Srihari is a State University of New York Distinguished Professor at the University of Buffalo in the Department of Computer Science and Engineering medicine 93 5298 discount divalproex 500mg online. He is the founding director of the Center of Excellence for Document Analysis and Recognition symptoms torn meniscus divalproex 250 mg fast delivery. Srihari is a member of the Board of Scientific Counselors of the National Library of Medicine medicine of the people order divalproex 250 mg without a prescription. Srihari has been general chairman of several international conferences and workshops: the Third International Workshop on Handwriting Recognition held in Buffalo treatment vs cure cheap 250 mg divalproex overnight delivery, New York, in 1993, the Second International Conference on Document Analysis and Recognition, in Montreal, Canada, 1995, the Fifth International Conference on Document Analysis and Recognition, 1999, held in Bangalore, India, and the Eighth International Workshop on Handwriting Recognition, 2002, held in Niagara-on-the-Lake, Ontario, Canada. Srihari received a New York State/United University Professions Excellence Award for 1991. He became a Fellow of the Institute of Electronics and Telecommunications Engineers (India) in 1992, a Fellow of the Institute of Electrical and Electronics Engineers in 1995, and a Fellow of the International Association for Pattern Recognition in 1996. He was named a distinguished alumnus of the Ohio State University College of Engineering in 1999. After finishing graduate school, he worked at DuPont at the Research Station in Wilmington, Delaware, during which time his research and scientific interests gradually changed toward materials science with a specialization in the mechanical behavior of ceramic materials. After three years, he began work at the National Bureau of Standards, where he carried out an independent research program on the mechanical behavior of glasses and ceramic materials. At the National Bureau of Standards, now the National Institute of Standards and Technology, Dr. Wiederhorn carried out a program on the mechanical reliability of brittle materials. He was one of the first to apply fracture mechanics techniques to study the fracture of ceramic materials. A result of his research was the development of techniques to assure the structural reliability of brittle ceramic materials. Wiederhorn are now used to assure the reliability of glass windows in airplanes and in space vehicles. Wiederhorn is best known for the experiments he developed to study and to characterize subcritical crack growth in glasses. The results of these studies illustrated the complexity of subcritical crack growth, and a natural conclusion of his study was that the failure of glass was caused by the slow growth of cracks to a critical size, which determined the timeto-failure. Wiederhorn directed a program to measure the deformation of structural ceramics at very high temperatures. The objective of this work was to develop ceramic materials that could be used as turbine blades in power turbines used for more efficient production of electricity. The program has resulted in the development of new measurement techniques for characterizing creep at elevated temperatures. Wiederhorn and his group, and ways have been suggested to improve the creep behavior of nonoxide materials at high temperatures. Wiederhorn has received many awards for his research and leadership at the National Institute of Standards and Technology. These include both a Silver and Gold Medal awarded by the Department of Commerce and the Samuel Wesley Stratton Award by the National Bureau of Standards. He is also a Fellow of the American Ceramic Society and has received a number of important awards for his research from this society, including the Jeppson Award for outstanding research on ceramic materials. Wiederhorn is now a Senior Fellow and continues to carry out a research this document is a research report submitted to the U. His current interests are to use the Atomic Force Microscope to investigate the atomistics of crack growth in glasses and ceramic materials, with the hope of learning more about the crack growth process and the relation between crack growth and the microstructure of glass. He received his undergraduate education from Wabash College in Crawfordsville, Indiana. He completed a rotating internship and one year of pathology residency at the Mary Imogene Bassett Hospital in Cooperstown, New York. Zumwalt then completed his pathology residency at the Southwestern Medical School and Parkland Hospital in Dallas. Zumwalt served in the United States Navy as director of laboratories at the Navy Regional Medical Center in Camp Lejeune, North Carolina. He spent two years as deputy coroner in Cleveland, Ohio, and six years as deputy coroner in Cincinnati, Ohio, before coming to the Office of the Medical Investigator in 1987. Zumwalt is certified in anatomic and forensic pathology by the American Board of Pathology. Zumwalt has served as president of the National Association of Medical Examiners and is a member of the following