and the assay was serum levels are more consistently above the cutoff repeated. Te result was found to be grossly point than random urine in very early pregnancy. A pipeting error was made in the first analysis α subunit and the other with the β subunit. Antigen excess caused a falsely low result in the where both antibodies are added together, a process undiluted sample called the “hook effect” is known to occur. Most cases of Down syndrome are the result of: or isochromosome formation, but most cases arise A. Nondisjunction of an E chromosome (E trisomy) from nondisjunction of chromosome 21 during B. Deletion of the long arm of chromosome 21 estriol is used to screen for Down syndrome during Body fluids/Apply knowledge of fundamental biological the second trimester. Which assay result is often approximately 25% below the expected level in pregnancies associated 10. Amniotic fluid bilirubin (free) estriol is almost all derived from the fetus and is D. Urinary chorionic gonadotropin a direct reflection of current fetal placental function. When all four assays are combined with adjustments for maternal age, gestational age, race, maternal weight, and diabetes, the detection rate is approximately 70–80% and the false-positive rate 7%.

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Do you find I mean I know you think your relationship with Dr A’s pretty good now cheap atorlip-5 5mg line, and you’ve mentioned in the past that you’ve had some not so great relationships with health workers generic atorlip-5 5mg online, psychiatrists and that. Um, some of them aren’t um, but I remember like, um, why can’t you have time off to come and get your injection, like 2 hours off to get the injection? And uh, why can’t you have um time off to come and see um, see the psychiatrist when you’re working? L: So he didn’t seem concerned about- O: No, I tried to explain to him I’m working, I’m fine at the moment and it’s like, two days won’t hurt. Cassie directly positions some of her past prescribers as “out of touch with reality”. Cassie and Oliver report that their prescriber and social worker, respectively, failed to take into account their work commitments when arranging medication appointments. They both indicate that past prescribers have held unrealistic expectations that they should be able to prioritise medication appointments over employment commitments and that prescribers were inflexible in organizing more suitable times. Whilst they do not link prescribers’ rigidity and failure to consider other commitments 235 directly to non-adherence, it could be argued that if appointments consistently interfere with other life commitments, some consumers may be more likely to become non-adherent. Thus, it may be important for prescribers to tailor the medication schedule around consumers’ other commitments, such as employment, in addition to tailoring it to symptom fluctuations and situational stressors. Whereas previous extracts have emphasized the importance of tailoring medication regimens to consumers’ situations, the following extracts highlight the importance of prescribers tailoring treatment information to their level of understanding or intelligence: Brodie, 21/08/2008 L: How do you think health workers could assist in I guess, well encouraging or helping people to take their medication? I’d like to think I’ve got some brains, but some people, they’re not educated or anything, so it’s probably harder for them. So yeah, but I think the health workers should individually, just um, get to know their patients a bit more than what they should I think. That’s why me and Dr A get along well now, because, I just said to her, look I know I’ve got this thing that lots of other people have but I don’t want to be talked down to like I’m stupid or anything. Amy, 10/02/2009 236 A: One of my mental health nurses, uh, she was looking after me and was really good at explaining, like from, because I’ve done biology in year 12 and I’m sort of, I used to do a mental health course at Tafe, non-clinical, um, he explained how the medication breaks do? And sort of like, the biological, medical properties of it…Um, because he knew I was intelligent enough, um, that really helped and encouraged me to take it more, because I had more thorough awareness. When asked directly about how health workers could assist with adherence, above, Brodie responds “not to patronize people”, as has been his experience in the past. He elaborates that prescribers should “individually, just um, get to know their patients a bit more” and thus target information accordingly. He implies that the therapeutic alliance with his prescriber improved following a conversation in which he told her to communicate with him as an equal (“I’ve got some brains…I don’t want to be talked down to like I’m stupid or anything”). In line with this, Amy recalls how a mental health worker assisted with her adherence (“that really helped and encouraged me to take it more”), by acknowledging her intelligence and pre- existing knowledge (“because he knew I was intelligent enough”) and, thus, explaining the mechanism of medication to her in appropriate terms. Several interviewees talked about prescribers making assumptions about their intelligence or capacity to process information and, therefore, failed to provide sufficient information regarding their diagnosis and the rationale for the treatment prescribed. As can be seen in the following extract, several interviewees also indicated that prescribers often questioned the validity of 237 their concerns or failed to take consumers seriously, possibly on the basis of such assumptions: Diana, 11/02/2009 D: See if you slipped, they didn’t care. You just get, that’s what I got, slipped and slipped and slipped and then, until I went off my medication and then I just told ‘em straight out, I’m low on medication, he didn’t get cross at me or anything. He didn’t hear, I know he was tired, because you can’t force the patient to go on it, you can’t put ‘em in hospital but he could’ve been a bit more open. L: And understanding and maybe even talk it through, like why you decided to go off it. D: Yeah, yeah, there’s so many things that he could’ve done but he left all the talking up to me and he didn’t do anything to- L: Yeah. Despite making her non-adherence explicit in the past (“I went off my medication and I just told ‘em straight out”), Diana describes how her prescriber failed to intervene (“he didn’t get cross at me or anything”). She positions prescribers as largely indifferent to her adherence statuses by stating, “they didn’t care”. Diana could be viewed to suggest that her prescriber did not listen to her, through the statement, “He didn’t hear”, followed by acknowledgement that prescribers “can’t force” adherence, but that her prescriber “could’ve been a bit more open” to discussing non- 238 adherence. She constructs her experience of prescribers failing to act on knowledge of non-adherence as typical (“every time I come off the medication, they wouldn’t do anything about it”). She also suggests that her prescriber had the resources to respond to her non-adherence helpfully (“there’s so many things that he could’ve done”), including by discussing “changing” medications. Below, Rachel and Diana talk about social worker and prescribers’ inaction in relation to their mental health and adherence: Rachel, 25/02/2009 R: They [social workers] need to interact with their clients a bit more, you know. Try and find out how their clients are going on a regular basis, not leave it to the point where the clients need hospitalization before they get involved with their clients. Diana, 11/02/2009 D: It wasn’t until I got really bad that they [mental health staff] actually decided to do something about it and when he decided to do something about it, it was that I was to go to the hospital and take the tablets, not try to get me to take my tablets. They didn’t say to me, oh look, I think you’re struggling, you should try to get back taking your medication or we can try to change it. According to Diana, her prescriber only intervened once she relapsed (“until I got really bad”) and the intervention involved admitting her into hospital, where she was required to take medication under supervision, thus, adherence was imposed. Rachel implies that her social worker also failed to 239 intervene until she relapsed and was hospitalized (“leave it to the point where the clients need hospitalization before they get involved with their clients”).

