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Vice Chair, University of Washington School of Medicine

Finger movement - the letters are made entirely by the action of the thumb allergy symptoms lymph nodes order promethazine on line, the pointing and middle fingers allergy medicine that makes you sleepy discount 25mg promethazine mastercard. Hand movement - the letters are produced by the action of the hand as a whole with the wrist as the center of action and with some action of the fingers allergy testing uk babies discount promethazine 25 mg mastercard. Most of the illegible allergy forecast ri buy 25 mg promethazine otc, scratchy and angular writings of women are produced by such movement. Arm movement - the movement in writing is made by the hand and arm supported with the elbow at the center of the lateral swing. The Form, Style and Characteristics of the Handwriting of a Person are Basically Determined By: A. Children who were under the same tutelage during their initial period of learning how to write have the tendency to develop similar writing habits. Inclusion of some characteristics due to admiration of a peculiar design in writing. Identifying characteristics may be the result of the great volume of writing done. The presence or absence of physical abnormalities or defects originating from illness, injury, psychological variations and other similar conditions. Temporary physical or psychological disturbances, such as excitement, fear, pain, exhaustion, injury to thd hand or arm, etc. Other external temporary variables, such as writing without glasses, bad lighting, irregular surface, external interference. Soft pencils have greater proportion of graphite while hard ones have relatively more clay. Cheap quality pencils have frequently gritty impurities which scratch the paper, while high-grade pencils are free from such grit. Papers are designated in weight which is in turn related to the thickness of the sheet. Ink: (1) Iron gallotannate ink - Commonly used in "blue-black" ink and still the basis of the greatest number of commercial ink. Points to be Considered in Questioned Document Examination: Size, slant, spacing, proportion of the letters, speed and rhythm in writing, shading and change of position in pen hold, pressure, penlift, initial and terminal strokes, alignment, etc. Inasmuch as handwriting examination is basically comparative, the standard for such comparison must be suitable and sufficient. The greater the variation in a way of writing, the greater is the amount of standard writing needed to form a reliable impression. Handwriting examination done by comparison with known standards: to determine whether a certain instrument or document has been written by a certain person, it is necessary to compare the writings on such instrument or document with some standard writings of the same person for the purpose of comparison and determine the similarities. The standard (exemplar) writings with which the questioned writing has to be compared are of two types: 1. Collected (procured) standards - these consist of handwriting by the person who is suspected to have written the questioned document. Requested standard - these are standards made by the alleged writer of the document in question upon request of the examiner or the persons interested in the examination. Considering that it is a request from a suspected maker of the questioned document, there is a strong possibility for it to be written in a disguised way. Steps to be Undertaken to Minimize Conscious Efforts to Disguise the Requested Standard: 1. The writer should be allowed to write sitting comfortably at a desk or table and without distraction. The suspect should not, under any condition, be shown the questioned document or be provided with instructions on how to spell certain words or what punctuation to use. The suspect should be furnished with a pen and a paper similar to those used in the questioned document. The dictated text may be the same as the contents of the questioned document, or at least should contain many of the same words, phrases, and letter combinations found in the document. In handwriting cases, the suspect must not be given any instruction on whether to use upper-case (capital) or lower-case lettering. If the writer is making a deliberate effort to disguise his writing, noticeable variations should appear between the three repetitions.

Essential hypertension Benign hypertension this causes gradual and progressive damage to the glomeruli allergy houston promethazine 25 mg online, which may lead to renal failure after the renal reserve has been lost or to malignant hypertension allergy medicine insomnia cheap 25mg promethazine. Malignant hypertension this causes arteriolosclerosis which spreads to the glomeruli with subsequent destruction of nephrons allergy symptoms newborn cheap generic promethazine uk, leading to a further rise in blood pressure and a variable degree of renal impairment in most people allergy symptoms 1dp5dt order cheap promethazine line. In a few people there are more serious effects; increased permeability of the glomeruli allows escape of plasma proteins and red blood cells into the filtrate causing proteinuria and haematuria, which may progress to renal failure. Secondary hypertension this is caused by long-standing kidney diseases and may lead to chronic renal ischaemia, worsening hypertension and renal failure. Acute pyelonephritis this is acute bacterial infection of the renal pelvis and calyces, spreading to the kidney substance causing formation of small abscesses. The infection may travel up the urinary tract from the perineum or be blood-borne. Abnormal reflux of infected urine into the ureters when the bladder contracts during micturition predisposes to upward spread of infection to the renal pelves and kidney substance. Blood-borne infection the source of microbes may be from septicaemia or elsewhere in the body. Due to their large blood flow (20% of cardiac output) the kidneys are susceptible to infection by blood-borne microbes. Pathophysiology When the infection spreads into the kidney tissue it causes suppuration and destruction of nephrons. The prognosis depends on the amount of healthy kidney remaining after the infection subsides. Necrotic tissue is eventually replaced by fibrous tissue but there may be some hypertrophy of healthy nephrons. There are a number of outcomes: healing, recurrence, especially if there is a structural abnormality of the urinary tract, and reflux nephropathy. Perinephric abscess and papillary necrosis are complications, usually if the condition is untreated. Reflux nephropathy Previously known as chronic pyelonephritis, this is