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If you have a formal shelter and long term supplies then there is probably a role for monitoring equipment buy 80mg inderal with visa. If you are using an expedient shelter it would seem to be logical that you stay in your shelter for as long as practical and if forced to leave only do so for brief periods order 80mg inderal otc. If you are forced to leave is there any value in knowing how much radiation you have received? Simple sheltering from the initial blast significantly reduces this initial exposure order inderal 80 mg mastercard. Added to this is exposure from fallout (residual radiation) over the short to medium term. Issues such as the weather and ground or air explosion will have a big impact on dose of radiation delivered. When considering clinical radiation effects they are broken down into: - Immediate symptoms (0. The brain is very sensitive to high doses and this leads to confusion, seizures, and coma. Patients presenting with cerebral and vascular signs and symptoms will die over a 1 to 2-week time frame. In an austere situation without access to dosimeters the timing of onset of initial symptoms, and the length of the symptom-free period enable you to estimate very roughly the likely exposure, and mortality, and provide a guide for triaging medical resources. Deaths approach 50% at the top end of the range 450-800rads: Initial symptoms 30-60 minutes post exposure lasting 12-48 hours. A significant number of deaths and injuries arise from other effects of the explosion. If you are planning for a nuclear disaster then you will need to address the issue of burn management and stock your supplies accordingly Blast: Injuries occur for 2 reasons. Firstly damage from the pressure wave itself – ear, lung, and gut injuries are most common, and secondly from collision with objects carried by the blast wave (wood, glass, nails), or the patient themselves colliding with solid objects when thrown by the wave. Potassium Iodide: Radioactive isotopes of iodine can be taken up by the thyroid gland following a nuclear blast. By - 119 - Survival and Austere Medicine: An Introduction taking potassium iodide or potassium iodate supplement (approximately 76% iodine); the uptake by the thyroid gland can be blocked to a degree. The dose is 130 mg once a day starting before exposure and continuing for 10 days. Potassium iodate has been shown to be more palatable to children as it tastes much less bitter in comparison to iodide. This determination is based on a careful review of published literature articles containing reports, data, and experiences of people who were exposed to high levels of thallium or cesium-137, and who were treated effectively with Prussian blue. Russian scientists following Chernobyl have suggested that the ingestion of excessive calcium in combination with vitamin D may decrease absorption of radioactive strontium. The excess calcium may be taken up in place of some of the otherwise bioavailable strontium leaving the rest to be cleared from the body without deposition. This is scientifically sound theory although there is no evidence demonstrating a benefit but no reason to think it would be harmful. Biological Prevention Hygiene is the single most important step to prevention illness/death from the use of biological weapons or biological agents in general. This includes clean drinking water, proper waste disposal, and hygienic food preparation, cooking, food storing, and slaughter of animals. Make sure that you have strict guidelines relating to hygiene, and that everybody in your group understands and follows them. Do a risk analysis of what you believe is the biggest biological threat for your group. Some infectious diseases (measles, polio, diphtheria) are returning because childhood vaccination rates are falling Equipment Firstly what is required for basic hygiene and cleanliness – brooms, dustpans, mops, bleach, disinfectants, etc. Simple barrier precautions will protect you from the majority of infectious agents. This refers to the filtration rate for a given particle size rather than the size of the particles themselves. These standards are effective for protection against many infective agents, not all (especially some viri), but they reduce the changes of inhalation significantly. If you purchase gas masks then you must ensure that the filter is against biological agents and not simply chemicals. The masks must be sized to the individual – find correct sizing needed before you need to depend on them. Gloves: These reduce the degree of skin contamination but are not an alternative to frequent hand washing. Gowns: These provide an additional layer of protection and reduce regular clothing contamination v. Over-suits: A waterproof over-suit combined with mask and gloves offers the most complete protection. Be aware though that the more complicated the personal protective equipment the more likely you are to contaminate yourself getting out of it. Scrubbing down with disinfectant prior to removing your equipment, removing your mask last, and through hand washing reduce the risk further. Medical Preparations: It is not practical to keep on hand supplies to deal with all biological possibilities. During a biological attack it may take several days to identify the agent but it is likely that early on you will know what you are dealing with. Common Biological agents: Inhalation anthrax Symptoms: Short period with non-specific flu like symptoms. Often a symptom-free period then one–two days later patient develops high fever and shortness of breath often associated with coughing up blood Primitive treatment: Doxycycline or Ciprofloxacin Inhalation anthrax is not contagious.

