By J. Musan. Principia College.

Which of the and cigarette smoking is admitted to the intensive care following therapies is indicated? Minority women aged 13–19 from the southeastern mens is recommended as first-line treatment for her United States account for a growing proportion of malarial infection? Which of the following is true years ago and is maintained on prednisone discount keppra 500mg without prescription, 5 mg discount keppra 500mg online, and cy- regarding enteroviruses as a cause of aseptic meningitis? A 38-year-old female pigeon keeper who has no sig- trichomonal parasites are identified discount 500 mg keppra overnight delivery. Which of the follow- nificant past medical history buy cheap keppra 250 mg line, is taking no medications discount 500mg keppra free shipping, has ing statements regarding trichomoniasis is true? When given as a first-line agent for invasive As- her shoulder presents with fever and severe low back pain. Bilirubin, lactose dehydrogenase, as well as gram-negative coverage and haptoglobin are all within normal limits. White blood cell count is 4300, with an of friends go on a 5-day canoeing and camping trip in ru- absolute neutrophil count of 2500. Which of the following tests is most likely to ers develops a serpiginous, raised, pruritic, erythematous produce a diagnosis? Treatment only for symptomatic illness ioides infection in an immunocompetent host? Asymptomatic seroconversion not been compliant with his physician’s request to off- C. A metal probe is used to probe the wound and it detects bone as well as a 3-cm deep cavity. You are a physician working on a cruise ship travel- Gram stain of the pus shows gram-positive cocci in ing from Miami to the Yucatán Peninsula. In the course of chains, gram-positive rods, gram-negative diplococci, 24 h, 32 people are seen with acute gastrointestinal illness enteric-appearing gram-negative rods, tiny pleomor- that is marked by vomiting and watery diarrhea. The phic gram-negative rods, and a predominance of neu- most likely causative agent of the illness is trophils. Isolation in cell culture health care provider after an accidental needle stick from E. The patient whose blood is on the contaminated therapeutic regimen for mono-infection with hepatitis B? Adequate therapy that allows for eradication of in- with severe dyspnea, confusion, productive cough, and fe- fection in index cases before person-to-person vers. She had been ill 1 week prior with a flulike illness spread can occur characterized by fever, myalgias, headache, and malaise. Earlier diagnosis due to a new culture assay Her illness almost entirely improved without medical in- C. Federal laws limiting the import of foreign cattle tervention until 36 h ago, when she developed new rigors D. Laws prohibiting the feeding of uncooked garbage followed by progression of the respiratory symptoms. On examination she is clammy, confused, and very cells, moderate gram-positive cocci in chains, and yeast dyspneic. Patient X > patient Y > patient Z resistant to which of the following antibiotics? Two weeks earlier she had a self-limited febrile ill- ness notable for a red facial rash and lacy reticular rash on A. Joint aspiration for crystals and culture most likely to occur after frequent use of which of the fol- D. She recalls having a fairly deep cut on vers after receiving 5 days of levofloxacin for pneumo- her hand during an operation about 14 days prior. A urinalysis drawn from a Foley catheter shows had no recent travel or other animal exposures. Her illness positive leukocyte esterase, negative nitrite, 15 white started ~9 days prior with fever, chills, severe headache, in- blood cells/hpf, 10 red blood cells/hpf, and 10 epithelial tense myalgias, and nausea. Thinking that she had influenza infection, she Patient Y: A 38-year-old female on hemodialysis presents stayed home from work and started to feel better 5 days into with low-grade fevers and malaise. However, within a day her symptoms had re- cultures grow Candida albicans in one out of a total of turned with worsening headache, and soon thereafter she three sets of blood cultures in the aerobic bottle only.

