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By: P. Denpok, M.B. B.CH. B.A.O., Ph.D.

Professor, University of Missouri–Kansas City School of Medicine

Option (E) depression definition chemical imbalance cheap anafranil 10 mg fast delivery, tarsal coalition depression symptoms feeling numb buy anafranil master card, is incorrect because this condition typically presents during the second decade of life but can present as early as 3 years of age bipolar depression journal articles trusted anafranil 50 mg, when the tarsal bones begin to ossify. Question 12 A 6-year-old boy is brought to the office by his parents because he has had pain in the right hip with weight-bearing as well as obvious limping for the past week. Physical examination shows tenderness on passive internal rotation of the hip joint and mild diffuse atrophy of the right thigh musculature. Option (A), aspiration of the hip, is incorrect because the patient has no history of current or recent illness and, therefore, septic joint is very low on the differential diagnosis list. Option (B), bone scan, is incorrect because it can only confirm the presence of avascular necrosis and not the extent of involvement of the femoral head. Question 13 A 12-year-old boy is brought to the office by his mother because he has had intermittent pain in the right hip during the past two weeks. On physical examination, vague pain in the groin is elicited on range of motion of the right hip. The most appropriate next step is x-ray studies to rule out which of the following conditions? The history and physical examination findings are characteristic of slipped capital femoral epiphysis, including obesity, limp, and pain with range of motion of the joint. Option (C), septic arthritis, is plausible but incorrect because the patient has no history of acute illness and x-ray studies do not rule this condition out. Question 14 A 19-year-old man who is a long-distance runner is referred to the office by his primary care provider because he has had dull, aching pain in his right thigh after running during the past nine months. All rights reserved Sample Orthopaedic Questions & Critiques femur show cortical thickening of the distal one-third of the shaft with a central nidus measuring approximately 8 mm in diameter. The x-ray finding of cortical thickening with a central nidus is characteristic of osteoid osteoma. Option (A), aneurysmal bone cyst, is incorrect because although the femur is the most common site of involvement of aneurysmal bone cyst, it usually presents as a large lytic lesion. Option (B), enchondroma, is incorrect because although the distal femur is a potential location for this lesion, it is characterized as a lytic area filled with a calcified matrix. Option (C), osteoblastoma, is plausible but incorrect because although it is closely related to osteoid osteoma, the two are distinguished by the size of the nidus: larger than 2 cm represents osteoblastoma, and 1 cm or less represents osteoid osteoma. In addition, the pain of osteoblastoma is less likely to be relieved by nonsteroidal anti-inflammatory drug therapy. Option (D), osteochondroma, is incorrect because this lesion arises from the growth plate on the metaphyseal side and results in an exostosis that points away from the joint of origin. Question 15 A 72-year-old man comes to the office for follow-up examination eight weeks after he underwent total arthroplasty of the right hip. All rights reserved Sample Orthopaedic Questions & Critiques patient says the pain is aggravated by walking and persists during sleeping hours even after he takes acetaminophen. The most commonly cultured microorganism (30% to 43%) from prosthetic joint infections is coagulase-negative staphylococcus. The likelihood of infection with other organisms depends on perioperative or contiguous factors, hematogenous seeding from distant infections, and/or other comorbid diseases. Option (B), Escherichia coli, and Option (E), Pseudomonas aeruginosa, are incorrect because they are gram-negative bacilli, which are uncommon causes of prosthetic joint infection. Option (C), group A betahemolytic streptococcus, is incorrect because streptococci account for only 9% to 10% of prosthetic joint infections. Option (D), Haemophilus influenzae, is incorrect because it is a very uncommon cause of prosthetic joint infection. We acknowledge the contributions of the following: the Center for Social and Behavioral Research staff and interviewers, University of Northern Iowa: Mary Losch, Director; Mary Jane Crew, Interviewer Supervisor.