professional organizations: the National Association of Medical Examiners; the American Academy of Forensic Sciences; the College of American Pathologists; the American Society of Clinical Pathologists; the United States and Canadian Academy of Pathology; the American Medical Association; and the American Association for the Advancement of Science. Staff Anne-Marie Mazza is Director of the Committee on Science, Technology and Law. She has served as Senior Program Officer with both the Committee on Science, Engineering, and Public Policy and the Government-University-Industry Research Roundtable. In 1999 she was named the first director of the Committee on Science, Technology, and Law, a newly created program designed to foster communication and analysis among scientists, engineers, and members of the legal community. In 2007, she became the director of the Christine Mirzayan Science and Technology Graduate Policy Fellowship Program. Mazza has been the study director on numerous Academy reports, including Science and Security in a Post - World, 00; Reaping the Benefits this document is a research report submitted to the U. Between October 1999 and October 2000, she divided her time between the Committee on Science, Technology, and Law and the White House Office of Science and Technology Policy, where she served as a Senior Policy Analyst responsible for issues associated with the governmentuniversity research partnership. In 1996, he established a new board to conduct annual peer reviews of the Army Research Laboratory, which conducts a broad array of science, engineering, and human factors research and analysis, and he later directed a similar board that reviews the work of the National Institute of Standards and Technology. He has worked full time with the Board on Mathematical Sciences and Their Applications since June 2004. He holds bachelor degrees in mathematics and materials science from Northwestern University and an M. David Padgham is Policy Director at the High Performance Computing Initiative Council on Competitiveness. His work there comprised a robust mix of writing, research, and project management, and he was involved in the production of numerous reports, including, most recently, Software for Dependable Systems: Sufficient Eidence John Sislin is a Program Officer with the Board on Higher Education and Workforce. His work focuses on topics in international affairs, higher education, globalization, and the impact of science and technology on society and security. His work on international affairs includes developing a system to monitor compliance with international labor standards for the U. Department of Labor and development of a biographical database on world leaders with foreign education or employment experience sponsored by the MacArthur Foundation. Steven Kendall is Senior Program Associate for the Committee on Science, Technology, and Law. Before joining the National Academies in 2007, he worked at the Smithsonian American Art Museum and the Huntington in San Marino, California. Hanna is a science and health policy consultant, writer, and editor specializing in biomedical research policy and bioethics. Hanna was a Senior Analyst at the congressional Office this document is a research report submitted to the U. Maddox is a science and health policy editor who served as senior editor for reports to the President of the National Bioethics Advisory Commission, including Ethical Issues in Human Stem Cell Research and Research Inoling Human Biological Materials: Ethical Issues and Policy Guidance. Court of Appeals for the District of Columbia Circuit Constantine Gatsonis, Director, Center for Statistical Studies, Brown University 8:45 Charge to Committee David W. Hagy, Deputy Assistant Attorney General for Policy Coordination, Office of Justice Programs, U. Department of Justice and Principal Deputy Director, National Institute of Justice, U. Department of Justice 9:10 9:30 Discussion Importance of Study to the Forensics Community Joe Polski, Chair, Consortium of Forensic Science Organizations 9:45 10:15 Discussion Current State of Forensics: Census of Publicly Funded Forensic Crime Labs Joseph L. Peterson, Director and Professor, School of Criminal Justice and Criminalistics, California State University, Los Angeles 0 this document is a research report submitted to the U. Department of Justice, Bureau of Justice Statistics 10:45 11:15 Discussion Overview of Forensics Training and Education Max M.