This is evident from what often happens during sleep: people think that it is lightning and thundering purchase keppra 250 mg otc, when there are only faint sounds in their ears buy discount keppra 250 mg on-line, and that they are enjoying honey and sweet flavours when a tiny bit of phlegm is running down their throats keppra 250mg for sale, and that they go through a fire and are tremendously hot when a little warmth is occurring around certain parts of the body cheap 250mg keppra. But when they wake up buy keppra 250mg cheap, they plainly recognise that these things are of this nature. Consequently, since of all things the beginnings are small, it is evident that also of diseases and of other affections which are going to occur in the body, the beginnings are small. It is obvious, then, that these are necessarily more clearly visible in sleep than in the waking state. If the dream is correctly interpreted, it can be reduced to its cause, which can be recognised as the cause of an imminent disease. Aristotle pays no attention to the rules for such a correct interpretation of dreams; he only analyses the causal structure of the relationship between the dream and the event foreseen in it. The first is one of the corner stones of his theory of dreams as set out in On Dreams (460 b 28ff. This principle is demonstrated by means of a number of examples derived from common experience (no. The second principle is that the origins of all things (including diseases) are small and therefore belong to the category of small movements. The two principles are combined in the form of a syllogism at the end of the paragraph. These points are most relevant for an assessment of what Aristotle is do- ing in the passage under discussion. It has, of course, long been recognised by commentators that the sentence 463 a 4–5 may very well be a reference to the Hippocratic treatise On Regimen, the fourth book of which deals with dreams and which I quoted at the beginning of this chapter. Although the Hippocratic Corpus contains several examples of the use of dreams as prognostic or diagnostic clues,49 we nowhere find such an explicit theoret- ical foundation of this as in this book. It is chronologically possible and plausible that Aristotle knew this treatise, because other places in the Parva naturalia show a close similarity of doctrine to On Regimen. Moreover, the author’s approach must have appealed to Aristotle for the very fact that the interest of dreams is that they reveal the causes of diseases. However, these similarities should not conceal the fundamental differ- ence of approach between the medical writer and Aristotle. This difference not only manifests itself in that Aristotle, as a natural scientist, is only inter- ested in the causal relationship between the dream and the event, whereas On Regimen is primarily a text about regimen (both from a preventive and from a therapeutic point of view), which explains the great amount of de- tailed attention paid to the interpretation of the contents of dreams and to prescriptions about preventive dietetic measures. The most important difference lies in the psycho-physiological explanation of the significance of dreams given by the two authors. The author of On Regimen appeals to a rather ‘dualistic’ conception of the relation between soul and body, of the type referred to earlier on in this chapter: 49 SeetheinstanceslistedinvanderEijk(1994)279. Ross (1955) 56–7, who points out that Aristotle’s ‘comparison of the heart-lung system to a double bellows [in De respiratione 480 a 20–3] is clearly borrowed from Vict. Aristotle on sleep and dreams 199 For when the body is awake, the soul is its servant: it is divided among many parts of the body and is never on its own, but assigns a part of itself to each part of the body: to hearing, sight, touch, walking, and to acts of the whole body; but the mind is never on its own. However, when the body is at rest, the soul, being set in motion and awake, administers its own household and of itself performs all the acts of the body. For the body when asleep has no perception; but the soul, which is awake, cognises all things: it sees what is visible, hears what is audible, walks, touches, feels pain, ponders, though being only in a small space. Whoever, therefore, knows how to interpret these acts correctly, knows a great part of wisdom. It would be impossible for Aristotle to say – as the writer of On Regimen does – that in sleep the body is at rest but that the soul works. Sleep is for Aristotle an affection of the complex of soul and body due to the heating and cooling of food and preventing the animal from perceiving actual sense movements. It is obvious, therefore, that we cannot say that Aristotle is influenced here by the medical writer’s views on dreams. It would be more appropriate to say that the non-specialised student of nature gives a theoretical explanation or even a justification of the view held by the distinguished doctors; this justification is given entirely in Aristotle’s own terminology and based on his own presuppositions (the two principles mentioned above). This procedure is completely in accordance with his general views on the relation between natural science and medicine discussed above. However, the incorporation of the medical view on the prognostic value of dreams into his own theory of sleep and dreams does confront Aristotle with a difficulty which he does not seem to address very successfully. For, as we have seen above, in On Dreams Aristotle says that dreams are based on the remnants of small sensitive movements which we receive in the waking state but do not notice at the time, because they are overruled by more powerful movements which claim all our attention. Yet during sleep, when the input of stronger competing sensitive movements has stopped, the remnants of these small movements come to the surface and present themselves to us in the form of dreams. As I have already said, it is exactly this mechanism to which Aristotle seems to refer in Div.