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Along the superior part of the tympanic crest anxiety disorder symptoms buy discount anafranil 10mg online, between i t and the cephalic condyle performance anxiety order 10mg anafranil amex, is a notch great depression definition safe 10mg anafranil, filled by a fibrous membrane over which the lateral border of the tympanic c r e s t continues a s a cartilaginous band. The tympanic c r e s t provides attachment for the anterior part of the tympanum, for p a r t of the origin of the adductor mandibularis externus superficialis muscle, and f o r the skin. Below the termination of the tympanic c r e s t is a constriction toward the condyle. The membrane of the tympanic s a c covers the entire posterior surface of the quadrate bone and excludes a l l the previously named structures from the sac. Extending between the pterygoid and the parietal is an elongate cylindrical bone, the epipterygoid, o r columella cranii. Its ventral end i s flattened into a wedge-shaped articular surface which s i t s in the colunlellar fossa of the pterygoid (see joints). Its mid-part i s flattened and presents a posterior and an anterior c r e s t which s e r v e the origin of muscles. It is slightly bowed laterally a s it passes over the origin of the levator pterygoideus muscle and the lateral surface of the cranial cavity. The dorsal tip, which lies against the lateral edge of the parietal, is flattened and held in place by the ligaments of origin of the pseudotemporalis superficialis muscle. The upper one-third of the epipterygoid s e r v e s the origin of the pseudotemporalis superficialis muscle, which a r i s e s on i t s anterolateral and posterior surfaces. The ventral two-thirds s e r v e s the origin of the pseudotemporalis profundus muscle. The five posterior elements form a circular tube; their anterior ends project into, and a r e encircled by, the dentary bone. The condylar part contains a facet which articulates with the condyle of the quadrate. Surrounding this facet i s a ridge for the attachment of the articular capsule, and along the posterolateral angle of the facet is a notch from which the lateral collateral ligament a r i s e s. At the apex of the triangle is a tubercle for the insertion of the depressor mandibularis muscle, and along its lateral bord e r is the tympanic c r e s t to which the skin of the tympanum is attached. A small part of the intermandibularis posterior muscle i n s e r t s below the tympanic crest. At the medial angle of the base of the retroarticular process is a foramen which transmits the chorda tympani nerve and the posterior condylar artery. Extending mesially from the condylar part is a second triangle, the angular process. The retroarticular depression receives the insertion of the dorsal f i b e r s of the pterygomandibularis muscle. The remaining dorsal, ventral, and angular surfaces receive the other fibers of the pterygomandibularis muscle. The anterior process of the articular f o r m s the floor and medial r i m of the mandibular foramen. It i s rounded dorsally and receives the insertion of the pterygomandibularis muscle posteriorly and the adductor mandibularis externus muscle anteriorly. It continues beneath the coronoid and f o r m s part of the floor of the coronoid recess. On the dorsomedial wall of this concavity, opposite the anterior end of the mandibular foramen, is a small foramen which transmits the chorda tympani nerve and is the exit of a bony canal which t r a v e r s e s the entire length of the articular bone. Its dorsal border is rounded and s e r v e s the insertion of the adductor mandibularis externus muscle. The lateral s u r face, smooth and rounded, i s the insertion of two muscles, the adductor mandibularis externus dorsally and the intermandibularis posterior ventrally. At i t s suture with the articular, below the condyle, is a posteriorly directed foramen, the posterior supra-angular foramen, and below the coronoid bone is an anteriorly directed anterior supra-angular foramen. Its anterior process extends into the dentary for approximately half of its length. It articulates with the angular, articular, supra-angular, dentary, and coronoid bones. Near its mid-point is the ant e r i o r mylohyoid foramen, transmitting the anterior mylohyoid nerve, and near i t s anterior end is a larger foramen f o r the lingual branch of the inf e r i o r alveolar nerve. It i s rounded anteriorly, and i t s tip t u r n s mesially to join i t s fellow in a syndesmosis. It is flattened posteriorly and extends dorsally a s a ridge; i t s medial surface is r e c e s s e d for the splenial.