almost always associated with reflux of urine from the bladder to the ureter allowing spread of infection upwards towards the kidneys. A congenital abnormality of the angle of insertion of the ureter into the bladder predisposes to reflux of urine, but it is sometimes caused by an obstruction that develops later in life. Progressive damage to the renal papillae and collecting ducts leads to chronic renal failure and concurrent hypertension is common. Renal failure Acute renal failure There is a sudden and severe reduction in the glomerular filtration rate and kidney function that is often reversible over days or weeks if treated. There is oliguria or anuria accompanied by metabolic acidosis due to retention of H+; electrolyte imbalance; accumulation of other mainly nitrogenous waste products; and, if not associated with severe fluid loss, retention of water, i. This occurs as a complication of a variety of conditions not necessarily associated with the kidneys. The causes of acute renal failure are classified as: prerenal: the result of reduced renal blood flow, especially as a consequence of. There is severe damage to the tubular epithelial cells caused by ischaemia or, less often, by nephrotoxic substances (Box 13. Oliguria, severe oliguria (less than 100 ml of urine per day in adults) or anuria (see Table 13. There is reduced glomerular filtration and selective reabsorption and secretion by the tubules, leading to: heart failure due to fluid overload generalised and pulmonary oedema electrolyte imbalance which may be exacerbated by the retention of potassium (hyperkalaemia) released from damaged cells anywhere in the body accumulation of urea and other metabolic waste products acidosis due to hydrogen ion retention. Profound diuresis (the diuretic phase) occurs during the healing process when the epithelial cells of the tubules have regenerated but are still incapable of selective reabsorption and secretion. Diuresis may lead to acute dehydration, complicating the existing high plasma urea, acidosis and electrolyte imbalance. If the patient survives the initial acute phase, a considerable degree of renal function is usually restored over several weeks (the recovery phase). Chronic renal failure this occurs when the renal reserve is lost and there is irreversible damage to about 75% of nephrons. Reduced glomerular filtration leads to accumulation of waste substances in the blood, notably urea and creatinine. When renal failure becomes evident, blood urea levels are raised and this is referred to as uraemia.

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Some hymen are thick allergy to alcohol order generic promethazine canada, elastic and fleshy such that they can resist certain degree of distention without causing laceration allergy shots memphis tn discount promethazine 25mg. Some women may inherently have lacerated hymen probably on account of previous trauma during the early age allergy testing san diego purchase promethazine 25mg with mastercard. The fact that the hymen is intact does not prove absence of previous sexual intercourse and the presence of laceration does not prove defloration allergy medicine 75 buy promethazine 25mg cheap. General condition of the hymen: 493 this includes the width, thickness, elasticity, vascularity, and laxity. It may include pathological condition, like inflammatory changes, signs of previous trauma, developmental abnormality and foreign elements. Original shape of the orifice (opening): In case laceration is present, try to reconstruct the hymen by means of a probe and determine the original shape of the opening. It may be linear, circular, stellate, cresentric, septate, cribiform, imperforate and fimbriated. If lacerated, the following must be noted: (1) Degree of laceration: this refers to the extent of damage to the hymen which may be: (a) Incomplete laceration - Rupture or laceration of the hymen is considered incomplete when it does not involve the whole width or height of the hymen. Superficial - the laceration does not go beyond one-half of the whole width of the hymen. Deep - the laceration involves more than one-half of the width of the hymen but not reaching the base. With the examiner facing the female genitalia, the location of the laceration will be described corresponding to the time in the face of a watch. Ordinarily it can be inferred that hymenal laceration took place approximately more than ten days or 2 to 3 weeks. The following are the possible complications: (a) Secondary infection - There may be activation of the bacterial flora in the vaginal canal or a superimposed infection may set in, especially among women with poor hygienic habit. Gonorrheal infection is not uncommon when the offender is suffering from the disease at the time of the sexual act. Blood analysis to determine the presence of blood disease may be indicated when there is disproportion between the injury and the amount of hemorrhage. This may require the services of a competent gynecologist to subject the patient to surgery. Local Changes: the parasympathetic innervation of the sex organ is from the 2nd, 3rd and 4th spinal sacral segments, and the sympathetic innervation is from the 11th thoracic down to the 1st lumbar. In the male, the stimulus may be central or somesthetic or local tactile in origin. In the male, stimulation will cause erection of the penis due to active dilatation of the arteries through the nervus origentis. The erection is also brought about by the contraction of the ischiocavernous muscle producing compression of the dorsal vein of the penis, thus causing accumulation of blood under pressure. More sexual stimulus will be attained through friction during the sexual act coupled with the physical activities of the partner. In the female, sexual stimulation will cause tomescence of the clitoris, vestibule and labia minora. The lubricant is a transudate coming from the vaginal wall and its production ceases when the stimulus is removed. At the level of the cervix there is a transverse expansion of the vaginal canal from 2 cm. An increase of peripheral flow of blood experienced as an increase of body warmth; d. Tomescence (engorgement of blood), which is the consequence of this peripheral flow concentrating on erectile tissue;. During Orgasm: In the male, orgasm is the sensation resulting from the contraction of the smooth muscles of the genitalia and the striated muscles of the pelvic floor coinciding with ejaculation. Seminal emission is carried on by the peristaltic action of the vas deferens, seminal vesicle and prostate. Ejaculation results from the contraction of the pelvic floor muscle and the bulbospongiosus and ischiocavernosus muscles.