The prothrombin time and bleeding time are normal administering medications 7th edition order divalproex 500mg line, but the activated partial thromboplastin time is prolonged treatment yeast infection women purchase divalproex 250mg overnight delivery. A 50-year-old man has been in the med ical intensive care unit for septic shock for the past few days treatment yeast infection home remedies order divalproex 250mg line. Which of the following sets of results for a panel of screening tests is most consistent with this diagnosis A 55-year-old woman with chronic pan creatitis undergoes coagulation screening tests before surgery xanthine medications cheap 250mg divalproex mastercard. The prothrombin time and activated partial thromboplastin time are found to be prolonged. Given the follow ing choices, which of the following is the most likely reason for the abnormal coagula tion test results Family history reveals that her father also has prolonged bleeding from wounds and minor trauma, as does her brother. An 80-year-old woman presents with recent onset of primary hemostatic (mucocu taneous) bleeding. Questioning reveals that she has been maintaining a "tea and toast" diet for the past 4 months. Her gums are hemorrhagic and spongy in consistency, and gingival bleeding is evident. Perifollicular hyperkeratotic papules, each surrounded by a hemorrhagic halo, are scattered over the lower extremities, and each papule surrounds a twisted, corkscrew-like hair. Deficiency of which of the following nutrients is most likely related to the findings in this patient A 60-year-old chronic alcoholic with known alcoholic cirrhosis presents with upper gastrointestinal hemorrhage. A 7-year-old boy presents with palpable purpura on the buttocks and legs, fever, abdominal pain and vomiting, arthritis in his knees and ankles, melena, and hema turia. His mother states that he had an upper respiratory illness approximately 1 week ago, but has otherwise been well. The most likely cause of the bleeding into the skin observed in this patient is coagulation factor deficiency. A 56-year-old physician who has had a recent episode of unstable angina is advised by his cardiologist to take one "baby aspirin" a day because of the antithrombotic effect of aspirin. The other laboratory tests listed remain normal, because the bleeding time is a measure of platelet plug formation, the prothrombin time a measure of the extrinsic pathway of coagulation, and the thrombin time an assay of the conversion of fibrinogen to fibrin. The classic pentad of thrombotic thrombocytopenic purpura includes fever, microangiopathic hemolytic anemia, thrombocytopenia, renal insufficiency, and neu rologic abnormalities. Hyaline microaggregates of platelets in small vessels can be observed on histologic examination. The enzyme deficiency can be caused by a mutation in the gene that codes for the enzyme, or it can be caused by an antibody inhibiting the enzyme. Treatment is by plasma exchange, and the disorder can be fatal if diagnosis and therapy are delayed. The patient has a disorder of the intrinsic pathway of coagulation (prolonged activated partial throm boplastin time). The abnormality is localized proximal to factor X Xa activation because the prothrombin time is normal. Significant platelet-related problems, such as von Willebrand disease, are ruled out by the normal bleeding time. There are many variants, all marked by either qualitative or quantitative deficien cies of von Willebrand factor. Chronic pancreatitis causes fat malabsorption, because pancreatic lipase is required for fat digestion. Fat malabsorption leads to deficiency of the fat -soluble vitamins A, D, E, and K. Vitamin C deficiency occurs in infants aged 6-1 2 months who are fed a diet deficient in citrus fruits or vegetables, or in elderly persons who maintain a "tea and toast" diet. Vitamin C cannot be synthesized by the body, and thus must be supplied by the diet. The clinical description is that of Henoch-Schonlein purpura, a form of leukocytoclastic angiitis (hypersensitivity vasculitis) resulting from an immune reaction that damages the vascular endothelium. This is the most common of all illnesses and is caused by viruses, espe cially the adenoviruses. This is mediated by an IgE type I immune reaction involving mucosal and submucosal mast cells. It is characterized by increased eosinophils in peripheral blood and nasal discharge. This infection may be superimposed on acute viral or allergic rhini this by injury to mucosal cilia, which may also occur from other environmental factors. Most commonly, the cause is streptococci, staphylococci, or Haemophilus inJluenzae. Fibrous scarring, decreased vascularity, and atrophy of the epithelium and mucous glands may result. Sinusitis is inflammation of the paranasal sinuses often caused by extension of nasal cavity or dental infection. It results in obstructed drainage outlets from the sinuses, leading to an accumulation of mucoid secretions or exudate. Laryngitis is acute inflammation of the larynx produced by viruses or bacteria, irritants, or overuse of the voice. It is characterized by inflammation and edema of the vocal cords, with resultant hoarseness. Acute epiglottitis is inflammation of the epiglottis and may be life-threatening in young chil dren. Acute laryngotracheobronchitis (croup) is acute inflammation of the larynx, trachea, and epiglot this that is potentially life-threatening in infants. Plasmacytoma is a plasma cell neoplasm that, in its extraosseous form, produces tumors in the upper respiratory tract. This small, benign laryngeal polyp, usually induced by chronic irritation, such as excessive use of the voice, is associated most commonly with heavy cigarette smoking. In adults, the neoplasm usually occurs singly and