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There may be some areas where you must maintain a fully operating back-up system psoriatic arthritis in the knee purchase discount diclofenac, while other aspects may not be critical arthritis pain back of hand safe 100mg diclofenac. Once you have decided what elements of your business are critical and the consequences of the potential loss of these elements arthritis pain during sleep discount 50mg diclofenac with mastercard, you can develop plans to arthritis medication herbal generic diclofenac 50mg on line work around these situations. Decide on your strategy — determine what your goals are for recovery or continuance of the business. For pandemic planning, it is also a good idea to choose flexible solutions that cover a wide range of events as the true impact of the pandemic will not be known until it happens. Since the pandemic will arrive in waves, you may also need to plan for both smaller and larger absenteeism rates. It is m Yes m No important to know ahead of time who will do what, and m Not applicable who will be the leader/commander. Appoint a pandemic manager who can co-ordinate m Yes m No prevention eforts, keep track of staf and who is available m Not applicable to come to work. They may be the person who is trained to determine the health status of employees and whether they should be sent home. Prepare for, and have training, in crisis communications m Yes m No and/or media relations. Write down what needs to be done and the resources that are required to implement the plan. Circulate the plan, get feedback, and make sure that all employees know about the plan (education/awareness). Conduct any necessary training, especially for back-up positions and for implementing the plan itself. Make sure that there is ongoing review and testing of the plan, at least annually or more often if some aspect of the business changes. You will also need to decide at what point your pandemic business plan will be put into action. Remember to plan for how your business will adapt when other organizations, and the community that you rely upon, are also in the same situation. Remember that absentee rates may be much higher than normal, with little outside resources available as a back-up (volunteers, contractors, temporary labour, etc. Investigate: Area Options Action Flexible Work When people cannot report to work m Yes m No Options but can work from home: set up m Not applicable infrastructure to allow people to work at home and continue job duties via the internet and phone. Responsibility: Increase the distance between the m Yes m No customer and the staf member by m Not applicable installing a protective barrier. These acrylic or glass barriers may provide useful protection for people such as front counter staf or public transport drivers, whose duties require them to have frequent face-to-face contact with members of the public. Responsibility: 8 Business Continuity Plan Area Options Action Alternative Create small working units to minimize m Yes m No Stafing their number of overall contacts. Investigate having a period of time between shifts to allow time to clean all surfaces in the workplace before the next group of people enter the building. Responsibility: Reduce the number of people per shift m Yes m No to allow for greater distances between m Not applicable people at workstations. Responsibility: Alternative Ways Are there aspects of your business m Yes m No to Conduct your that you can conduct using the m Not applicable Business internet or phone, more than you do now Responsibility: Can packages or information be m Yes m No shipped or delivered electronically m Not applicable instead of hand delivered Responsibility: Transportation If public transportation is not available m Yes m No or not recommended, but staf are m Not applicable required to report to work, investigate car pooling or hiring a private bus. Responsibility: Training Cross train employees so they can m Yes m No efectively cover other duties. Make sure employees know m Not applicable exactly what your policies are for sick leaves or family care leaves and issues regarding pay. Communicate if the company will be following special rules for a pandemic situation. Responsibility: Keep an up-to-date list of all employ m Yes m No ees for communication purposes. Responsibility: 10 Business Continuity Plan Area Options Action Human Resource Be aware of health and safety, employ m Yes m No Issues ment or compensation legislation, and m Not applicable continued any emergency measures acts, and how they may apply in a pandemic situation to your business. Responsibility: Management Document guidelines for what, how, m Yes m No Issues who and when business decisions are m Not applicable made – remember, the pandemic can afect anyone. Responsibility: Be prepared to make decisions about m Yes m No when to stay open, when to close m Not