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The patient says buy inderal 80mg with mastercard, “My friend seems to be doing really well with this new medication 80 mg inderal overnight delivery, and I think I’d like to try it out to see if it would work for me order 40 mg inderal with amex, too. A 2-year-old boy who recently emigrated from Somalia is brought to the physician because of a 1-day history of pain of his arms and legs. Which of the following post-translational modifications is most likely to be found on a cyclin B protein that is targeted for degradation? A previously healthy 16-year-old girl is brought to the physician because of abdominal cramps, bloating, and loose stools for 6 months. After the patient ingests milk, there is an increased hydrogen concentration in expired air. A deficiency of which of the following enzyme activities is the most likely cause of the gastrointestinal symptoms in this patient? A married couple is screened to assess the risk for Gaucher disease in their children. The activities of glucocerebrosidase in the sera of the mother and father are 45% and 55%, respectively, of the reference value. Which of the following is the probability of the child possessing one or more alleles of the Gaucher mutation? The release of epinephrine from the chromaffin granules of the adrenal medulla into the bloodstream in response to neural stimulation is mediated by which of the following? During normal screening for phenylketonuria, a male newborn has a serum phenylalanine concentration of 35 mg/dL (greater than 20 mg/dL is considered a positive test). Enzymatic analysis using cultured fibroblasts, obtained after circumcision, shows normal activity of phenylalanine hydroxylase. A possible explanation for these findings is a deficiency in function of which of the following coenzymes? A 2-year-old boy with mental retardation has chewed the tips of his fingers on both hands and a portion of his lower lip. His serum uric acid concentration is increased, and he has a history of uric acid renal calculi. Which of the following abnormal enzyme activities is the most likely cause of these findings? A 14-year-old girl is brought to the physician because of a recent growth spurt of 15 cm (6 in) during the past year. Cardiac examination shows a hyperdynamic precordium with early click and systolic murmur. Abnormal synthesis of which of the following proteins is the most likely cause of this patient’s disorder? Native collagen is composed almost entirely of which of the following types of structures? An otherwise healthy 20-year-old woman of Mediterranean descent is given sulfamethoxazole to treat a bladder infection. Three days after beginning the antibiotic regimen, the patient has moderately severe jaundice and dark urine. Her condition worsens until day 6 of antibiotic therapy, when it begins to resolve. Which of the following conditions is the most likely explanation for these findings? Urinalysis shows increased concentrations of metanephrine and vanillylmandelic acid. The patient is most likely to have a neoplasm that secretes which of the following? An inherited disorder of carbohydrate metabolism is characterized by an abnormally increased concentration of hepatic glycogen with normal structure and no detectable increase in serum glucose concentration after oral administration of fructose. These two observations suggest that the disease is a result of the absence of which of the following enzymes? A 15-year-old girl limits her diet to carrots, tomatoes, green vegetables, bread, pasta, rice, and skim milk. She has an increased risk for vitamin A deficiency because its absorption requires the presence of which of the following? An increased concentration of fructose 2,6-bisphosphate in hepatocytes will have a positive regulatory effect on which of the following? During the processing of particular N-linked glycoproteins, residues of mannose 6-phosphate are generated. Which of the following proteins is most likely to undergo this step in processing? A 65-year-old man with coronary artery disease comes to the physician for a follow-up examination. Serum studies show a glucose concentration of 95 mg/dL and homocysteine concentration of 19. Which of the following amino acids is most likely to be decreased in this patient? Which of the following is required to transport fatty acids across the inner mitochondrial membrane? A 67-year-old man has a restricted diet that includes no fresh citrus fruits or leafy green vegetables. This patient’s disorder most likely results from a defect in collagen synthesis that involves which of the following amino acids? D - 16 - Gross Anatomy and Embryology Gross Anatomy Module (125 items) Systems Blood & Lymphoreticular System 1%–5% Nervous System & Special Senses 5%–10% Musculoskeletal System 10%–15% Cardiovascular System 20%–25% Respiratory System 10%–15% Gastrointestinal System 20%–25% Renal & Urinary System 1%–5% Female Reproductive System & Breast 5%–10% Male Reproductive System 1%–5% Endocrine System 1%–5% Embryology Module (20 items) Systems Blood & Lymphoreticular System 5%–10% Nervous System & Special Senses 5%–10% Musculoskeletal System 5%–10% Cardiovascular System 5%–10% Respiratory System 5%–10% Gastrointestinal System 10%–15% Renal & Urinary System 5%–10% Female Reproductive System & Breast 1%–5% Male Reproductive System 1%–5% Endocrine System 5%–10% - 17 - 1.