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Chronic obstructive pulmonary disease in the elderly (1) Epidemiology in the elderly (a) Incidence in the elderly i) Combined bronchitis and emphysema in patients with a United States Department of Transportation National Highway Traffic Safety Administration Paramedic: National Standard Curriculum 10 Special Considerations: 6 Geriatrics: 3 B depression negative thoughts order discount anafranil online. History (b) United States Department of Transportation National Highway Traffic Safety Administration Paramedic: National Standard Curriculum 11 Special Considerations: 6 Geriatrics: 3 3 depression chemical imbalance buy discount anafranil 50 mg on line. Physical exam (1) the heart increases in size (2) Hypertension and orthostatic hypotension (3) Dependent edema (4) Consider checking the blood pressure in both arms (5) Check pulses in all extremities routinely (6) Check for carotid bruits (7) Check for dehydration Management implications for the elderly a inbreeding depression definition biology cheap anafranil online mastercard. Pharmacological/ non-pharmacological (1) Use caution to avoid medication interaction (2) Proper dosing is very important due to (a) Less lean body mass (b) Low fluid reserve (c) Slow metabolism (d) Decreased renal and hepatic function d. Heart failure in the elderly (1) Epidemiology in the elderly (a) Incidence in the elderly i) More frequent in older adults ii) Large incidence of non cardiac causes United States Department of Transportation National Highway Traffic Safety Administration Paramedic: National Standard Curriculum 12 Special Considerations: 6 Geriatrics: 3 c. Slight changes in the following are normal (1) Difficulty with recent memory (2) Psychomotor slowing (3) Forgetfulness (4) Decrease in reaction time 2. Assess for (1) Weakness (2) Chronic fatigue (3) Changes in sleep patterns (4) Syncope,ornearsyncope 3. Cerebral vascular disease (1) Epidemiology in the elderly Incidence (a) (b) Morbidity! Dementia (1) Epidemiology Incidence (a) i) Increases with age Half of nursing home patients have some form of ii) dementia (b) Morbidity! Transport considerations iii) United States Department of Transportation National Highway Traffic Safety Administration Paramedic: National Standard Curriculum 16 Special Considerations: 6 Geriatrics: 3 4. Thyroid diseases in the elderly (1) Epidemiology in the elderly (a) Incidence in the elderly (b) Morbidity/ mortality in the elderly (c) Risk factors (d) Prevention strategies (2) Assessment findings specific for the elderly patient (3) Management considerations for the elderly patient Gastroenterology in the elderly 1. Lidocaine toxicity in the elderly (1) Epidemiology in the elderly (2) Assessment findings in the elderly United States Department of Transportation National Highway Traffic Safety Administration Paramedic: National Standard Curriculum 17 Special Considerations: 6 Geriatrics: 3 b. Risk factors i) Vision and memory changes ii) Polypharmacy iii) Nutritional deficits (2) Assessment findings (a) Memory changes (b) Drowsy (c) Decreased vision/ hearing (d) Orthostatic hypotension (e) Poor dexterity (3) Management implications (a) Requires identification and referral Environmental considerations in the elderly 1. Depression in the elderly (1) Epidemiology in the elderly (a) Incidence in the elderly (b) Morbidity/ mortality in the elderly (c) Risk factors (d) Prevention strategies (2) Assessment findings specific for the elderly patient (3) Management considerations for the elderly patient b. Suicide in the elderly (1) Epidemiology in the elderly (a) Incidence in the elderly (b) Morbidity/ mortality in the elderly (c) Risk factors (d) Prevention strategies (b) United States Department of Transportation National Highway Traffic Safety Administration Paramedic: National Standard Curriculum 19 Special Considerations: 6 Geriatrics: 3 I. Pressure ulcers in the elderly (1) Result from tissue hypoxia (2) Usually over bony areas (3) Common in immobile patients (4) Possibility increases with (a) Altered sensory perception Skin exposure to moisture (b) (c) Decreased activity (d) Decreased mobility (e) Poor nutrition (f) Friction or shear Musculoskeletal changes with age 1. Osteoarthritis in the elderly (1) Epidemiology in the elderly (a) Incidence in the elderly (b) Morbidity/ mortality in the elderly (c) Risk factors (d) Prevention strategies (2) Assessment findings specific for the elderly patient (3) Management considerations for the elderly patient United States Department of Transportation National Highway Traffic Safety Administration Paramedic: National Standard Curriculum 20 Special Considerations: 6 Geriatrics: 3 K. Osteoporosis in the elderly (1) Epidemiology in the elderly (a) Incidence in the elderly (b) Morbidity/ mortality in the elderly (c) Risk factors (d) Prevention strategies (2) Assessment findings specific for the elderly patient (3) Management considerations for the elderly patient Trauma in the elderly 1. Observe scene for clues of abuse Physical abuse (1) (2) Active and passive neglect (3) Psychological abuse (4) Financial abuse (5) Self abuse (6) Reporting 4. Airway and ventilation (1) Dentures may need to be removed Oxygen is very important due to vascular disease (2) b. Circulation (1) Fluid administration should be closely monitored for signs/ symptoms of pulmonary edema c. United States Department of Transportation National Highway Traffic Safety Administration Paramedic: National Standard Curriculum 21 Special Considerations: 6 Geriatrics: 3 5. Orthopedic injuries (1) Hip fracture is the most