sometimes undergoes malignant c. This neoplasm is the most common malignant tumor of the larynx and is usually seen in b. Supraglottic and subglottic carcinomas are less common and typically have a poorer prognosis. This specimen came from a patient who died from intractable asthma (status asth maticus). Prominent features include thickening a n d hya l i nization of the basement membrane, smooth muscle hyperplasia, and infiltration ofthe lesion with numerous eosinophils. There is marked episodic dyspnea and wheezing expiration is mediated by a type I hypersensitivity response involving IgE bound to mast cells. I ntrinsic (non immune) asthma includes asthma associated with chronic bronchitis. Morphologic manifestations include bronchial smooth muscle hypertrophy, hyperpla sia of go blet cells, thickening and hyalinization of basement membranes, proliferation of eosinophils, and intrabronchial mucous plugs containing whorl-like accumulations of epithelial cells (Curschmann spirals) and crystalloids of eosinophil-derived proteins (Charcot -Leyden crystals). Chronic bronchitis is clearly linked to cigarette smoking and is also associated with air pollution, infection, and genetic factors. Typical characteristics include hypersecretion of mucus due to marked hyperplasia of mucus-secreting submucosal g lands. Emphysema is dilation of air spaces with destruction of alveolar walls and lack of elas b. Clinical characteristics include increased anteroposterior diameter of the chest; increased total vital capacity; and hypoxia, cyanosis. Dilation of the respiratory bronchioles is most often local ized to the upper part of the pulmonary lobes. T h i s form o f em physema is c h a ra cter ized by m a rked e n l a rgement of the alveoli, m a ny of which have d a m a g e d w a l l s or loss o f walls. Paraseptal emphysema (1) Dilation involves mainly the distal part of the acinus, including the alveoli and, to Dilation of the entire acinus, including the alveoli, alveolar ducts, respiratory bronchioles, and terminal bronchioles, is most often distributed uniformly throughout the lung.
Patients often excrete red pigmented urine because of excessive excretion of coproporphyrin I and uroporphyrin I treatment 5ths disease cheap 250mg divalproex with mastercard. This porphyria is a disease of early adulthood that exhibits mild skin photosensitivity medications equivalent to asmanex inhaler purchase divalproex 250 mg on line. Patients are commonly first seen with skin lesions because of solar photosensitivity treatment wasp stings buy divalproex 250mg with mastercard. Patients who have this porphyria have a medical history associated with liver disease symptoms hepatitis c buy divalproex 500 mg on line, alcoholism, estrogen therapy, or ingestion of hexachlorobenzene. Iron metabolism-associated disorders most commonly occur as a result of an iron deficiency but can result from a block of the enzyme that inserts iron. Ferritin values usually decline below 12 ng/mL, which indicates low iron stores (normal range is 15 to 200 ng/mL). Disorders of iron excess result from the slow accumulation of excess quantities of tissue iron stores. This can result from increased intestinal absorption, administration from transfused blood. Globin dysfunction can occur from genetic mutations giving rise to either of the following two anemia classifications: a. These Hb disorders result from a single amino-acid substitution in one of the polypeptide chains. Thalassemias are caused by an abnormal long or short polypeptide resulting from gene coding termination errors, frame-shift mutations, crossover in phase, deletion of codons, or fused hybrid chains. These gene coding abnormalities result in the deficiency or absence of one of the types of globin chains. Nomenclature (1) the abnormal Hb disorder is most commonly represented by its letter abbreviation. For example, sickle cell anemia is denoted as Hb S, methemoglobinemia is written as Hb M. This results in intravascular hemolysis, and the marrow becomes hyperplastic early in childhood, expanding the marrow space. Patients can develop functional asplenia, which leads to an impaired immune system and renders the patient more susceptible to infections. Patients cannot produce a concentrated urine; they commonly are seen with hematuria. The genetic trait is present in 9% of American blacks and normally has no clinical signs or symptoms. Doubly heterozygous -hemoglobinopathies are disorders in which the individual inherits a different abnormal -chain gene from each parent. In some heterozygous hemoglobinopathies, the amino acid substitutions occur in the heme pocket where they either increase the stability of the Hb M or alter the affinity of the heme ring for oxygen. However, with -chain Hb M, cyanosis does not occur until -chain production reaches adult levels. Unstable hemoglobins have an amino acid substitution at a place in the or chain that affects the formation of the bonds between chains. Background (1) Thalassemias are disorders of Hb synthesis that occur mainly in persons of Mediterranean, African, and Asian ancestry. Globin-chain molecular