applicable to visitors, or when to close your business completely. Responsibility: Be sure that core business activities m Yes m No can be sustained over several months. Responsibility: Make sure that everyone knows their m Yes m No roles – managers, employees, unions, m Not applicable health and safety committees, pandemic manager, etc. Responsibility: Do you need to keep your building m Yes m No secure if staf are not present You m Not applicable may be able to coordinate some of these functions with other local businesses in your building, area or industrial complex. Responsibility: 11 Business Continuity Plan What else can a workplace do in the event of a pandemic Your local public health depart ment or municipality will be able to provide information about conditions in your area. In Canada, information will also be available from the Public Health Agency of Canada canada. You can help minimize the impact by implementing stafing measures, encouraging hand washing, and other good hygiene practices. Preventing Communicable Diseases Common Communicable Diseases 620 What’s Your Health Status Read each statement below and respond by writing yes, no, or some times for each item. I wash my hands after using the bathroom, before handling food, before meals, and after I blow my nose. For instant feedback on your health status, go to Chapter 24 Health Inventory at health. To avoid spreading disease, rest, drink plenty of fluids, and stay home when you are ill. Although most microorganisms—living things too small to be seen without a microscope—are harmless, a few, such as the viruses shown on this page, can cause communicable diseases. A communicable disease is a disease that is spread from one living thing to another or through the environment. Knowing how communicable diseases spread can help you choose behaviors to reduce your risk of getting them. Causes of Communicable Diseases n organism that causes disease is called a pathogen. An infection is a condition that cold virus (bottom), are occurs when pathogens enter the body, multiply, and damage body cells. Viruses are pieces of genetic In 1993 four children were material surrounded by a protein coat. Viruses invade all sickened by undercooked known forms of life—mammals, birds, reptiles, insects, plants, and hamburger from a fast-food even bacteria. The culprit was After a virus penetrates a cell, called the host cell, the virus takes E. The new viruses burst ria causes severe damage to from the cell, usually killing it, and take over other cells. Like other the cells lining the human pathogens, viruses usually run their course and eventually are killed intestines and can lead to by the immune system. Common sources of the Bacteria bacteria are undercooked, Bacteria are single-celled microorganisms that live almost every contaminated ground beef and unpasteurized milk and where on earth. For example, bacteria in your digestive system help digest food and make some of the vitamins you need. Some bacterial pathogens, such as the ones that cause tetanus, produce a toxin, a substance that kills cells or interferes with their functions. Like most other microorganisms that enter the body of a healthy indi antibiotics For more infor vidual, bacteria are usually destroyed by the immune system.
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Polyclonal increases diseases arthritis pain relief otc buy diclofenac online from canada, inammatory lung diseases treating arthritis joint pain order 100 mg diclofenac with visa, and in cirrho in IgG4 subclass have been reported to arthritis cramps in feet purchase 50 mg diclofenac with amex mimic a sis (see above) (Figs 5 arthritis lumps 100mg diclofenac amex. IgG4 typically is polyclonal gammopathies can be large, producing increased under conditions of chronic antigen bands that give an impression of monoclonality exposure and can be enhanced by the presence of (Fig. When in doubt, however, perform immunotherapy, patients with Wegener’s granulo ing an immunoxation is recommended because 76–84 By performing matosis or Sjogren’s syndrome. Recently, a benign markers prove the polyclonal nature of the pro lymphoproliferation has been demonstrated with a liferation). The condition occurs more often in the X-linked hyper-IgM immunodeciency syn in women, and especially in those that are cigarette 89 drome. Because the capillary zone electropherogram patterns have relatively small g-globulin regions compared with gel-based systems, large polyclonal increases can have the appearance of monoclonal gammopathies. IgG1 = 549 (180–780) IgG2 = 440 (100–460) IgG3 = 20 (30–140) IgG4 = 450 (8–180) Figure 5. I recommend performing an immunoxation or narrow restriction, I have seen cases of IgA and IgD monoclonal immunosubtraction on such restrictions. In this case, the be monoclonal gammopathies, and should have the polyclonal restriction was caused by a polyclonal increase in IgG4 