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Afever and a new or changing murmur is endocardi- r Full blood count shows an anaemia with neutrophilia buy inderal 80mg overnight delivery. Urine cultures may be required to identify r Acute bacterial endocarditis presents with fever purchase inderal 40mg overnight delivery, new aurinary tract infection buy discount inderal 40 mg, and renal ultrasound may be or changed heart murmurs, vasculitis and infective indicated to demonstrate a renal abscess. Severe acute heart failure may occur due to r Chest X-ray may show heart failure or pulmonary in- chordal rupture or acute valve destruction. General signs: r Malaise, pyrexia, anaemia and splenomegaly, which Complications may be tender. Cerebral emboli may cause infarction or my- disturbance due to the valve lesion(s), e. Chapter 2: Hypertension and vascular diseases 73 Management carditis; this is due to changing patterns of the disease It is important to identify the organism responsible (elderly, drug addicts, prosthetic valves, antibiotic resis- for the endocarditis; however, this should be balanced tance). Once cultures are sent, intravenous antibiotics should be commenced based on the most likely pathogens if there is a high suspicion of Hypertension and vascular bacterial endocarditis. The r When the culture results are known endocarditis World Health Organisation latest guidelines define hy- should be treated with the most appropriate antibi- pertension with three grades of severity that reflect the otics. It is best to have a multidisciplinary approach fact that systolic and diastolic hypertension are indepen- with early microbiological and surgical advice. M > F The timing of surgery is a balance between the desire to eradicatebacteriapriortotheprocedureandtheneedfor early surgery due to the compromised haemodynamic Geography state. Aftersurgeryafullcourseofdrugtreatmentshould Rising prevalence of hypertension in the developing be given to eradicate the organisms. For example, amoxycillin for dental procedures, tension: and amoxycillin and gentamicin for oropharyngeal, gas- Essential hypertension (>90%) r Non-modifiable: Genetic (racial and familial), gender trointestinal or genitourinary procedures. Prognosis r Modifiable: Obesity, alcohol intake, diet (especially Despite advances in treatment, overall mortality is still high salt intake). Complications Hypertension is a major risk factor for cerebrovascular Pathophysiology disease (strokes), heart disease (coronary artery disease, r Hypertension accelerates the age-related process of left ventricular hypertrophy and heart failure) (see Table arteriosclerosis ‘hardening of the arteries’ and predis- 2. Arterioscler- include peripheral vascular disease and dissecting aortic osis, through smooth muscle hypertrophy and intimal aneurysms. In r The chronic increased pressure load on the heart re- severehypertension,retinalhaemorrhages,exudatesand sults in left ventricular hypertrophy and over time this papilloedema are features of malignant hypertension. Saltand r Benign hypertension and small arteries: There is hy- water retention occurs, which can itself worsen hyper- pertrophy of the muscular media, thickening of the tension. In cases of doubt, r Routine investigations must include fasting plasma 24-hour blood pressure recordings may be helpful such glucose, serum total cholesterol and lipid profile, as when ‘white coat’ hypertension is suspected. Management Peripheral arterial disease Treatment is based on the total level of cardiovascular Definition risk and the level of systolic and diastolic blood pressure Peripheralarterialdiseasedescribesaspectrumofpatho- (see Tables 2. Stopping smoking as well as the ac- tions mentioned above will also reduce overall cardio- Age vascular risk. If after 3 months their M > F systolic blood pressure is above 139 or the diastolic above 89, treatment should be started. The remainder Geography of patients and those with low or average risk should More common in the Western world. Atheromatous plaques form especially in larger vessels at areas of haemodynamic stress such as at the bifurcation Prognosis of vessels and origins of branches. It may affect younger Patients with untreated malignant hypertension have a patients, particularly diabetics and smokers. In general the risks from Arteriosclerosis, ‘hardening of the arteries’, is an age- hypertension are dependent on: related condition accelerated by hypertension. Arterial Venous This can lead to ‘unfolding of the aorta’ and aortic Position Tips of toes and Gaiter area regurgitation. With increasing severity of ischaemia the Hypertension may be the underlying cause or may be claudication distance falls. Eventually the patient develops pain at rest arterial tree, therefore associated symptoms and signs and this indicates critical arterial insufficiency and is a should be elicited, e. On examination, signs include cool, dry skin with loss of hair, thready or absent pulses in the affected areas Complications and a lack of venous filling. Prognosis Management r Five-year patency rates with femoro-distal bypass vary Risk factors should be modified where possible, stop- between 30 and 50%, aortoiliac reconstruction has a pa- ping smoking in particular may prevent further dete- tency rate of 80%. Care peri-operatively and during long-term follow-up is is- should be taken to avoid trauma. Arterioscle- An aneurysm is defined as an abnormal focal dilation of rosis in older patients is difficult to treat surgically, as an artery (see Table 2. A true aneurysm may be further subdivided stenoses or occlusions in medium-sized arteries into saccular in which there is a focal out-pouching suchastheiliac,femoralandrenalarteries;however, or fusiform where there is dilation of the whole cir- as patients often present late the disease may be too cumference of the vessel. A guide wire is inserted and then a bal- occurs following penetrating trauma when there is a loon fed over the wire and inflated within the lesion. They may dissect and cut off blood critical ischaemia or severely limiting intermittent supply to tissue or rupture with resulting haemor- claudication, because failed grafting worsens symp- rhage. In addi- r Altered flow patterns predispose to thrombus forma- tion, most patients have other conditions such as tion, which may embolise to distal arteries or cause ischaemic heart disease, diabetes and cerebrovascu- occlusion at the site of the aneurysm. Abdominal aortic aneurysms may be found incidentally as a central expansile mass on examination or as calcifi- Sex cation on an X-ray. Patients may present with a dull, aching chronic or intermittent epigastric or back pain due to expansion. Geography Rupture causes a tearing epigastric pain that radiates Becoming more common in the developed world. Occasionally a small leak ‘herald bleed’ Riskfactorsareasforatherosclerosis,includingsmoking, maycauseashorter,lesssevereepisodeofpainsomedays hypercholesterolaemia, age, sex, diabetes. More than half of aneurysms over 6 cm will rupture Pathophysiology within 2 years – thromboembolism.

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