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Complications can Stereotaxis can be used to direct a biopsy buy 500 mg keppra fast delivery, external include hepatitis 500mg keppra fast delivery, nephritis 500mg keppra sale, gastrointestinal bleed- radiation generic keppra 250 mg with visa, or the insertion of radiation implants 500mg keppra. The distinction manubrium (the upper segment of the sternum, a between a stillbirth and a miscarriage is arbitrary. These Before that time it is a miscarriage, and after that sections of the sternum arise as separate bones, and time it is a stillbirth. Steroids can have stoma An opening into the body from the outside that is created by a surgeon. When food strain 1 An injury to a ligament, tendon, or mus- enters the stomach, muscles in the stomach wall cle that results from overuse or trauma. After about 3 hours, the food becomes a liq- strawberry hemangioma or strawberry mark uid and moves into the small intestine, where diges- See hemangioma, capillary. Under a microscope, strepto- coccus bacteria look like a twisted bunch of round stomatitis An inflammatory disease of the berries. Illnesses caused by streptococcus include mucous lining of the mouth that can be a complica- strep throat, strep pneumonia, scarlet fever, rheu- tion of chemotherapy for cancer. Other causes matic fever (and rheumatic heart valve damage), include vitamin deficiency, infection, or trauma. Group B strep can infect the mother’s uterus, placenta, and urinary tract; in fact, stone, renal See kidney stone. Infants develop the infection in utero or at the time stool The solid matter that is discharged in a of delivery from women who have vaginal group B bowel movement. Infections in the infant can strabismus A condition in which the visual axes be localized, or it may involve the entire body. In of the eyes are not parallel and the eyes appear to be babies, strep infections are divided into early-onset looking in different directions. In con- within the first 6 days of life, with breathing diffi- vergent strabismus or esotropia, the visual axes culty, shock, pneumonia, and occasionally infection converge. The danger with strabismus is that the of the spinal fluid and brain (meningitis). Late- brain may come to rely more on input from one eye onset disease presents between the seventh day and than the other, and the part of the brain circuitry that the third month of age, with a bloodstream infection is connected to the less-favored eye may fail to (bacteremia) or meningitis. The bacteria can also develop properly, leading to amblyopia (weakened infect an area of bone; a joint, such as the knee or vision) in that eye. Group B strep infection in a new- moderate strabismus is to cover the stronger eye born is a serious and potentially life-threatening with a patch, forcing the weaker eye to do enough event, particularly because fever and warning signs work to catch up. Atropine eyedrops can also be are often minimal or absent and because the newborn’s immune system is not mature. Group B strep infection of the newborn is treated, there is a high risk of major stroke in the treated aggressively with antibiotics, usually in a future. Prevention and early An operation called a carotid endarterectomy can detection are critically important. These medications act by par- tially blocking the blood-clotting function of the Streptococcus pneumoniae The most common platelets in the patient’s blood. Controlling other cause of bacterial pneumonia and middle ear infec- factors that contribute to strokes, such as high tion (otitis media) and the third most frequent blood pressure and diabetes, is also important for cause of bacterial meningitis. The strep throat (streptococcal pharyngitis), impetigo, stroke volume is not all the blood contained in rheumatic fever, scarlet fever, glomerulonephritis, the left ventricle; normally, only about two-thirds invasive fasciitis, strep skin infections, and rheu- of the blood in the ventricle is expelled with each matic fever. Neurological symp- toms of Sturge-Weber syndrome may include stricture of the esophagus, chronic See seizures and developmental delay. Sudden loss of speech, usually be eliminated or significantly modified with weakness, or paralysis of one side of the body can be speech therapy. In contrast, acute indicates very sudden stroke prevention Methods of preventing the onset or rapid change, and chronic indicates indef- occurrence of a cerebrovascular accident. For example, stenosis may be present at birth (congenital) or a sublingual medication is a type of lozenge that is acquired as part of a specific form of heart disease dissolved under the tongue. Treatment options include use of drugs sublingual gland A salivary gland that is located and surgery. See also idiopathic hypertrophic under the floor of the mouth, close to the midline. The sublingual gland is the smallest of the three major salivary glands (the parotid, submandibular, subarachnoid Literally, beneath the arachnoid, and sublingual glands). A com- ally refers to the space between the arachnoid and plete dislocation is a luxation.