The oxygen consumption and cardiac output/m2 are much higher in the newborn allergy medicine enlarged prostate purchase promethazine 25 mg otc, and there is very little systolic reserve allergy symptoms weakness buy promethazine us. Tachycardia is therefore the usual neonatal response to stress allergy medicine for 2 year old buy 25mg promethazine, because any increase in stroke volume is limited allergy shots cost order promethazine 25mg overnight delivery. Supraventricular arrhythmias with significant heart failure require prompt pharmacologic or electrical cardioversion. Dopamine is a good inotrope to use (depending on dose) if there is a risk of renal ischemia, low cardiac output, or hypotension with decreased systemic vascular resistance. Dobutamine is a good inotrope to use for low cardiac output in patients at risk for myocardial ischemia, pulmonary hypertension, and left ventricular diastolic dysfunction. What is the most frequent primary cause of hypotension in the preterm neonate in the immediate postnatal period In the preterm infant the immature cardiovascular system is poorly equipped to handle the transitional circulation from a low vascular resistance circulation, when the placenta is removed, to the sudden presence of a high systemic circulation. The immature myocardium, residual fetal circulatory shunts, cytokine release mediated hypotension, and the impact of positive pressure ventilation on venous return and cardiac output all contribute to inadequate systemic perfusion. However, the primary mechanism of hypotension in a preterm infant is inadequate peripheral vasomotor regulation. Although hypovolemia is a common cause of hypotension in the pediatric population, hypovolemia in sick preterm infants is infrequently the cause of hypotension during the immediate postnatal period. Why are the deleterious effects of hypotension of greater concern in preterm neonates Preterm neonates have a relative inability to regulate cerebral blood flow compared with those born at term. Hypotension and rapid wide swings in blood pressure have been shown to be predictive of both germinal matrix-intraventricular hemorrhage and periventricular leukomalacia. What are the mechanisms of action of the cardiovascular effects of dopamine in the preterm neonate In preterm neonates dopamine increases blood pressure primarily through vasoconstriction (increased afterload) as the immature cardiovascular system has an enhanced alpha-adrenergic sensitivity. Dopamine also increases preload by decreasing the venous capacitance, which may also contribute to the beneficial cardiovascular effects of dopamine. Dopamine has a renal but not mesenteric or cerebral vascular effect in preterm infants. What are the pros and cons of dopamine and dobutamine in the treatment of hypotension in a preterm neonate Dopamine may be the preferred inotrope in the treatment of hypotension secondary to neonatal sepsis because it increases peripheral vascular contractility. However, dobutamine may be preferred in treatment of hypotension secondary to cardiomyopathy, which frequently occurs with perinatal asphyxia. Whereas dopamine has a greater increase in arterial blood pressure than dobutamine, dobutamine has been shown to increase superior vena cava blood flow and may improve end-organ perfusion to a great extent. Summary Proceedings from the Cardiology Group on Cardiovascular Instability in Preterm Infants. An unrestrictive atrial communication is crucial in certain cyanotic congenital heart lesions to provide mixing (right-to-left) and/or cardiac output. The most common cyanotic lesion presenting in the newborn period is d-transposition of the great arteries. An electrocardiogram with a left axis shift in a cyanotic newborn baby may be consistent with tricuspid atresia. D-transposition of the great arteries is the most common form of cyanotic congenital heart disease in the neonate, and accounts for between 6% and 10% of infants with congenital heart disease. In children "outside" the newborn period, tetralogy of Fallot is the most common, representing 7% to 9% of cardiac cases of cyanosis. In d-transposition of the great arteries, the aorta arises from the morphologic right ventricle and the pulmonary artery arises from the morphologic left ventricle. Variation in the origin and course of the right and left coronary arteries may occur and can generally be determined by echocardiography before surgery. Patients with d-transposition of the great arteries may have an intact ventricular septum and exhibit cyanosis in the first hours to days of life. They will develop tachypnea, respiratory distress, and acidosis and die if not treated.