USMLE Step 3 Review Course,Online Video Course,General Medicine. A Akhter MD, Usually after drinking bootleg whiskey comes with visual disturbance. PE mydriasis hyperemia of optic disc, Lab Anion gap metabolic acidosis osmolal gap serum methanol level. Treatment Fomepizole antidote of choice IV, Alternative ethanol hemodialysis for severe toxicity 50 mg dL. Ethylene Glycol,Secondary to ingestion of antifreeze solution. Clinical Feature confusion tachypnea, Lab Anion gap metabolic acidosis urine test has oxalate crystal osmolal gap. Treatment same as methanol poisoning,Organophosphate insecticide. History of insecticide spray or a farmer coming from work. Complaints Abdominal pain diarrhea vomitting Shortness of breath. Physical Exam Miosis constricted pupil sweating wheezing. Treatment Wash the skin with soap and water,Atropine I V decreases sweating and wheezing. Pralidoxime 2 PAM I V specific antidote,Salicylate Poisoning. Nausea vomiting tinnitus tachypnea,Lab metabolic acidosis and respiratory alkalosis. Treatment Alkalinize urine by sodium bicarbonate I V. Hemodialysis for severe acidosis or altered mental status. Black Widow Spider Bite, Clinical Feature generalized muscular pain muscle spasm rigidity. Treatment parenteral narcotic for pain,Muscle relaxant methocabomol I M or I V for spasm. Calcium gluconate I V for rigidity,Rarely antivenin I V. Brown Recluse Spider Bite, Clinical Feature extensive local necrosis and hemolytic reaction may not be felt. at all or only as a pinprick,Lesion is small 2cm, o supportive measures dress the wound tetanus toxoid rest analgesics and. close follow up,Large massive necrotic lesion 2cm,o Treat with systemic corticosteroids 5 7 days. Opioid Intoxication, Copyright Premier Review DO NOT copy Copying this material is violation of copyright law 2. USMLE Step 3 Review Course,Online Video Course,General Medicine. A Akhter MD, Morphine Codeine Heroin Meperidine Methadone Oxycontin. Clinical Feature Euphoria drowsiness constricted pupil hypotension. bradycardia hypothermia and respiratory arrest, Seizure likely secondary to Meperidine especially in patients with renal failure. due to accumulation of metabolite nor meperidine,Duration of effect of Heroin 3 5 hr. Methadone intoxication may last 48 72 hrs, Most opioids are detectable on routine urine toxicology except Methadone newer. Fentanyl derivative,Treatment Naloxone 0 4 mg to 2 mg IV. Duration of effect of Naloxone is 2 3 hr, Repeated dosage required for patients intoxicated with Methadone. Patient should be observed at least 3 hours after the last dose of Naloxone. Poisoning Specific Antidote,Beta Blocker Glucagon,Acetaminophen Acetylcysteine. Carbon Monoxide 100 Oxygen,Benzodiazepine Flumazenil. Cyanide Nitrite Amyl nitrite Sodium nitrite,Digoxin Fab antibody fragment digibind. Opiates Naloxone,Iron Defuroxamine,Methanol ethylene glycol Fomepizole. Methemoglobinemia Methylene blue,Snake Bite, Venom could be cytolytic Rattle snake other Pit Vipers most common in USA. Neurotoxic Coral Snake, Cytolytic venom causes tissue destruction by digestion and hemorrhage due to. hemolysis and destruction of endothelial lining of blood vessels. Manifestation local pain redness swelling extravasation of blood nausea. vomiting hypotension coagulopathy may also occur, Neurotoxic venom causes ptosis diplopia dysphagia respiratory paralysis. Management, Immobilize the patient and bitten part in neutral position. Avoid manipulation of bitten area,Avoid any stimulant. Do not apply ice, Copyright Premier Review DO NOT copy Copying this material is violation of copyright law 3. USMLE Step 3 Review Course,Online Video Course,General Medicine. A Akhter MD,Do not apply tourniquet, Incision and suction by unskilled people is not justified in view of small amount. of venom that can be recovered,Transport pt to nearest facility. In hospital,Labs CBC Chem 7 CPK PT PTT Urine for myoglobin. If no local or systemic signs and symptoms and coagulation profile normal. discharge home in 12 hours,Specific Antidote, Pit Vipers Rattle Snake Crotalid antivenin CroFab Slow IV in normal saline. antihistamine keep epinephrine ready in case of