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Bicipital tendonitis is produced by friction on the tendon of the long head of the biceps as it passes through the bicipital groove purchase 500mg keppra with mastercard. Patients experience anterior shoulder pain that radiates down the biceps to the forearm generic 500 mg keppra overnight delivery. Five to 10% of patients with psoriasis will develop an arthritis associated with the rash keppra 250mg without prescription. However generic keppra 250 mg overnight delivery, another 15 to 20% of patients will have joint complaints as the presenting symptom of their psoriasis generic keppra 500mg overnight delivery. Erosive joint disease ultimately develops in almost all these patients, and most of them become disabled. Changes that are frequently seen include pitting, horizontal ridging, onycholysis, yellowish discoloration of the nail margins, and dystrophic hyperkeratosis. Thus, in patients with joint symptoms that pre- cede the onset of rash, the diagnosis is frequently missed until dermatologic or nail changes develop. A family history of psoriasis is important to ascertain in any patient with an undiagnosed inflammatory polyarthropathy. Radiog- raphy may show typical changes, particularly in patients with arthritis mutilans. Other treatments include methotrexate, sulfasalazine, cyclosporine, reti- noic acid derivatives, and psoralen plus ultraviolet light. The peak age of onset is in the for- ties to fifties, but it may occur at all ages. Approximately 30% of patients will have an- other rheumatologic disorder, most commonly systemic vasculitis. Auricular chondritis is the most common clinical manifestation of relapsing polychondritis, occurring 43% of the time as the presenting complaint, and with 89% cumulative frequency. Aortic regurgitation, due to dilation of the aortic ring or de- struction of the cusps, is an uncommon finding in this illness, occurring in ≤5% of cases. The diagnosis of relapsing polychondritis is based on recognition of the characteristic clinical features, including two or more separate sites of cartilaginous inflammation that responded to treatment with prednisone or dapsone. Biopsy can confirm the diagnosis but may not be necessary if the clinical features are typical. The primary non-Hodgkin’s lymphoma associated with Sjögren’s syndrome is a low-grade, marginal zone B cell lymphoma that usually presents extranodally. Persistent parotid enlargement, leukopenia, cryoglobulin- emia, and presence of rheumatoid factor should prompt evaluation for possible lymphoma. Treatment for Sjögren’s syndrome should be same as that for other B cell non-Hodgkin’s lymphomas. Factors that influence survival include size >7 cm, pres- ence of B symptoms, and high or intermediate histologic grade. Adenoid cystic carci- noma is the second most common malignant tumor of the salivary glands after mucoepidermoid carcinoma, but it does not occur more commonly in Sjögren’s syn- drome. An impacted sialolith could cause unilateral enlargement of the parotid gland but should present with pain with palpation. Pain is worse with eating or the anticipation of eating, which would stimulate saliva production. The ulcer- ations are generally painful, occur in groups, and subside spontaneously in 1–2 weeks without leaving scars. The diagnosis requires the presence of recurrent oral ulcers plus two of the fol- lowing criteria: recurrent genital ulcers, eye lesions, skin lesions (including erythema nodosum), or positive pathergy test. A pathergy test is considered positive when nonspe- cific skin inflammation develops 2–3 days after a scratch or injection of sterile saline. Other clinical manifes- tations of Behçet’s syndrome include nonerosive arthritis, gastrointestinal ulcerations, and neurologic involvement. In addition, individuals with Behçet’s syndrome are at in- creased risk of venous thromboembolic disease. It is more common in individuals from the Mediterranean region, Middle East, and Far East. In advanced disease, antibodies to α-enolase of endothelial cells and Sac- charomyces cerevisiae have been shown. The pathologic lesion is perivasculitis with neu- trophilic infiltration, endothelial swelling, and fibrinoid necrosis. Oral and genital lesions can usually be treated with topical glucocorticoids alone. Other treatments that are effec- tive include thalidomide, colchicine, and systemic glucocorticoids.

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