defects and nomenclature includes the following: (1) -Thalassemia denotes a condition in which -chain synthesis is absent. This results in an elongated -chain with 31 extra amino acids and slowed or reduced -globin synthesis. Homozygous -Thalassemia (thalassemia major) results from either a decrease or an absence in -chain production by both gene alleles. Persons of Mediterranean descent with this form of thalassemia have severe clinical symptoms. Double heterozygotes for -Thalassemia and -hemoglobinopathies occur when an individual inherits a thalassemia gene from one parent and a hemoglobinopathy gene from the other parent. Megaloblastosis is almost always caused by deficiencies of vitamin B12 or folic acid. Macrocytic anemia with a megaloblastic marrow can result in ineffective hematopoiesis. If vitamin B12 intake is stopped, total body stores of 2 to 5 mg last for several years before a megaloblastic anemia results. Inadequate dietary intake of vitamin B12 is extremely rare in the United States; it is usually seen in strict vegetarians. Lack of availability of vitamin B12 in the small intestine can result from competition for dietary B12. Folate is primarily acquired from the diet in such foods as eggs, milk, leafy vegetables, yeast, liver, and fruits. Clinically, symptoms from inadequate dietary folate can occur within weeks, as compared with years for a vitamin B12 deficiency. Unlike vitamin B12 deficiency, a megaloblastic anemia caused by folate deficiency is most commonly due to insufficient dietary intake. Causes of deficiency (1) Liver disease associated with alcoholism results in a dietary folate deficiency. A differential diagnosis is necessary to distinguish this condition from an anemia of liver disease, which has a normal folate but is macrocytic with a normoblastic marrow. In addition to inhibiting tumor growth, chemotherapeutic drugs also produce a megaloblastic anemia. These subtypes are Type A and Type B, depending on their electrophoretic mobility. These individuals have clinically mild conditions but can be affected by oxidants to produce a hemolytic crisis. These patients are more susceptible to severe oxidant hemolysis than are Type A individuals. Acute posthemorrhagic anemia, caused by a sudden blood loss, first results in early hypovolemia without any signs of anemia. With reticulocytosis, the anemia may be macrocytic with polychromasia caused by shift reticulocytosis. Cell structures that take up acid stains are known as acidophilic or eosinophilic. Acidophilia can result from the following errors in technique: (a) Insufficient staining time (b) Prolonged washing time (c) Excessive acidity of the stain or buffer B. Promyelocytes are the second stage following one or more mitotic divisions of myeloblasts. The myelocyte stage of maturation begins with the appearance of a new type of granulocyte-specific granule. These granules (secondary granules) give the mature granulocyte its characteristic appearance and functional destiny. Therefore, the maturation of the myelocyte, which is based on granule type, gives rise to neutrophils, eosinophils, or basophils. Phagocytic function involves the following general steps: (1) Increase in cell numbers at the infected site (2) Cell attachment to the foreign or dead material (3) Engulfment of foreign or dead material (4) Dissolving of foreign or dead material (5) Disposition of catabolic components b. Well-known chemotactic factors are activated complement C3b and C5a, lymphocyte secretions, and bacterial products, such as endotoxins or bradykinin.
For infants adhd medications 6 year old buy divalproex 250mg mastercard, recognition of dislocated hips is of critical importance 9 treatment issues specific to prisons buy generic divalproex 500 mg, as lifelong growth abnormalities may result symptoms to pregnancy generic 500 mg divalproex visa. For adolescents treatment deep vein thrombosis order divalproex 500mg mastercard, identification of scoliosis is important to prevent the debilitating complications of that condition. Athletes require evaluation of the integrity of their joints, especially those joints that will be used in sporting activities. Neurologic: Neurologic evaluation of the older child is similar to that in adults. The motor system should be evaluated (including strength, tone, coordination, and involuntary movements). Superficial and deep sensory systems, and deep tendon reflexes should be reviewed. In younger infants a variety of normal primitive reflexes (Moro, parachute, suck, grasp) can be found, but ensuring that these reflexes have extinguished by the appropriate age is equally important. Newborn metabolic screening is done in all states, usually after 24 hours of age, but the exact tests performed vary by state. Conditions commonly screened for include hypothyroidism, phenylketonuria, galactosemia, hemoglobin type, and adrenal hyperplasia. Other conditions that may be assessed include maple syrup urine disease, homocystinuria, biotinidase deficiency, cystic fibrosis, tyrosinemia, and toxoplasmosis. Hemoglobin or hematocrit levels are recommended for high-risk infants (especially