subclass. Other antibody positive had oligoclonal bands by serum oligoclonal expansions are the result of signi protein electrophoresis. These In other instances, patients with autoimmune oligoclonal responses were once thought to repre diseases can have complex serum protein electro sent immune complexes, but it is now clear that phoresis patterns because they may have aberrant they reect the immunoglobulin products of a few immunoregulation with T-cell dysfunction, be clones of B cells/plasma cells. Patients with chronic receiving a variety of immunosuppressive regi lymphocytic leukemia and chronic B-cell lym mens, suffer from infections related to the phoma may have hypogammaglobulinemia and immunosuppression, and may be receiving plasma oligoclonal bands (Fig. Occasionally, a combination of several factors is Oligoclonal gammopathies have been described responsible for an oligoclonal pattern. For in the serum of patients with circulating immune example, transplant patients have profound 109–111 109,110 complexes. Thus, a particular pattern with occasionally massive polyclonal sample from such a patient may show only the larger peak that could be mistaken for a mono clonal gammopathy that was part of a lymphopro 109,112 liferative process. This massive expansion is also seen in patients with hepatitis and occasionally in angioimmunoblastic lymphadenopathy. In some cases, specic mechanisms can be serum electrophoresis in 3–6 months to see if the identied that explain the response. Infections are a frequent gammaglobulinemia at the onset of acute myeloid feature of patients with multiple myeloma. In one case of mantle cell lymphoma, mine if a Bence Jones protein is present and the polyclonal hypergammaglobulinemia was following the serum immunoglobulin concentra associated with the presence of autoreactive T-cells tions to determine if the process regresses or that were thought to provide a polyclonal stimulus 127 evolves. Polyclonal B-cell lymphocytosis -Globulin patterns 133 often with an oligoclonal pattern. Occasional cases with cryoglobulinemia and, uncommonly, mono clonal proteins have been demonstrated. This, together with the polyclonal increase in IgG, often with a decrease in albumin and increase in a1-antitrypsin will produce a pattern that looks like that seen in patients with cirrhosis. Angiofollicular lymph node hyperplasia is charac tiated lymphocytic lymphoma, the g-globulin terized histologically by lymph node hyperplasia region is usually decreased in concentration. Some with hypocellular germinal centers, prominent cases, however, display small monoclonal or occa polyclonal plasma cells, and prominent sionally small oligoclonal bands, often on the immunoblasts. With the not specic and has been reported in patients with increased sensitivity afforded by serum immunox autoimmune syndromes, acquired immunode ation, cases of lymphocytic leukemia with two, ciency syndrome, Wiskott–Aldrich syndrome, and three or more monoclonal proteins (oligoclonal 139 Takatsuki’s syndrome (an unusual dysproteinemic expansions) have been described. About 2 per cent of these patients develop a lar proliferation with nely arborized vessels. The serum often demonstrates marked polyclonal lymphoproliferative disorder associated with 140–142 increases in g-globulin (especially IgG and IgA), Epstein–Barr virus. Many of these lesions will 134 Approach to pattern interpretation in serum Figure 5. The prominent b–g bridging together with the marked diffuse increase in g-globulins, and the slightly decreased albumin, give this serum the appearance of a cirrhotic pattern. There are also several small areas of restriction (oligoclonal bands) in this g-region (indicated on the immunoxation in (b). This emphasizes the altered polyclonal B-cell proliferation that occurs in some cases of immunoblastic lymphoma. Isolated hypogammaglobulinemia, how disease is often regional, but may be widespread. The plant patients had oligoclonal bands; 15 per cent immunodeciency may be congenital or acquired had monoclonal components. The most common owing to suppression by a neoplasm or suppres protein band found was IgG and it was seven times sion by chemotherapy. Even individuals in their more common than IgM; IgA was not found in eighth and ninth decades should have normal g 105 their series. Oligoclonal bands in these patients regions (assessed by densitometric scan) (Fig. Monoclonal gammopathies in are of great importance in evaluating a patient with these patients may precede the demonstration of hypogammaglobulinemia. It Decreased g-globulin is caused by mutations in the gene coding for g-Globulin is decreased in several clinically impor tant circumstances (Table 5. Chronic lymphocytic leukemia the albumin and other major protein bands are normal (perhaps Well-differentiated lymphocytic transferrin is slightly decreased). Therefore, the decrease in g lymphoma globulin likely