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It must be established that there are no sedating medication or neuromuscular blocking agents present 5mg atorlip-5 otc. The patient’s electrolytes order atorlip-5 5mg amex, blood count, body tempera- ture, and arterial blood gas all must be within the normal range. The neurologic exam should demonstrate the absence of all brainstem reflexes and no response to central painful stimuli. Two neurologic exams and two confirmatory tests are required to estab- lish brain death. Outcome The outcome of traumatic brain injury, as one would expect, is related to the initial level of injury. Summary Traumatic brain injury is a common problem in the United States, affecting approximately 550,000 people annually. If no surgical lesion is present or following surgery if one is present, specific treatment of the head injury begins. There are many potential neurologic complications of head injury including cranial nerve deficits, seizures, infections, hydrocephalus, and brain death. While patients with mild head injury usually do well, some of those who develop a postconcussive disorder are disabled perma- nently. It is very difficult to predict the outcome of moderate and severe head injuries, and most algorithms devised for this purpose do not reli- ably predict outcome. Brain Trauma Foundation, American Association of Neurologi- cal Surgeons, Joint Section on Neurotrauma and Critical Care. Scandinavian guidelines for the initial management of minimal, mild & moderate head injury. Present a case of an isolated musculoskeletal injury using appropriate terminology. Describe the commonly encountered muscle, tendon, and skeletal injuries that occur in the upper and lower extremities as well as the pelvis and spine. It is assumed that the reader understands the basic anatomy of the mus- culoskeletal, circulatory, and peripheral nervous systems. Case A 35-year-old man sustained an isolated injury to his right lower leg as a result of direct trauma from an exploding truck tire. The patient did not lose consciousness, and, other than right lower leg pain, he had no complaints of pain in other body regions. Musculoskeletal Injuries 589 Introduction The musculoskeletal system consists of the bony skeleton, ligaments, joint capsules, and muscle tendon units. Each individual segment of the skeleton is connected to adjacent segments by ligaments and joint capsules. The ligaments and capsules are considered static restraints, and they have no contractile ability. However, as static restraints, the ligaments and capsules control motions between adjacent skeletal segments. The muscle tendon units derive their structural support from the underlying skeleton. The muscle tendon units, having the ability to contract, generate motion between skeletal segments. Thus, the musculoskeletal system consists of three general components that rely on each other in order to function properly. Injury to one compo- nent may lead to dysfunction of and ultimately to deterioration of the other two components. In addition, the musculoskeletal system relies on and supports the circulatory system and the nervous system. Musculoskeletal injuries can result in damage to either of these two systems, and damage to the circulatory and or nervous system can result in dysfunction or deterioration of the musculoskeletal system. Upon completion of the chapter, the reader should have a familiarity with basic principles of musculoskeletal injuries as well as a general knowledge base of specific musculoskeletal injuries. Muscles: Contusions, Lacerations, and Strains A muscle contusion occurs when muscular tissue sustains a direct blow. Bleeding and a hematoma can form deep within the muscle tissue, and this usually results in sur- rounding edema. Since muscle tissue is surrounded by a layer of fibrous tissue, or compartment, that has limited expansile ability, pres- sure can build up within the muscle compartment, leading to pain and sometimes to neurovascular compromise, resulting in a compartment syndrome. Lacerations heal with formation of scar tissue, and, conse- quently, the continuity of muscle fibers is disrupted permanently. In addition, neurologic damage at the site of the laceration results in de- nervation of the muscle fibers distal to the site of the laceration. This injury results in localized inflammation at the musculotendinous junction, with the 590 C. In the vast majority of these cases, the injuries heal spontaneously and result in minimal, if any, permanent dysfunction.

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