Case Study of diagnosis and treatment of Gout

Case Study of diagnosis and treatment of Gout A 50 year-old male presented for an evaluation of rapid onset of pain and swelling in his right toe. The patient reported that he had two similar previous episodes with the same symptoms lasting four to five days and was treated by emergency physicians. The patientà ¢Ã¢â€š ¬Ã¢â€ž ¢s past medical history is significant for hypertension and treated with Hydrochlorothiazide. The review of systems was negative for headache, fever, chills, rash, earache, sore throat, cough, rhinorrhea, vision changes, weight loss, or change in appetite or disposition. The patient was afebrile, and this blood pressure was slightly elevated. PHYSICAL EXAMINATION: General: The patient is a pleasant male who appears to be in no apparent distress. Vital Signs: blood pressure 123/48, heart rate 76, Temperature 38.3 and 98% on room air. HEENT: Extraocular muscles are intact. Pupils are equal, round, and reactive to light and accommodation. Neck: Supple. No jugular vein distention noted. No carotid bruits noted . Lungs: Clear to auscultation bilaterally. No wheezes, rubs or rhonchi. Heart: Regular rate and rhythm. Normal S1, S2. A 2/6 to 3/6 systolic ejection murmur at the right upper sternal border. PMI is nondisplaced. Abdomen: Notable for laparoscopy surgical wound. Positive bowel sounds. Extremities: MTP is red, hot and swollen. Neurologic: The patient is alert and oriented x3. No focal neurologic deficits noted. Pathophysiology Gout is an inflammatory disease characterized by the deposition of uric acid crystals in and around joints, subcutaneous tissues, and kidneys. Although men and women are equally affected by gout, men are six times more likely to have serum concentrations above 7 mg per dL. Gout typically occurs during middle age and is uncommon before the age 30 years old. Women rarely have gouty arthritis attacks before menopause 1. Clinical Presentation Gout attacks are usually associated with precipitated events. Patients usually present with rapid onset of severe pain, swel ling, redness, and warmth in one or tow joints. This pain and inflammation are caused by inflammatory response. Acute attack untreated attacks usually last two to 21 days depending on cases. There are four clinical stages of gout according to the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS). The first stage is known as asymptomatic hyperurecemia. During this stage, the patients can have an elevation of uric acid in the blood but they do not have any symptoms yet. After more and more urate deposits around a joint and if any trauma triggers the release of crystal into the joint space, patients will suffer acute attacks of gout. This second stage is known as acute gouty arthritis. The third stage, known as interval or intercritical gout, involves the interval between acute flare gout attacks with persist crystals in the joints. When crystals deposits continue to accumulate, patients are likely to develop chronically stiff and swollen joints. This stage is called chronic tophceous gout. Some permanent damage to affected joints and sometimes to kidneys can be seen. This advanced stage is relatively uncommon if patients receive proper treatment. Differential Diagnosis Gout in the elderly is often polyarticular and involves upper extremity joints (especially proximal interphalangeal joints and distal interphalangeal joints). Women present 70% of the time with polyarticular disease rather than the classic monoarticular arthritis seen in men. Gout can be mistaken for rheumatoid arthritis because tophi may resemble rheumatoid nodules and rheumatoid factors often become weakly positive as people age. It may be difficult to differentiate cellulitis or septic arthritis from gout, particularly when a fever, leukocytosis, redness, or desquamation is present. The term pseudogout, for calcium pyrophosphate deposition disease, belies the difficulty in clinically differentiating it from gout. For definitive diagnosis, joint fluid must be aspirate d for culture and a search for urate crystals.