anaphylactic reaction. Oxygen IV fluid Asses need for Tetanus toxoid antibiotic Augmentin. Coral Snake For specific antivenin call the regional poison center they help you. to locate antisera Horse serum based antivenom is available in USA. Adequacy of treatment is indicated by clinical signs and symptoms and rate of. swelling slows down also follow up the coagulation profile. DO NOT FORGET ABC,Control airway oxygen pulse oximeter intubation. If trauma first immobilize cervical spine with hard collar until you r o fracture. or instability,IV line cardiac monitor check cardiac monitor. Vitals stabilize it if hypotensive start Inravenous normal saline vasopressors. dopamine norepinephrine, Order finger stick CBC Chem 7 LFT ammonia ABG PT PTT type and. cross match blood cx UA urine toxicology blood toxicology screen alcohol. level serum osmolality urine osmolality cardiac enzyme portable chest x ray. EKG Foley catheter,IV thiamine 50 dextrose 50 cc IV Naloxone IV. Flumazenil IV if the suspicion of Benzodiazepine is high Routine use is not. advisable since it can cause Seizure, Exam look for signs of head trauma cirrhosis sepsis rash of meningococcemia. Look at the pupils, o Small but reactive narcotic overdose or metabolic encephalopathy. o Dilated fixed unilateral r o uncal herniation hyperventilation. mannitol IV dexamethasone IV urgent neurosurgery consult CT head. o Dilated fixed bilateral drug intoxication with methyl alcohol or severe. anoxic encephalopathy, If patient is febrile vancomycin and gentamycin IV. Copyright Premier Review DO NOT copy Copying this material is violation of copyright law 4. USMLE Step 3 Review Course,Online Video Course,General Medicine. A Akhter MD, Follow up labs If serum osmolality high and anion gap metabolic acidosis. hyperemia of optic disc Fomepizole, If vitals stable CT head non diagnostic Lumbar puncture. Send CSF for cell count cx glucose protein, Still undiagnosed EEG to diagnose non convulsive status epilepticus. encephalitis encephalopathy,CCS Case Coma,Location Emergency Room. CC Unresponsive, Vitals B P is 120 60mm of Hg Pulse is 100 minute Temperature is 990F. RR is10 12 minute,History of Present Illness, 30 year old male brought by his girlfriend as was found unresponsive in his apartment A. bottle of liquor 75 empty and couple of bottles of medicines of anxiety were empty. Past Medical History Alcohol Abuse Anxiety Depression. Personal History Smokes one pack of cigarette daily Smoked Marijuana five years ago. Drinks alcohol everyday No history of IV drug abuse. Allergy Unknown,Family History Unknown,DO NOT FORGET ABC. Airway oral To maintain the patency of airway,Oxygen continuous. Pulse oximeter,Cardiac monitor,Intravenous access,Intravenous fluid Normal saline. Finger stick glucose, Pulse oximeter should have oxygen saturation more than 90 if it is less than 90. Intubation, Note If history is suggestive of some poisoning and you are planning to do gastric. Lavage in a comatose patient always intubate prior to gastric Lavage Gastric Lavage is. Copyright Premier Review DO NOT copy Copying this material is violation of copyright law 5. USMLE Step 3 Review Course,Online Video Course,General Medicine. A Akhter MD, not being used routinely except if you have clear history of ingestion of life threatening. amount of toxin and patient presents within 60 minutes of ingestion of the substance if. they want you to do gastric Lavage history will be patient took this medication this. many pill while arguing with a family member or friend who brought the patient to the. hospital If patient is conscious you can perform gastric Lavage without intubation But. if patient is unconscious first intubate before gastric Lavage. Again order battery of test and procedure, CBC Chem8 Liver Function Test LFT Ammonia Arterial Blood Gas ABG PT. PTT Type and cross match blood c s Cardiac enzyme Blood toxicology screen. Blood Alcohol level Serum osmolality X ray chest AP Portable EKG Foley s catheter. U A Urine toxicology Urine Osmolality, After above orders Order the following in the same sequence. Thiamine therapy I V one time bolus Dextrose 50 in water I V stat. Naloxone I V one