relates to a dysfunction of the immune system and not merely to protein loss (renal or gastrointestinal). I recommend that any case aCommon variable immunodeciency is usually detected in where the g-region is below our cut-off, has urine evaluated for young adults. A mat urational arrest occurs between the cytoplasmic atypical lymphoid hyperplasia, reactive lymphoid negative and positive stages. By that age, most normal children will chronic lymphocytic lymphoma and well-differen begin to synthesize their own IgG. This is usually a much more subtle tions because of the lack of opsonins and comple decrease than the hypogammaglobulinemia associ 89 ated with the immunodeciency diseases men ment-xing antibody. We also recommend performing immunoxa possess normal numbers of peripheral blood B lym tion on a urine sample to rule out the possibility of phocytes. Some patients with transient hypo a monoclonal free light chain (Bence Jones gammaglobulinemia of infancy develop mucosal protein). It usually manifests with diarrhea plasma exchange, most plasma components are or respiratory tract infections in young adults. The decreased, but they usually recover within a day disease is uncommon in childhood or in the elderly. Therefore, when hypogamma hypogammaglobulinemia (usually less than globulinemia is detected on protein electrophore 250 mg/dl of IgG). These patients respond well to sis, clinical correlation is important to help avoid -globulin replacement and judicious antibiotic confusion as to the signicance of this nding for 154 the patient. Serum protein electrophoresis in by peripheral blood mononuclear cells from Laennec’s and postnecrotic cirrhosis. Genesca J, Gonzalez A, Torregrosa M, Mujal A, electrophoresis in healthy subjects and patients Segura R. Tessari P, Barazzoni R, Kiwanuka E, Davanzo G, immunoglobulin synthesis by circulating De Pergola G, Orlando R, Vettore M, Zanetti M. Serum levels postprandial protein synthesis in compensated of secretory immunoglobulin A in liver disease. Effects acyltransferase and erythrocyte lipids in liver of nutrition and alcohol on albumin synthesis. Albumin synthesis Immunoelectrophoretic analysis of serum gamma rates in cirrhosis: correlation with globulins in chronic hepatitis and hepatic Child–Turcotte classication. Abnormal high density associated antigen in blood donors, chronic liver lipoprotein of primary biliary cirrhosis analyzed disease and primary hepatoma. J Assoc Physicians India electrophoretic anomalies in the serum of liver 1966;14:141–144. Relation to plasma albumin mixed cryoglobulinemia secondary to hepatitis C concentration, oncotic pressure, and viscosity. The effects of heparin of C3 in plasma from patients with primary on lipoproteins in high-resolution biliary cirrhosis.
The next best thing is a broad comparison of devices crystal arthritis definition cheap diclofenac on line, using standardized protocols gonorrheal arthritis definition diclofenac 50mg online, by a third party psoriatic arthritis in neck symptoms cheap 50mg diclofenac with visa. Steam cleaning devices what does arthritis in your neck look like purchase diclofenac 50mg free shipping, in particular, show promise as chemical-free disinfection, and we look forward to the results of efficacy testing currently underway at the Massachusetts Toxics Use Reduction Institute. In summary, this report provides the City and County of San Francisco with the information necessary to identify effective disinfectants and sanitizers posing lower risks to human health and the environment, which supports the City’s commitment to the Precautionary Principle. While our conclusions are constrained by data and regulatory limitations, they suggest reasonable steps to protect custodial workers and the general public. New products enter the market regularly, and more options meeting these criteria are expected in the future. The list includes brands that have the same registration number as products that were evaluated and recommended in this assessment, as well as products with the same (or a similar) amount of an active ingredient (or combination of active ingredients). They are, however, substantially more expensive, and concentrates are much preferred for environmental reasons: Since they contain 1/16 to 1/128 as much water, concentrates can be shipped much more cheaply, with less fuel use and therefore greenhouse gas impacts. The recommended concentrates have relatively few health warnings on their diluted use solution, but most are corrosive in their concentrated form. Pump-style dilution systems are generally insufficient, as they do not eliminate risks of spills or splashes of the corrosive materials. More detailed information about each of the evaluated disinfectants, including recommended products, can be found in Table 4 below. Table 5 details whether the sample products included in this evaluation claim efficacy against the athlete’s