common acute orthopedic condition Elderly are susceptible to stress fractures of femur, pelvis, tibia (2) (3) Packaging should include bulk, and padding to fill in areas (4) Kyphosis may require extra padding under the shoulders to maintain alignment b. Children of abusive and unloving homes are more likely to become spouse or child batterers and later, abusers of their elderly parents 4. Reasons for not reporting (1) Fear (a) For her self (b) For her children (2) Believes behavior will change (3) Lack of financial support (a) No money (b) No one to turn to (c) No knowledge of where to go (4) Believes she is the cause of the violent behavior (5) Believes that it is part of the marriage and must endure in order to keep the family together c. Characteristics of wife-battering (1) the beatings do not stop (2) Beatings become more severe and more frequent (3) Beatings occur without provocation whatsoever (4) At some point will turn violence toward the children d. United States Department of Transportation National Highway Traffic Safety Administration Paramedic: National Standard Curriculum 2 Special Considerations: 6 Abuse and Assault: 4 (3) (4) (5) (6) (7) (8) (9) (10). Some believe they are demonstrating discipline They do not like being out of "control" Fail to see any alternatives and do not know what else to do Both parties do not know how to back down from conflict He/ she may feel powerless to change the use of alcohol seems to be a factor Mental illness occurs in less than 10% of abusers Abuse does occur in all socio-economic groups, however most abusers are in the lower socio-economic groups (11) the abuser goes into sudden rages (12) Abusers feel insecure and jealous (13) the abuser can appear charming and loving after the incident of battering (14) the abuser may have money difficulties, problems holding a job and possible legal issues Ten "risk factors" for domestic violence (as taken from "Domestic Violence: Cracking the Code of Silence") (1) Male is unemployed Male uses illegal drugs at least once a year (2) (3) Partners have different religious backgrounds Family income is below poverty line (4) (5) Partners are unmarried (6) Either partner is violent toward children at home (7) Male did not graduate from high school (8) Male has a blue-collar job, if employed (9) Male is between 18-30 (10) Male saw father hit mother C. Same psychological and emotional effects Guilt (1) (2) Loss of self-control (3) Loss of control f. Homosexuals are conditioned the same as heterosexuals Identifying the battered patient 1. Difficult to do because the description of the injuries may be incorrect, inaccurate and protective of the attacker 2. May avoid eye contact and be hesitant or evasive about the details of the injuries 4.

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Household computer use in construction versus all industries bipolar depression 800 buy generic anafranil 10mg online, by type of device depression test blogthings buy anafranil 10mg with amex, 2015 30 depression litmus test purchase on line anafranil. Joint labor-management apprenticeship programs, by state, 2016 (Share of all active programs) 30b. New registrations in construction apprenticeship programs, union versus non-union programs, 20062016 30c. Number of Hispanic construction workers among new apprenticeship registrations, union versus nonunion programs, 2006-2016 30d. Number of new registrations in construction apprenticeship programs, by race and ethnicity, 2016 30e. Number of new registrations in construction apprenticeship programs, by gender and union status, 2016 31. Percentage of projected employment change, selected construction occupations, 2014-2024 31c. Percentage of projected replacement needs, selected construction occupations, 2014-2024 31d. Projected numbers of job growth and replacement needs, selected construction occupations, 2014-2024 31e. Percentage of construction workers exposed to hazards, by exposure level (Production workers) 33. Exposure Risks for Work-Related Musculoskeletal Disorders and Other Illnesses in Construction 33a. Percentage of construction workers using hands to handle, control, or feel objects, tools, or controls, by exposure level (Production workers) 33f. Percentage of construction workers exposed to very hot or very cold temperatures, by exposure level (Production workers) 34. Percentage of workers exposed to silica, by exposure level, construction versus all industries (Micrograms per meters cubed) 34b. Percentage of construction workers exposed to silica, by exposure level and construction subsector (Micrograms per meters cubed) 34c. Distribution of silica exposures among construction workers, by level and activity (Micrograms per meters cubed) 34d. Exposure to contaminants (such as pollutants, gases, dust, or odors) at work, selected occupations 35. Fatal and Nonfatal Injuries in Construction and Other Industries Number of fatalities, by major industry, 2015 (All employment) Number of fatalities in construction, selected years between1992 and 2015 (All employment) Rate of fatalities, selected industries, selected years between 1992 and 2015 (All employment) Number of nonfatal injuries resulting in days away from work in construction, selected years between 1992 and 2015 Rate of nonfatal injuries resulting in days away from work, by major industry, 2015 Rate of nonfatal injuries resulting in days away from work, selected industries, selected years be tween 1992 and 2015 Fatal and Nonfatal Injuries among Construc tion Sectors Number and percentage of fatalities among major construction sectors,* 2015 (Private wage-and-salary