time bolus,Flumazenil I V one time bolus. Note Thiamine is give before the administration of Dextrose because if dextrose is. administered in a Thiamine deficient patient it can precipitate Wernicke s. Encephalopathy Usually thiamine deficiency occurs in Alcoholics. If patient becomes conscious after the administration of I V Naloxone suggest opiate. intoxication If this patient again becomes unconscious suggest long acting opiate. intoxication eg Methadone which will need multiple dosages of Naloxone I V. If patient becomes conscious after the administration of Flumazenil suggests. Benzodiazipine intoxication, Patient did not respond to above treatment If Urine toxicology result becomes available. and is positive for benzodiazepine this does not mean patient has benzodiazepine. toxicity since patient did not respond to Flumazenil Although benzodiazepine was. positive in urine because patient has history of anxiety and was on benzodiazepine. Scenario 1, If patient has hypotension and EKG shows Arrhythmia Prolonged PR QRS and QT. interval likely diagnosis is Tricyclic Antidepressant poisoning since patient has history. of depression and anxiety Order Sodium bicarbonate I V continuous. Check vitals if vitals remain stable order CT scan of the head If the scan report is. normal transfer the patient to the Intensive care unit. Follow up serum and urine toxicology to confirm the diagnosis of TCA poisoning. Scenario 2, Copyright Premier Review DO NOT copy Copying this material is violation of copyright law 6. USMLE Step 3 Review Course,Online Video Course,General Medicine. A Akhter MD, If patient has not responded to above cocktail look into the examination HEENT. finding dilated pupils hyperemia of optic disc check labs serum osmolality. Serum osmolality high check anion gap Anion gap 14 Anion gap metabolic. acidosis check U A normal No crystals most likely diagnosis Methanol. poisoning Start IV Fomepizole or Ethanol, Check vitals if vitals remain stable order CT scan of the head If the scan report is. normal transfer the patient to the Intensive care unit. Scenario 3, If patient has not responded to above cocktail look into the examination HEENT. finding Pupils are normal check labs serum osmolality Serum osmolality. high check anion gap Anion gap 14 Anion gap metabolic acidosis check U A. calcium oxalate crystals most likely diagnosis Ethylene Glycol anti freeze. poisoning Start IV Fomepizole or Ethanol, Check vitals if vitals remain stable order CT scan of the head If the scan report is. normal transfer the patient to the Intensive care unit. Scenario 4, If patient has not responded to above cocktail look into the examination HEENT. finding pupils are normal check labs serum osmolality Serum osmolality. high check anion gap Anion gap normal 12 2 check U A increased ketones. in the urine no crystals Order serum ketone Follow up the serum toxicology result. which tells you about isopropyl alcohol level most likely diagnosis Isopropyl. Alcohol poisoning Treatment is supportive continue above management. Check vitals if vitals remain stable order CT scan of the head If the scan report is. normal transfer the patient to the Intensive care unit. Primary Immune Deficiency,Common Variable Immune deficiency disease CVID. Abnormality in B cell function,Presents between one year to adulthood. When onset is in adulthood they may have underlying lymphoid malignancy. Presents with recurrent bacterial infection involving sinuses middle ear lung with. systemic spread,Treatment IVIG lifelong,Hyper IgE syndrome Job s syndrome. Recurrent skin and visceral hepatic renal pulmonary perianal abscess. Mostly secondary to staphylococcal infection,Elevated IgE level. DiGeorge Syndrome, Copyright Premier Review DO NOT copy Copying this material is violation of copyright law 7. USMLE Step 3 Review Course,Online Video Course,General Medicine. A Akhter MD, Secondary to deletion of chromosome 22q11 development of 3 and 4 pharyngeal. pouch gets affected causing anomaly of face thymus parathyroid and cardiac. structures,1 Absent T cells secondary to absence of thymus. 