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To demonstrate a fluid wave it is necessary to enlist the aid of the patient or another individual medicine 230 order olanzapine 20 mg with amex. With the patient in the supine position medicine kim leoni order 7.5 mg olanzapine with visa, the examiner places one palm on the patients flank symptoms ectopic pregnancy discount olanzapine 2.5mg with visa. This is to apply sufficient pressure to dampen any wave that may pass through adipose tissue in the anterior abdominal wall. The sensitivity of this technique is approximately 50% but it has a specificity of greater than 80%. To test for shifting dullness, percuss from resonance in the mid-abdomen to dullness in the flanks. The area of transition is then marked and the patient rolled to the opposite side. For example, if flank dullness is demonstrated on the left then the patient should be rolled onto the right side. One should allow approximately 30 seconds for the fluid to move between the mesentery and loops of bowel into the inferior portion of the abdomen. In three separate studies shifting dullness had a sensitivity that ranged from 6088% First Principles of Gastroenterology and Hepatology A. In one study involving six gastroenterologists and 50 hospitalized alcoholic patients, the overall agreement was 75% for the presence or absence of ascites and reached 95% among senior physicians (i. The absence of a fluid wave, shifting dullness or peripheral edema is also useful in ruling out the presence of ascites. Description A number of gastrointestinal disorders are associated with oral or cutaneous manifestations. When seen in association with dysphagia, the patient likely has esophageal candidiasis. Lesions sometimes follow the course of the intestinal disease, however not always. This disorder is characterized by vascular lesions including telangiectasias and arteriovenous malformations. This syndrome is an acronym for calcinosis, raynauds, esophageal dysfunction, sclerodactyly and telangiactasia. Calcinosis is a deposition of calcium in the soft tissue, often around the elbows. Raynauds is a discolouration of fingers due to vasospasm that often results from exposure to cold. Gardners syndrome is a form of Familial Adenomatous Polyposis, patients develop hundreds to thousands of colonic polyps at a young age. Peutz-Jeghers syndrome is characterized by hamartomatous polyps, mucocutaneous hyperpigmentation and an elevated risk of various cancers. In cirrhosis, palmar erythema, telangiactasia, and caput medusa (dilated periumbilical veins) may also be seen. Patients with hemochromatosis, a condition of iron overload, may develop a bronze discolouration of the skin. Xanthomas, deposits of yellowish, cholesterol rich material, develop on the trunk and face of patients with primary biliary cirrhosis. John McKaigney, University of Alberta Case 1 Scleroderma Case 2 - Peutz-Jeghers syndrome Case 3 - Crohn disease First Principles of Gastroenterology and Hepatology A. Shaffer 37 Case 4 - Osler-Weber-Rendu Case 5 - Black TongueBismuth Licorice, Fungal infection, Post antibiotic Case 6 - Canker Sores and Angular Cheilosis Case 7 Syphylis Case 8 Macroglossia First Principles of Gastroenterology and Hepatology A. Shaffer 38 Case 9 - BehetssyndromeOral and genital ulceration Case 10 - Anterior uveitis Case 11 Xanthelasmata Case 12 Dermatomyositis Case 13 - Acanthosis nigricans First Principles of Gastroenterology and Hepatology A. Shaffer 39 Case 14 - Spider angioma Case 15 - Blue rubber bleb nevus syndrome Case 16 - Leukocytoclastic vasculitis Case 17 - Dermatitis herpetiformis First Principles of Gastroenterology and Hepatology A. Shaffer 40 Case 18 - Cullens sign Case 19 - Grey Turners signFlank hemorrhage again in acute pancreatitis Case 20 - Erythema nodosum Case 21 - Pyoderma gangrenosus First Principles of Gastroenterology and Hepatology A. Shaffer 41 Case 22 - Ascitic abdomen with caput medusa Case 23 - Caput medusa type veins and umbilical hernia Case 24 - Skin pigmentation Case 25 Carotenemia hemochromatosis First Principles of Gastroenterology and Hepatology A. Shaffer 42 Case 26 - Palmar erythema Case 27 Dupuytrens Case 28 - White nails Case 29 - Beaus lines Case 30 - Nail pitting-psoriasis Case 31 - Psoriatic Nails First Principles of Gastroenterology and Hepatology A.