premature infants and those with low birth weight), at 9 to 12 months of age, and yearly on all menstruating adolescents. Urinalyses are recommended at 9 to 12 months of age and at 5 years of age, and dipstick urinalysis for leukocytes annually for sexually active adolescents. Lead screening is done, especially in high-risk areas, at 9 to 12 months of age, and again at 2 years of age. Cholesterol screening is performed in high-risk patients (those with positive family histories) older than 24 months. Sexually transmitted disease screening is performed yearly on all sexually active patients. Plain radiographs offer the advantage of inexpensive testing that reveals global views of the anatomy. Unfortunately, fine organ detail is not revealed sometimes, requiring further radiographic study. Bone films for fracture, chest films for pneumonia, and abdomen films for ileus are common uses of this modality. Ultrasonography is a fairly inexpensive modality that requires little or no sedation and has no radiation risks. Common examinations include the head for intraventricular hemorrhage in the premature infant, the abdomen for conditions such as pyloric stenosis, and the kidneys for abnormal structure. Because it is a slow procedure, sedation is often needed for younger children, and contrast is sometimes required. It allows for superb tissue contrast in multiple planes, and excellent anatomic and functional imaging. It is frequently used to provide detail on the brain in patients with seizures or developmental delay or to provide tissue detail on a mass located virtually anywhere in the body. It provides functional information (usually organ specific) but provides poor anatomic detail. Approach to Clinical Problem Solving There are generally four steps to the systematic solving of clinical problems: 1. The process includes knowing which pieces of information are more meaningful and which can be discarded. Experience and knowledge from reading help to guide the physician to key in on the most important concerns. A diagnosis can be reached by systematically reviewing each possible cause and reading about each disease. Usually a long list of possible diagnoses can be pared down to two or three top suspicions, based on key laboratory or imaging tests. For example, an adolescent presenting with a fever as the chief complaint can have an extensive differential diagnosis reduced to far fewer possibilities when the history reveals an uncle in the home with cough, weight loss, and night sweats, and the physical examination shows an increased respiratory rate, lymphadenopathy, and right lower lobe lung crackles. Asthma categories range from mild intermittent (least severe) to severe persistent (most severe). For some conditions, such as syphilis, the staging depends on the length of time and follows along the natural history of the infection (ie, primary, secondary, or tertiary syphilis). If neither the prognosis nor the treatment was affected by the stage of the disease process, it would not make much sense to subcategorize something as mild or severe. As an example, mild intermittent asthma poses less danger than does severe persistent asthma (particularly if the patient has been intubated for asthma in the past). Accordingly, with mild intermittent asthma, the management would be intermittent short-acting -agonist therapy while watching for any worsening of the disease into more serious categories (more severe disease). In contrast, a patient with severe persistent asthma would generally require short-acting -agonist medications as well as long-acting -agonists, inhaled steroids, and potentially oral steroids. Group A -hemolytic streptococcal pharyngeal infection ("strep throat") is associated with complications, including poststreptococcal glomerulonephritis and rheumatic fever. Hence, the student should approach new disease by learning the mechanism, clinical presentation, how it is staged, and how the treatment varies based on stage. Obviously the student must work on being more skilled in eliciting the data in an unbiased and standardized manner. The student must know what to do if the measured marker does not respond according to the expected. Is the next step to treat further, or to repeat the metastatic workup, or to follow up with another more specific test Approach to Reading the student must approach reading differently than the classic "systematic" review of a particular disease entity. Patients rarely present with a clear diagnosis; hence, the student must become skilled in applying the textbook information to the clinical setting. Experience teaches that with reading, there are several crucial questions to consider thinking clinically. This is a difficult task to give to the medical student; however, it is the basic problem that will confront clinicians for the rest of their careers. One way of attacking this problem is to develop standard "approaches" to common clinical problems. The infant is term, large for gestation age, and was born by repeat cesarean section. Using the "most common cause" information, the student would guess transient tachypnea