2 Congenital heart disease,3 Hypocalcemia secondary to hypoparathyroidism. Characteristic facial appearance cleft palate small mouth low set ears short. palpebral fissure widened distance between the inner canthi telecanthous. Congenital heart disease Tetralogy of fallot Truncus arteriosus atrial and ventricular. septal defect,Hypocalcemia presents with tetany seizure. Treatment Bone marrow transplant,Wiscott Aldrich syndrome. Mix of immunoglobulin defect and T cell deficiency. Clinical Features Eczema develops during first year of life resembles atopic. dermatitis,Thrombocytopenia presenting with bleeding. Characteristic immunoglobulin pattern IgG normal IgM very low IgA and IgE. Prone to have infection with encapsulated organisms due to immunoglobulin defect. Increased incidence of non Hodgkin s lymphoma,Treatment Bone marrow transplant. If bone marrow transplant not feasible due to absence of HLA matched donor. splenectomy is the treatment of choice for patients with platelet count less than 50 000. IVIG every 3 to 4 weeks, Antibiotic prophylaxis Amoxicillin or Trimethoprim sulfamethoxazole daily. Severe combined immunodeficiency disease SCID,Absence of both cellular and humoral immunity. Usually symptoms starts in newborn period, Classical symptoms are recurrent severe infection chronic diarrhea and failure to. Chronic mucocutaneous candidiasis is a common early finding. Attenuated vaccine such as OPV can cause severe infection. Copyright Premier Review DO NOT copy Copying this material is violation of copyright law 8. USMLE Step 3 Review Course,Online Video Course,General Medicine. A Akhter MD, Blood transfusion can cause graft versus host disease GVHD. Lab lymphopenia absolute lymphocyte count less than 2000 mm3 in a newborn is an. absolute indication for evaluation of SCID,Hypoglobulinemia. Impaired specific antibody response,Cutaneous anergy. Treatment Bone marrow transplant,Adenosine deaminase deficient SCID. Profound lymphopenia absolute lymphocyte count less than 500 mm3. Chondro osseous dysplasia of costochondral junction. Vertebral bodies reveal Rachitic Rosary rib cage,Chediack Higashi Syndrome. Phagocytic disorder Neutrophils contain abnormal Giant granules due to. inappropriate fusion of lysosomes and endosomes,Recurrent pyogenic infection. Partial oculocutaneous albinism, Neurologic abnormality Photophobia Nystagmus Peripheral neuropathy seizure. dysfunction of spinal tract and cerebellum,IgA deficiency. Most common primary immunodeficiency, Predominent immunoglobulin of nasal secretion is IgA. Most patients are asymptomatic but may develop recurrent sino pulmonary infection. recurrent gastrointestinal infection particularly giardia lamblia secretory IgA usually. binds with pathogens and toxins,Anaphylactic blood transfusion reaction. Ataxia Telangiectasia, Progressive cerebellar ataxia since the beginning of walking appear healthy for the. first year of life which slowly gets worst and by 10 12 years of age become. wheelchair bound, Ocular or facial Telangiectasia mostly appear when child is 3 5 year of age. Elevated alpha feto protein is found in more than 95 patients over the age of 8. Immunodeficiency Absent or low IgA and IgE level mostly develop sino pulmonary. infections,No effective treatment,Vitamin Deficiency. Copyright Premier Review DO NOT copy Copying this material is violation of copyright law 9. USMLE Step 3 Review Course,Online Video Course,General Medicine. A Akhter MD, Vitamin deficiency syndromes develop gradually symptoms are non specific and. physical exam is rarely helpful in early diagnosis. Some vitamins can be used efficaciously as drugs, o Vitamin A derivatives Treat cystic acne and skin wrinkles. o Niacin Treats hyperlipidemia,Vitamin A Deficiency. Important for normal retinal function wound healing and cell growth and. differentiation, Causes Fat malabsorption syndromes and mineral oil laxative abuse it occurs. commonly in the elderly and urban poor in the US, CLINICAL FEATURE Night blindness xerosis dryness of the conjunctiva. Bitot s spots Keratomalacia perforation endophthalmitis and blindness. Treatment Vitamin A 30 000 IU day x 1 week for early deficiency. Toxicity staining of the skin orange yellow and with