History of the Mexican Trains Ferrocarriles Research Paper

History of the Mexican Trains Ferrocarriles - Research Paper Example The transportation network has had a major part to play in the economic progression of every nation on the planet. A well constructed and collaborative transportation network is the only guarantee that goods, people and services can be located from one part of the country to another with speed, flexibility and at little cost. Transportation can be seen as having a direct link to economic expansion and sustenance. It is unrealistic to expect that one region or nation has the ability to produce all that it consumes. In a similar manner, it is unrealistic to assume that a region can consume all that it produces. In order to strike the balance between demand and supply of various kinds of goods and service it is essential to have a well planned and integrated transportation network to rely on. Only such a transport network could allow the impeccable coordination required between various sectors of the economy such as agriculture, mining, manufacturing, retailing etc. While the provision of a transport network is highly relevant to the modern economic system, but this was not always the case. Instead, a well integrated transportation network was required by nearly all great nations for keeping up with their military ambitions. Economic priorities remained secondary when the creation of a well integrated transportation network was taken into account during the nineteenth and twentieth centuries. Given the need to move economic goods as well as military goods, the preferential method of enhancing the transport network was to use railway links. This also coincided with the fact that road based automobiles were neither common nor highly appreciated in the nineteenth century. Instead, the railway networks of the era were highly preferred given the technical expertise in manufacturing and operating railway linkages. Another major factor that contributed to the growth of the railways in the era related to disposable incomes and the cost of early automobiles. Early automobi les were not only expensive to buy but were equally fiscally demanding in terms of operating and maintenance costs. The problem was compounded by the fact that the majority of people did not have the kinds of disposable incomes to buy and use road based vehicles as yet. In this scenario, it made far greater sense to set up railway linkages in order to enhance the overall transport infrastructure rather than concentrating on roads and automobiles. Vehement development of the railway networks continued throughout the nineteenth century and through the early to mid parts of the twentieth century around the world. Contemporary super powers and countries looking for economic development all looked towards large railway networks in order to support and sustain their economic growth. It is from this era that the British railway networks emerged and spanned nearly half the globe ranging from Africa to the Tibet plateau. In a similar manner, the United States was bent upon enlarging the exis ting railway network to connect the East Coast to the West Coast. A number of different strategies were adopted in order to provide impetus for the expansion of the existing railway network. Conditions in Germany and France were similar with Germany attempting to bridge the Middle East and Europe using a railway link

MANAGEMENT OF HEALTH PROGRAMS (Module 1 SLP) Essay

MANAGEMENT OF HEALTH PROGRAMS (Module 1 SLP) - Essay Example The manager of our interest was appointed as head of a health service and research institute in 1993, that time it was on the verge of closure due to mismanagement and inefficiency. The head excelled in planning, organizing, communicating, leading, controlling and monitoring. As showed by Koontz and O'Donnel (1959) the head had proficiency in all the major functions of a manager (Koontz & O'Donnel 1959). No doubt the head was an active leader. As showed by Bateman and Zeithaml (1993) the head used vision and judgement to create opportunities and did the right things (Bateman& Zeithaml, 1993). The head gave opportunity for high performance. Incentive was given for excellent performers. The head always ensured success and used to project ones own success as institutes success. Finally the head made everybody to believe that head is the personification of institute. The institute started progressing and at the end of a decade it became one of the internationally renowned institutes. Lot of laurels and praise came to the head of the institute. People started praising the head as one of the successful managers. the head got retired, the employees of the institute were divided in to two groups, one the so called high performers patronised by the head and two, the worthless low performers! Institute fell into internal squabbles and was in great trouble. Nobody had direction as everybody was accustomed to orders. Analysis of Strengths and Weaknesses In spite of being an active leader and visionary the head failed to develop positive work environment because the head gave orders rather than directions. Though the head gave opportunity and incentive for high performance in the process the head formed a group of henchmen. As depicted by Agars and Wilson (2005) the head applied the principles of classical conditioning in its crude form (Agars & Wilson, 2005). Person and group of persons took precedence over activity. Bateman and Zeithaml (1993) outlined effective manager as an active leader who creates a positive work environment in which the organization and its employees have the opportunity and the incentive to achieve high performance (Bateman & Zeithaml, 1993). Though successful the head failed to become an effective manager. References Agars, W.S., & Wilson, G.T. (2005). Learning theory. In B.J. Sadock & V.A.Sadock