of the newborn. This question in many ways is even more difficult than the most likely diagnosis, because insufficient information may be available to make a diagnosis and the next step may be to pursue more diagnostic information. Another possibility is that the diagnosis is clear, but the next step is the staging of the disease. Hence, from clinical data a judgment needs to be rendered regarding how far along one is on the road of: Make diagnosis Stage disease Treat based on the stage Follow response In particular, the student is accustomed to regurgitating the same information that someone has written about a particular disease but is not skilled at giving the next step. This talent is optimally learned at the bedside, in a supportive environment, with freedom to take educated guesses, and with constructive feedback. The student in assessing a child in the hospital should go through the following thinking process: 1. A chest radiograph shows no lobar consolidation (I believe this is important because a lobar consolidation would suggest a bacterial etiology). Also, if in the next few days he does not get better or if he worsens, I think he will need a repeat chest radiograph to assess whether he has an evolving bacterial pneumonia. In a similar patient, when the clinical presentation is not so clear, perhaps the best "next step" may be diagnostic in nature such as blood cultures to determine if bacteremia is present. This information is sometimes tested by the dictum, "the gold standard for the diagnosis and treatment of a bacterial infection is a culture. This question goes further than requiring the student to make the diagnosis; it also requires the student to understand the underlying mechanism for the process.
Papillary carcinomas show a uniform growth of cells with similar appearance with enclosed tubular spaces; the whole arrangement bridges across the entire lumen at times or simply lines the outer rim of the duct (cribriforming) medications used to treat fibromyalgia order 250 mg divalproex fast delivery. Peripheral invasion of the stroma treatment tinnitus generic divalproex 500mg on line, if present at all symptoms 5 days after iui discount 500 mg divalproex amex, makes the diagnosis of carcinoma rather certain medicine natural discount divalproex 500 mg online. There are lesions in which the differentiation is exceedingly difficult, even in the hands of renowned surgical pathologists. Many competent pathologists understandably prefer to defer the diagnosis on all papillary lesions of the breast on frozen section until well-fixed and optimally prepared permanent sections are available. Fibroadenomas are characterized histologically by a mixture of fibrous tissue and ducts, with no increase in cellularity or mitoses. Another neoplastic tumor that arises from the stromal cells is the phyllodes tumor. It is distinguished from fibroadenomas by a more cellular stroma and the presence of stromal Reproductive Systems Answers 419 mitoses. The phyllodes tumor, which has been called a cystosarcoma phyllodes, may either be benign or malignant. A benign phyllodes tumor is characterized by increased stromal cells with few mitoses, while a malignant phyllodes tumor has increased numbers of stromal cells that are atypical along with numerous mitoses. It is difficult to predict survival rate, but the status of the axillary nodes is of major importance since negative nodes suggest 70 to 80% 10-year survival. There is a significant decrease in 5-year survival if one to three nodes are positive (only 50%), and four or more positive nodes at the time of diagnosis usually mean about 20% disease-free survival. Obviously, a large number of involved nodes, invasion of the capsule, and fixation to adjacent tissue adversely affect survival. The histologic type and grade of tumor and its size are also important, but nodal involvement (number and size) is the outstanding factor in prognosis. Unfortunately, more than 20% of patients with negative lymph nodes do have recurrences and die within 10 years. Although they are of lesser prognostic importance in breast cancers, high levels of estrogen receptors mean a better prognosis than lower levels or none, although the best response to endocrine (antiestrogen) ablation therapy is noted with tumors containing both estrogen and progesterone receptors. Amplified or activated tumor oncogenes, particularly c-erb B2, may be associated with an aggressive tumor and poor prognosis. Noninvasive carcinomas (carcinoma in situ) may be located within the ducts (intraductal carcinoma) or within the lobules (lobular carcinoma in situ). There are several variants of intraductal carcinoma, including comedocarcinoma, cribriform carcinoma, and intraductal papillary carcinoma. Comedocarcinoma grows as a solid intraductal sheet of cells with a central area of necrosis. Cribriform carcinoma is characterized by round, ductlike structures within the solid intraductal sheet of epithelial cells, while intraductal papillary carcinoma has a predominant papillary pattern. In contrast, invasive malignancies are characterized by infiltration of the