hypervitaminosis dry scaly. skin hair loss mouth sores painful hyperostosis anorexia and vomitting early on. Late findings hypercalcemia increased ICP cirrhosis. Vitamin A derivatives also used to treat Cystic Acne and Skin wrinkles. remember however it is teratogenic therefore always do a pregnancy test in. females of child bearing age Topical use can increase the risk of skin cancer. Vitamin B1 Thiamine Deficiency,Causes alcoholic chronic dialysis. CLINICAL FEATURE, o Wet beriberi Symptoms are cardiovascular heart failure ascites edema. o Dry beriberi Symptoms are neurological both peripheral and central. o Wernicke s encephalopathy nystagmus ophthalmoplegia ataxia. change in mental status, o Korsakoff s psychosis confabulation and retrograde amnesia. Treatment large parenteral doses 50 100 mg day for first few days followed by. daily doses 5 10 mg day,Vitamin B2 Riboflavin Deficiency. Causes drugs phenothiazine tricyclic antidepressants. CLINICAL FEATURE Glossitis cheilosis angular stomatitis seborrheic. dermatitis weakness corneal vascularization and anemia. Treatment meat fish dairy or oral preparation of vitamin 5 15 mg day. Vitamin B6 Pyridoxine Deficiency, Causes patient on INH Penicillamine OCPs or alcoholism. CLINICAL FEATURE mouth soreness glossitis cheilosis if severe peripheral. neuropathy seizure, Treatment oral supplements 10 20 mg day typically given with INH. Copyright Premier Review DO NOT copy Copying this material is violation of copyright law 10. USMLE Step 3 Review Course,Online Video Course,General Medicine. A Akhter MD, Toxicity irreversible sensory neuropathy on high doses. Niacin Deficiency, Causes Historically it occurred when corn which is relatively deficient in niacin. was the major source of calories Today Alcoholism INH Carcinoid syndrome. CLINICAL FEATURE Pellagra 3D diarrhea dementia dermatitis and if. advanced even death,Treatment oral doses 10 150 mg day. It is also used to treat hyperlipidemia, Toxicity can be seen when treating hyperlipidemia Cutaneous flushing to avoid. pre treat with Aspirin 325 mg day,Vitamin C Deficiency. Potent antioxidant also required for the synthesis of collagen. Increases absorption of Iron,Decreases effect of Warfarin. Causes hyperoxaluria, CLINICAL FEATURE Scurvy Due to impaired collagen synthesis Symptoms. are bleeding gum ecchymoses petechiae hyperkeratosis impaired wound. healing weakness joint pain and swelling neuropathy. Treatment Ascorbic acid 300 1000 mg day, Toxicity gastric irritation flatulence and diarrhea at high doses Fecal occult. blood could be false negatives and urine glucose could be false positives. Vitamin D Deficiency, Causes insufficient sun exposure malnutrition malabsorption rickets. anticonvulsants often seen in institutionalized elderly. CLINICAL FEATURE osteomalacia osteopenia,Treatment Sunlight Vitamin D supplements. Vitamin E Deficiency, Functions as an antioxidant protecting cell membranes and other structures from. the attack of free radicals,Investigational use to prevent Alzheimer s. CLINICAL FEATURE Hemolysis Ataxia Myopathy, o Increases effect of Warfarin Causes Vitamin K deficiency. Treatment oral doses of 100 400 units day, Toxicity nausea diarrhea and may cause bleeding in those taking coumadin. Factor II VII IX X protein C and S are vitamin K dependent clotting factors. Causes poor diet malabsorption broad spectrum antibiotics. CLINICAL FEATURE bleeding from venipuncture site,Treatment Subcutaneous vitamin K supplement. Selenium Deficiency of Selenium can cause Congestive Heart Failure. Chromium Deficiency of chromium can cause Insulin Resistance. Copyright Premier Review DO NOT copy Copying this material is violation of copyright law 11. USMLE Step 3 Review Course,Online Video Course,General Medicine. A Akhter MD, Zinc Deficiency of Zinc can cause delayed wound healing. Complications of modern day hobbies, Tanning beds Addictive can cause basal cell carcinoma especially in women who. are taking OCP or Antihistamine, Hair Removal Eflornithine ornithine decarboxylase inhibitor is FDA approved. for the use of abnormal facial hair,Complication Reversible Anemia Leucopenia. Laser Hair removal Side