workers) Rate of fatalities, by major construction sector,* 2003-2015 (Private wage-and-salary workers) Number and percentage of nonfatal injuries resulting in days away from work among major construction sectors,* 2015 (Private wage-and-salary workers) Rate of nonfatal injuries resulting in days away from work, by major construction sector,* 20032015 (Private wage-and-salary workers) Fatal and Nonfatal Injuries in Construction by Employment, Establishment, and Geographic Trends Number of fatalities in construction, by class of worker, 1992-2015, selected years (All employment) Distribution of construction fatalities and employment, by establishment size, 2015 (Wage-and-salary workers) Rate of nonfatal injuries resulting in days away from work in construction, by establishment size, 1994-2015 (Private wage-and-salary workers) Rate of fatalities in construction, by state, 20112015 average (All employment) 40e. Rate of nonfatal injuries resulting in days away from work in construction, by state, 2011-2015 average (Private wage-and-salary workers) 41. Demographic Trends of Fatal and Nonfatal Injuries in Construction Distribution of fatalities in construction, by age group, selected years (All employment) Distribution of nonfatal injuries resulting in days away from work in construction, by age group, selected years (Private industry) Rate of fatal and nonfatal injuries in construction, by age group, 2013-2015 average Median days away from work by age group, construction versus all industries, 2015 Rate of fatalities in construction, by Hispanic ethnicity, four time periods from 1992-2015 (All employment) Rate of nonfatal injuries in construction, by Hispanic ethnicity, four time periods from 1992-2015 Fatal and Nonfatal Injuries within Construction Occupations Number of fatalities, selected construction occupations, 2011-2015 total (All employment) Number of nonfatal injuries resulting in days away from work, selected construction occupations, 2015 (Private wage-and-salary workers) Rate of fatalities, selected construction occupations, 2011-2015 average (All employment) Rate of nonfatal injuries resulting in days away from work, selected construction occupations, 2011-2015 average (Private wage-and-salary workers) Leading Causes of Fatal and Nonfatal Injuries in Construction Distribution of leading causes of fatalities in construction, 2015 (All employment) Distribution of leading causes of nonfatal injuries resulting in days away from work in construction, 2015 (Private wage-and-salary workers) Leading causes of fatalities in construction, 19922015 (All employment) Rate of leading causes of nonfatal injuries resulting in days away from work in construction, 1992-2015 (Private wage-and-salary workers) 41c. Fatal Injuries from Falls to a Lower Level in Construction Number and rate of fatal falls to a lower level in construction, 2003-2015 (All employment) Fatal falls to a lower level in construction, by height of fall, 2011-2015 total Fatal falls to a lower level in construction, by primary source, 2011-2015 total Distribution of fatalities from falls to a lower level in construction, by establishment size, 2011-2015 total (Wage-and-salary workers) Number and rate of work-related fatalities from falls to a lower level in construction, selected occupations, 2011-2015 total 47. Number of fatalities in construction, road construction sites and other fatalities, 2003-2015 47b. Fatal injuries at road construction sites, by major industry, 2011-2015 total 47c. Fatal injuries at road construction sites, by event or exposure, 2011-2015 total 47d. Fatal injuries at road construction sites, by primary source, 2011-2015 total 47e. Fatal injuries at road construction sites, selected construction subsectors, 2011-2015 total 47f. Fatal injuries at road construction sites, selected occupations, 2011-2015 total 48. Musculoskeletal Disorders in Construction and Other Industries Number and rate of work-related musculoskeletal disorders in construction, 1992-2015 Work-related musculoskeletal disorders in construction, by body part, 2011-2015 Distribution of risk factors for work-related musculoskeletal disorders resulting in days away from work in construction, 2015 Rate of overexertion injuries resulting in days away from work, selected industries, 2015 Rate of overexertion injuries resulting in days away from work, selected construction subsectors, 2015 Work-related musculoskeletal disorders resulting in days away from work in construction, by nature of injury, 2015 Back Injuries in Construction and Other Industries Distribution of nonfatal injuries resulting in days away from work in construction, by body part, 2015 (Private wage-and-salary workers) Number and rate of back injuries resulting in days away from work in construction, 1992-2015 (Private wage-and-salary workers) Rate of back injuries resulting in days away from work, selected industries, 2015 (Private wage-and-salary workers) Rate of back injuries resulting in days away from work, by construction subsector, 2015 (Private wage-and-salary workers) Rate of self-reported back pain among construction workers, by age group, 2015 (All employment) 45. Number of nonfatal injuries due to falls, slips, and trips involving days away from work in construction, by cause, 2011-2015 45b. Distribution of nonfatal injuries due to falls, slips, and trips on the same level resulting in days away from work in construction, 2015 45c. Nonfatal injuries due to falls to a lower level resulting in days away from work in construction, by height of fall, 2015 45d.

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