foot fungus. Though use of the suggested product parameters referred to in the California Bloodborne Pathogen Standard is not a requirement, prudence would suggest the use of a product that claims efficacy against both pathogens. Personal Protection: When handling items soiled with blood or body fluids, use disposable impervious gloves, gowns, masks and eye coverings. Cleaning Procedure: Blood and other body fluids must be thoroughly cleaned from surfaces and other objects before applying this product. Disposal of Infectious Materials: Use disposable impervious gloves, gown, masks and eye coverings. Blood and other body fluids must be autoclaved and disposed of according to local regulations for infectious waste disposal. Table 7 lists the evaluated products that are registered for use in California and claim efficacy against norovirus (aka Norwalk virus), which can cause stomach flu or gastroenteritis. Appendix C: Best Practices for Cleaning, Sanitizing and Disinfecting Surfaces Product selection is only one element of a comprehensive risk reduction strategy for disinfection and sanitizing. Below are our recommendations for best practices relating to the selection, dilution and use of antimicrobial cleaning products. Use disinfectants and sanitizers only on 43 surfaces with high public health significance, where germs (such as flu virus) might be easily transferred to others, or where required by law. If sanitizers and/or disinfectants are needed, public agencies should establish procedures detailing where, when and how they should be used, and ensure that all janitorial staff are properly trained. General guidelines for targeting disinfectant/sanitizer use: • Use disinfectants on touch points. Products with general disinfecting claims are primarily needed for touch points: Faucets, doorknobs, sinks, toilet seats, railings, and other surfaces frequently touched by building occupants. To kill viruses or fungi, look for disinfectants specifically registered for use against these organisms, since some disinfectants are registered to kill only bacteria. Certain types of facilities have specialized cleaning, sanitizing and disinfection requirements. For example, licensed childcare operations often have specific requirements in diaper-changing and bathroom areas. Similarly, restrooms in correctional or healthcare facilities may fall under specific state or local regulations. Public health regulations usually require surfaces that come in direct contact with food primarily in the kitchen to be pre-cleaned and then treated with a product that is approved for use as a food-contact surface sanitizer. Disinfectants claiming bloodborne pathogen efficacy may be needed if there is an incident resulting in contamination with bodily fluids (such as blood or vomit). Disinfectants that are registered to kill athlete’s foot fungus are appropriate for locker rooms and gym areas. Flu epidemics require products registered for influenza, and more extensive use of disinfectants. Read labels carefully and consider clearly labeling which product is used for each situation. Microbes adhere to organic matter, which means that effective cleaning is usually 123 sufficient to eliminate 80-99% of germs. Surfaces such as mirrors (even restroom mirrors), windows and walls, for example, generally do not need to be treated with sanitizers or disinfectants. Public agencies should consider using microfiber mops and cloths since they are more effective at removing dirt and germs than conventional string mops. Microfiber systems are popular in health care facilities because they minimize transferring microbes from room to room because a new microfiber pad is 129 used in each room. In situations where disinfection is required, a two-step process is ideal: Clean the surfaces first, followed by a U. Although some products are labeled as one-step cleaner-disinfectants, it is not advisable to use them because it is difficult to monitor whether they are being used properly. However, if a surface exceeds that level, the product will no longer be effective. An important first step in developing a cleaning plan is to conduct a baseline assessment of the cleaners, sanitizers and disinfectants that are used on various surfaces in the facility’s restrooms and other areas. It is important to develop an inventory of products currently in use on various surfaces in hallways, restrooms, offices, and other parts of the building. Together, these documents will help users identify many of the important health and environmental risks, as well as the efficacy and dwell time of products currently in use. As a general rule, target for elimination those products containing ortho-phenylphenol, chlorine bleach, quaternary ammonium chloride compounds (quats), peroxyacetic acid, pine oil, and thymol. Compare their efficacy to products containing hydrogen peroxide, citric acid, lactic acid, or caprylic acid and choose