stroma, which may produce 420 Pathology a desmoplastic response within the stroma (schirrous carcinoma). Infiltrating ductal carcinomas also produce yellow-white chalky streaks that result from the deposition of elastic tissue around ducts (elastosis). Other patterns of invasion that produce specific results include infiltration of cells in a single file in infiltrating lobular carcinoma, and mucin production in colloid carcinoma. Lobular carcinoma in situ is characterized histologically by proliferation of cells of the terminal duct lobular unit, which fills and expands the lobules. Unlike the case with intraductal carcinoma, papillary and cribriform structures are not formed and neither is central necrosis present. Invasive lobular carcinoma is distinguished by its tendency to infiltrate the stroma in a single file. This pattern is not seen with invasive ductal carcinoma, which tends to cause a marked desmoplastic response, causing a schirrous carcinoma. The term does not refer to the presence of inflammatory cells, abscess, or any special histologic type of breast carcinoma; rather, it refers to more of a clinical phenomenon, in that the breast is swollen, erythematous, and indurated and demonstrates a marked increase in warmth. These changes are caused by widespread lymphatic and vascular permeation within the breast itself and in the deep dermis of the overlying skin by breast carcinoma cells. The clinical induration and erythema are presumably related to lymphatic-vascular blockage by tumor cells; if present, these findings mean a worse prognosis. Eczematous dermatitis of the nipples is a major differential diagnosis, but is usually bilateral and responds rapidly to topical steroids. Mammary fibromatosis is a rare, benign spindle cell lesion affecting women in the third decade. It should be treated by local excision with wide margins since there is risk of local recurrence. A 42-year-old man presents because recently he has had to change his shoe size from 9 to 101/2. She delivered her first child several months ago and has been breast-feeding since then. She also says that lately she has been tired and has been "feeling cold" all of the time. What is the classic visual disturbance produced early by a large pituitary adenoma (>1 cm) that compresses the central portion of the optic chiasm Bitemporal hemianopsia Homonymous hemianopsia Homonymous inferior field defect Homonymous superior field defect Mononuclear anopsia 403. Which one of the listed individuals is most likely to have a prolactinsecreting tumor of the anterior pituitary A 25-year-old female with amenorrhea, galactorrhea, and a negative pregnancy test b. A 45-year-old female with coarse facial features, large hands and feet, and headaches d. A 54-year-old male with central obesity, purple abdominal stria, and mental changes 404. A 49-year-old man who smokes two packs of cigarettes a day presents with a lung mass on x-ray and recent weight gain. Serum Sodium Hypernatremia Hypernatremia Hyponatremia Hyponatremia Normal Urine Low osmolarity and low specific gravity High osmolarity and high specific gravity Low osmolarity and low specific gravity High osmolarity and high specific gravity Normal osmolarity and normal specific gravity 406. A lesion that originates within and selectively destroys the ventromedial nucleus of the hypothalamus would most likely result in a. Decreased appetite Increased appetite Increased urination Paralysis of the extraocular muscles Tunnel vision 407. Physical examination reveals a small infant with dry, rough skin; a protuberant abdomen; periorbital edema; a flattened, broad nose; and a large, protuberant tongue. A perimenopausal woman presents with increasing swallowing difficulty and fatigue. No thyroidstimulating immunoglobulins are identified in the serum, but antimicrosomal antibodies are present. Intense lymphoplasmacytic infiltrate with lymphoid follicles and scattered oxyphilic cells c. Hyperplasia of follicular cells with scalloping of colloid at the margin of follicles d. Granulomatous inflammation with multinucleated giant cells surrounding fragments of colloid. Central obesity, "moon" face, and abdominal striae Hyperthyroidism, exophthalmus, and pretibial myxedema Polyuria, polydipsia, and hyponatremia Polyuria, polydipsia, and polyphagia Progressive lethargy, cold intolerance, and myxedema Endocrine System 427 411. Histologic sections of a follicular carcinoma of the thyroid would characteristically reveal a. Diagnostic nuclear changes including "Orphan Annie eyes," nuclear grooves, and intranuclear inclusions d. Histologic examination of the mass in this 37year-old male reveals organoid nests of tumor cells separated by broad bands of stroma, as seen in the photomicrograph below. The stroma stains positively with Congo red stain and demonstrates yellow-green birefringence. Follicular carcinoma Papillary carcinoma Squamous cell carcinoma Medullary carcinoma Anaplastic carcinoma Endocrine System 429 414. Which one of the listed signs or symptoms is more characteristic of hypocalcemia than of hypercalcemia
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