effect could be hypo pigmentation flare up of Acne and. End of 1st Hour, Copyright Premier Review DO NOT copy Copying this material is violation of copyright law 12. USMLE Step 3 Review Course,Online Video Course,General Medicine. A Akhter MD,Medicine Use Comment,St John s Wort Depression Avoid with SSRI. Activates Cytochrome P450system,and so decreases the plasma. concentration of Theophylline,Cyclosporine Indinavir Warfarin. Digoxin Simvastatin Oral,contraceptive, Saw Palmetto Benign Prostatic Hypertrophy Improves urinary symptoms. Does not decrease Prostate size or,May cause Hypertension. Ginseng Fatigue Diabetes Hypertension Hypoglycemia. Witch Hazel Hemorrhoids and Acne External use has no side effect. Ginkgo Dementia Avoid with NSAID Warfarin,Heparin increased risk of bleeding. Glucosamine Osteoarthritis, Creatine Athletes to increase Avoid in renal failure. performance,DHEA Anti aging agent sexual,enhancer depression. Ephedra Sympathomimetic used for Hypertension arrhythmia stroke. weight loss stimulant, Licorice Used in chewing gum and Inhibits 11 hydroxy steroid. chewing tobacco dehydrogenase which converts,Cortisol to Cortisone if Cortisol. level is high it will stimulate,Aldosterone receptors Patient will. have symptoms of primary,hyperaldosteronism like,hypertension hypokalemia and. metabolic alkalosis, Black Cohosh Active ingredient Side effect Nausea vomiting and. Also known as Phytoestrogens estrogen like hypotension. Actaea racemosa L effect helps in menopausal, Cimicifuga symptoms Caution when used patient taking. racemosa anticoagulant and antihypertensive, Black Snakeroot Isoferulic acid aspirin like medication Patient having. Bugwort effect helps in rheumatic pain undiagnosed uterine bleeding. Rattle Root,Rattle Weed, Copyright Premier Review DO NOT copy Copying this material is violation of copyright law 13. USMLE Step 3 Review Course,Online Video Course,General Medicine. A Akhter MD,Geriatrics,Changes in physiologic function with age. Organ System Age Related Decline in Function,Special Senses Presbyopia. Lens opacification,Decreased hearing,Decreased taste and smell. Cardiovascular Impaired intrinsic contractile function. Decreased conductivity,Decreased ventricular filling. Increased systolic blood pressure,Impaired baroreceptor function. Respiratory Decreased lung elasticity,Decreased maximal breathing capacity. Decreased mucous clearance,Decreased arterial PO2, Gastrointestinal Decreased esophageal colonic motility. Renal Decreased Glomerular filtration rate,Immune Decreased cell mediated immunity. Decreased T cell number,Increased T suppressor cells. Decreased T helper cells,Loss of memory cells,Decline in Ab titers to known Ag. Increased autoimmunity, Endocrine Decreased hormonal responses to stimulation. Impaired glucose tolerance,Decreased Androgens and Estrogens. Impaired norepinephrine response, Autonomic Nervous Impaired response to fluid deprivation. Decline in baroreceptor reflex,Increased susceptibility to hypothermia. Neurologic Decreased vibratory sense,Decreased proprioception. Musculoskeletal Decreased muscle mass,Sensory Impairment. o The most common cause of hearing loss is sensorineural Presbycusis. o Screening test Hearing Handicap Inventory for the Elderly Screening. Version HHIE S whispered voice test audioscopy, o Hearing loss leads to social isolation and depression. Copyright Premier Review DO NOT copy Copying this material is violation of copyright law 14. USMLE Step 3 Review Course,Online Video Course,General Medicine. A Akhter MD, o The most common causes of age related visual impairment Age related. macular degeneration AMD cataracts glaucoma,o AMD leading cause of blindness in those 65. o Screening test Snellen or Jaeger eye chart, Q 87 yo M living in an assisted living home recently became socially isolated no longer. visiting with friends eating in the common dining room or watching television Vitals are all. stable All labs WNL Geriatric depression score 1 5 low risk for depression What to do. Q An 81 year old man is evaluated for a 6 month history of a constant buzzing sound in both. ears The noise interferes with reading watching television