an alternative product with the efficacy you need. All antimicrobial products must be left on the surface for the required “dwell time” in order to be effective against the organisms claimed on the label. If a product is wiped or rinsed off before the required dwell time, it is not likely to effectively kill the germs you are trying to target. Some products must also be rinsed off to prevent exposure to building occupants who may touch the residual disinfectant, and to prevent corrosive damage to the surface. Aerosol cans often contain a significant amount of propellant, making the 130 per-unit cost of product high compared to non-aerosol delivery systems. Most propellants have environmental concerns, and the use of aerosol products also increases exposure because the product is delivered in a fine mist, which can easily penetrate the lungs. Because disinfectants need to saturate a surface for 1 to 10 minutes in order to be effective, there is almost no germ-killing benefit from spraying disinfectants or sanitizers into the air. These products are often used to mask odors but result in unnecessary exposure, are generally not effective at killing germs, and can cause or aggravate asthma, adding to any health impacts of the active ingredient or other components. Even better, identify the source of the odor and devise a chemical-free solution such as improved ventilation, if possible. Concentrated cleaning, sanitizing 131 and disinfecting products are the most cost-effective options. Concentrates are also environmentally preferable, since they avoid the need to ship large volumes of water long distances. For these reasons, we recommend closed-loop delivery systems, which are recognizable by the use of sealed bottles that can only be opened once they are fixed to the dilution apparatus. Workers cannot simply open these bottles and pour them into a bucket, and there is no possibility of contact with the concentrates. A poor second choice to closed-loop systems would be measuring pumps, which can be purchased separately and attached to the (unsealed) bottle. Besides protecting workers, dilution systems also make it easy to dilute the product accurately, reducing the likelihood of making solutions that are too strong or too weak, which is the case when concentrates 45 are diluted by hand.
Squamous cell carcinoma of the lip is least (A) Radiotherapy likely to arthritis pain scale purchase 100mg diclofenac mastercard develop in which of the following A 62-year-old man undergoes excision of a drinks tea cylindroma of the submandibular gland arthritis relief otc products generic 50mg diclofenac amex. He is (E) Mentally defective man who smokes most likely to arthritis in neck shoulder and arm order diclofenac 50mg line have an injury to artritis ziekte best diclofenac 100 mg which of the 40 cigarettes a day and keeps the butt in following The prognosis for squamous carcinoma of the floor of the mouth is adversely affected by which of the following (Fig. Composite resection specimen of a T4 floor of mouth squamous cell (B) Local excision of the ulcer carcinoma. A 59-year-old woman has discomfort in the (D) No tongue involvement posterior part of her tongue. Adenocarcinoma is the predominant malignant (C) Lateral rectus palsy lesion in which of the following A 52-year-old woman has metastatic epider attempts suicide by jumping out of the window moid carcinoma on the left side of her neck. He requires mul Complete head and neck workup fails to iden tiple operations during a prolonged, compli tify the primary tumor. A 46-year-old Texan develops a lesion in the vestibule of his mouth that on histological 68. A 58-year-old woman undergoes excision examination is revealed to be verrucous carci biopsy of a tumor in the left posterior triangle noma of the upper aerodigestive tract. A 16-year-old boy complains of difficulty in carcinoma have shown a 50% response rate. Which organism is most likely to be (C) Both thyroid lobes isolated on throat culture A 69-year-old endocrinologist complains of (D) Group A streptococci progressive facial weakness and loss of taste (E) Diphtheroid sensation on the right side of her tongue. A 72-year-old man presents to the emergency (A) Lingual nerve department complaining of frequent nose (B) Middle ear bleeds. A 22-year-old female student was found to (D) Ethmoid sinus have an anterior mediastinal mass on a chest (E) Sphenoid sinus x-ray for a persistent cough. A 40-year-old woman is suspected of having (A) It is located in the posterior mediastinum. After undergoing a minor nasal operation, a 65-year-old man is given a neuroleptic agent. Following surgical resection of a large thyroid mass, a patient complains of persistent hoarse ness and a weak voice. On physical examination, 1-day history of drooping of the right side of mild inspiratory stridor is heard. What is the most likely cause of (A) Bilateral vocal cord paralysis the