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Usually medicine 031 quality 7.5 mg olanzapine, it is not necessary for a licensee to possess a survey meter solely for use during sealed source diagnostic procedures medicine hunter buy olanzapine 20mg without a prescription, since it is not expected that a survey be conducted each time such a procedure is performed medications mitral valve prolapse order olanzapine master card. In these cases, it is acceptable for the meter to be available on short notice in the event of an accident or malfunction that could reduce the shielding of the sealed source(s). Surveys may be required to verify source integrity of the diagnostic sealed source and to ensure that dose rates in unrestricted areas and public and occupational doses are within regulatory limits. Provide one or both of the following: A statement that: "Radiation monitoring instruments will be calibrated by a person qualified to perform survey meter calibrations. Furthermore, licensees may rely on the providers dose label for the measurement of the dosage and decay-correct the dosage to the time of administration. Equipment used to measure dosages must be calibrated in accordance with nationally recognized standards (e. The measurement equipment may be a well ion chamber, a liquid scintillation counter, etc. For other than unit dosages, the activity must be determined by direct measurement, by a combination of radioactivity measurement and mathematical calculation, or by a combination of volumetric measurement and mathematical calculation. Licensees must assay patient dosages in the same type of vial and geometry as used to determine the correct dose calibrator settings. Using different vials or syringes may result in measurement errors due, for example, to the variation of Bremsstrahlung created by interaction between beta particles and the differing dosage containers. Licensees are reminded that beta emitters should be shielded using a low atomic-numbered material to minimize the production of Bremsstrahlung. When a high activity source is involved, consideration should be given to adding an outer shield made from material with a high atomic number to attenuate Bremsstrahlung. To perform these measurements, the applicant must possess appropriately calibrated dosimetry equipment. Except for manual brachytherapy sources and low dose-rate remote afterloader sources where the source output or activity is determined by the manufacturer, the applicant must possess a calibrated dosimetry system (e. The licensee must maintain records of calibrations of dosimetry equipment for the duration of the license. The calibration procedures should address, in part, the method used to determine the exposure rate (or activity) under specific criteria (i. For sealed sources used in therapy, and in particular, for new types of use, licensees should select dosimetry equipment that will accurately measure the output or the activity of the source. Other Equipment and Facilities The applicant must describe additional facilities and equipment for the radiopharmaceutical therapy program to safely receive, use, store, and dispose of radioactive material. The applicant should focus on facilities to be used for radioactive drug therapy administration and patient accommodations (i. I-131 sodium iodide is the most widely used source of radiopharmaceutical therapy. If the radionuclide is administered in volatile liquid form, it is important to place the patient dosage in a closed environment (i. Also note there are hazards associated with volatile iodine in pill form; applicants should consider this in establishing their radiological controls. If a shielded viewing window will be used, the thickness, density, and type of material used should 30 be specified. If a closed-circuit television system (or some other electronic system) will be used to view the patient, the backup system or procedure to be used in case the electronic system malfunctions should be specified, or the applicant must commit to suspending all treatments until the electronic system is repaired and functioning again. The communication system should allow the patient to communicate with the unit operator in the event of medical difficulties. An open microphone system can be used to allow communication without requiring a patient to move to activate controls. The interlock system must cause the source(s) to be shielded if the door to the treatment room is opened when the source is exposed. The interlock system must also prevent the operator from initiating a treatment cycle unless the treatment room entrance door is closed. Further, the interlock must be wired so that the source(s) cannot be exposed after interlock interruption until the treatment room door is closed and the source(s) on-off control is reset at the console. This would constitute a circuit that generates the audible alarm when either the source retracted and radiation present or appropriate internal error condition(s) exist; o The source safe and radiation present signal should also be self-testing.