and sleep He denies headache. vertigo or sinus pain Depression screening results are negative Vitals are stable PE normal. What to do, The prevalence of dementia doubles every 5 years after age 60 by the age of 85. about 30 50 of individuals have some degree of impairment. Short term memory is important to inquire about finding out whether patients. have difficulty forgetting to take medications forgetting appointments or getting. lost while driving, Screening test Folstein Mini Mental State Examination 24 30 is significant. Level of education can affect performance, Identification of dementia early can identify potentially reversible causes like. folate B12 deficiency syphilis hypothyroidism depression. Treatment for dementia, o Donepezil a centrally acting cholinesterase inhibitor modestly improves. cognition global function and psychiatric symptoms. o Memantine is recommended for patients for moderate to severe. Alzheimer s,o Vitamin E may help slow progression, Q A 78 year old F concerned that she is losing her memory visits her primary care. physician accompanied by her daughter The daughter confirms that the patient is forgetful. and does not recall conversations that have occurred in recent days The patient appears. cheerful physical exam well groomed and friendly Which of the following is the most. appropriate next step in the assessment of this patient s cognitive impairment. Depression, A simple 2 question screen has shown 96 sensitivity for detecting major. depression in the general population and even higher in those 65. o In the last month have you often been bothered by feeling sad depressed. or hopeless, Copyright Premier Review DO NOT copy Copying this material is violation of copyright law 15.
Manufacturing Processes Based on Relational Measurements of Key Product Characteristics Variation source identi?cation for manufacturing processes is critical for product dimen-sional quality improvement, and various techniques have been developed in recent years. Most existing variation source identi?cation techniques are based on a linear ...
deal with Michaels, a national arts and crafts store. The retail craft giant started carrying the injection molded ABS looms and hooks in its 1,125 stores the first week of August. Rainbow Loom sales skyrocketed for Ng, the owner of Choon Designs LLC, which is based in Wixom.
Lord of the Rings LCG Comprehensive Card Reference & Unofficial FAQ (version 6.1) Quest Scenario-specific cards reflecting the current quest. Arrange quest cards in sequential order, with Side A face-up. Resolve any text on Side A on the top card, then flip to Side B and resolve text there as well. Hero Starting characters for players.
v CAPTAIN JAMES T. KIRK Federation, Soldier Unwinnable Kobayashi Maru If you control no other characters, during your turn he may use Outwit a number of times equal to the number of opposing characters on the map.
alone as hero. These literary heroes areof course, prime examples of the , distinguished warrior type of hero as well, hence aspects of the heroic codewhich , defines such heroes, also feature in the depiction of the protagonists/ antagonist of these poems. There remains the first term in the title, namely, the parentchild relationship, which is -
Entire code is always current. The Register date on each page is the date the chapter was last published. Register May 2012 No. 677 Chapter SPS 341 APPENDIX A EXCERPTS FROM: ASME BOILER AND PRESSURE VESSEL CODE SECTION I ? POWER BOILERS 2010 EDITION INTRODUCTION This Code covers rules for construction of power boilers1,
RIFLE RELOADING DATA 1 of the wide range of bullet weights available in 6.5mm. Reloaders should keep in mind that the 6.5 Creedmoor works best with medium to medium-slow powders such as H4350, Varget, Win 760, and RE-17. The light recoil and adaptability of the efficient 6.5 Creedmoor cartridge has already proven
e. a and c ANSWER: e 15. Through war, many of the factories in country 1 are destroyed and many of its people are killed. As a result, the country's a. production possibilities frontier (PPF) after thewar has probably shifted toright compared its PPF prior to the war.