patient’s facial nerve weakness A 32-year-old teacher presents at her physi (E) Idiopathic cian’s office complaining of hearing loss in her right ear. A 6-year-old girl complains of otalgia, fever, men completely obstructing the ear canal. Physical examination reveals a wax removal is recommended using which of stiff, bulging, red tympanic membrane. Clinical response to amoxicillin is maximized on which (A) Jet irrigation (Water Pik) of the following durations A 4-year-old boy requires prolonged intuba tion and nasogastric tube placement in an 87. An 85-year-old hypertensive man is evaluated intensive care setting following a closed head in the emergency department for recent onset injury incurred in a car accident. His blood pressure is 150/80 mm Hg, recurrent fever but is hemodynamically stable. A 25-year-old accountant is seen by her family (E) Nystagmus practitioner for a sore throat. In most children, the appearance of the tympanic mem (B) 45% brane returns to normal following a single (C) 65% antibiotic regimen for an episode of otitis (D) 80% media within what period A 33-year-old female noted a discharge from a (B) 2 weeks sinus in the overlying skin below the right angle (C) 3 weeks of the mandible. She recalls previous episodes of (D) 1 month fullness and mild pain in this region over the (E) 3 months past several years. During an examination, the dentist notices a (D) Pharyngeal branch of vagus lump between the earlobe and mandible in (E) Phrenic 6-year-old boy. It feels soft, but it is difficult to (F) Sympathetic distinguish from the rest of the parotid gland. After undergoing a left thyroid operation, a (C) Metastatic skin cancer 42-year-old opera singer notes no change in speech, but she has difficulty in singing high (D) Benign mixed tumor pitched notes. During a baseball game, the pitcher is hit in Question 94 the left eye with a hard-hit line drive. She had previously tube placement for treatment of chronic bilat undergone treatment for tuberculosis. Which of the following lymph node enlargement in the neck that has complications is least likely to occur subse broken down to form sinus with overhanging quent to surgery For each numbered item, select the (G) Schistosomiasis appropriate lettered option. A 63-year-old man with insulin-dependent dia Question 93 betes develops a black, crusting lesion in the nose and left maxillary sinus. Biopsy reveals (A) Recurrent laryngeal nonseptate hyphae, which confirms the diag (B) Internal laryngeal nosis of what What is the most likely cause of a mass in the parotid (A) Cholesteatoma gland in this patient This develops along lines of embryological (F) Foramen jugulare fusion in the floor of the mouth. A 46-year-old accountant notices that he keeps (A) Optic neuroma cutting the right side of his lower face while (B) Constricted pupil shaving. On self-examination, he notes a loss of (C) Cerebellar dysfunction sensation of the skin and lower teeth on that (D) Hamartomatous polyps in the small side. Which structure should be carefully (E) Diverticulitis evaluated for this patient’s complaint A 4-year-old boy is brought to the physician’s (H) Melanoma office by his father for evaluation of small stature. On examination, he is noted to have pig ologically related to the thyroid gland and mented spots in the buccal region. His wife thinks 64 3: Endocrine, Head, and Neck Question 102 (G) Dermoid cyst (H) Nevi (A) Mental status change (I) Lipoma (B) Anosmia (J) Tay-Sachs disease (C) Hypopituitarism (D) Meningitis 104. A middle-aged woman from China presents at and subperiosteal resorption of the her physician’s office with a history of nasophar phalanges ynx cancer. What is the most common complaint (C) Atypical mycobacterium of patients presenting with nasopharynx cancer A 5-year-old boy is taken to his pediatrician for (D) Benign mixed tumor a laceration on his right knee. A mass on his (E) Hemangioma neck is noticed; his mother states it has been (F) Sebaceous cyst there for several months and is slowly getting (G) Sjogren’s syndrome larger. A 63-year-old bartender presents at his physi cian’s office complaining of a painful sore on his tongue. On examination, it is found that he has an ulcerated lesion on his tongue and a mass in the submandibular gland triangle. Question 104 (A) Funnel chest (pectus excavatum) (B) Pectus carinatum (protrusion at the sternum) (C) Flail chest (D) Cystic hygroma Figure 3–6. Midline hypoechogenic mass anterior and supe (E) Rickets rior to the thyroid gland. Blood tests reveal primary hyper pains and muscle ache has a normal physical thyroidism. Which one of the (B) Lugols iodine following is not associated with this condition Which one of the following is not part of the (D) Pancreatic tumors may be present management of a patient with hyperparathy roidism (E) Pituitary tumors (A) Hydration with intravenous normal 107.
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