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AEI currently utilizes a RIEGL VZ400 Terrestrial Laser Scanner on various job sites.  This proecss utilizes a high accuracy 3D terrestrial LiDAR unit.  The data collected will be brought into a feature extraction software, TopoDOT.  TopoDOT utilizes a variety of tools to identify adn quickly extrapolate features within pointcloud data.  All features can then be imported into an AutoCAD drawing file.  AEI can provide an accurate 3D pointcloud of terrain plus any existing building or structures.  The pointcloud can also be converted for Building Information Models.

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Allen Engineering is involved with the civil design and surveying for the new park in Palm Bay, Flordia.  This Regional Park will feature 150 full service campsite hookups and is scheduled to break ground in 2018.  We are extremely proud to be involved in this project.

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Allen Engineering is beginning its 21st year associated with the Space Coast Post of the Society of American Military Engineers (SAME).  During our 21 years, we have helped raise over $350,000 in scholarships and endowments.  We are extremely proud to be associated with SAME and its continued commitment to offer opportunities for students pursuing careers in the engineering field.


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  • S. Ward Casscells Professor, Department of Orthopaedics, University of Virginia, Charlottesville, Virginia


Clinical Manifestations of cirrhosis -The Manifestations of cirrhosis are variable quit smoking nicotine withdrawal order nicotinell 35mg with visa, ranging from asymptomatic Hepatomegally to quit smoking organizations proven 52.5mg nicotinell hepatic failure quit smoking body changes trusted 35 mg nicotinell. Early manifestations:- right upper quadrant pain - Sensation of fullness Late manifestation:The late manifestations are related to quit smoking years ago buy discount nicotinell 52.5 mg online portal hypertension and liver cell failure(Hepatocellular failure) - Portal Hypertension:o the fibrotic bands cause narrowing of the portal vein cause portal hypertension o It is followed by back ward congestion of all tributaries of portal veins. It is commonly categorized into two as gastric and duodenal peptic ulcer diseases. Gastric and duodenal peptic ulcers with their remissions and exacerbations represent a chronic health problem. While Gastric 140 Pathophysiology ulcers tend to affect the old age group with peak incidence in the 6th 7th decade. Inability of the mucosal barrier to resist the destructive action of the gastric secretions (enzymes & acids). B:-It is more likely that both of the above factors contribute to the development of peptic ulcer diseases. Inability of the mucosal Barrier to Resist Gastric Secretions the defense of the mucosal surface depends on an adequate blood flow and intact mucosal barriers. Basic abnormality in person with gastric-peptic ulcer is an increased permeability of the epithelial layer of the stomach to hydrogen ion. The following conditions affect mucosal barrier integrity: Chronically diseased mucosal membrane is unable to secrete sufficient mucus to form an effective barrier 143 Pathophysiology Reflux of bile from intestine to stomach has been implicated in peptic ulcer. Also numbers of drugs are recognized as a "barrier- breaker" both aspirin and alcohol are known to damage this barrier. Which colonize the mucus secreting epithelial cells of stomach and duodenum and digest the protective mucus secreting membranes. Pain, which is described, as waning, gnawing or crampy like, is usually rhythmic and frequently occurs when the stomach is empty. The Pain is usually over small area near the mid-line in the epigastrium and may radiate below the costal margins in to back or rarely to the right shoulder. An ulcer may penetrate only 144 Pathophysiology the mucosal surface or it may extend in to the smooth muscle layer. Healing of muscularis layer involving replacement with scar regeneration is often less than perfect in which repeated episodes of ulceration occur. Complications of peptic ulcer includes: Hemorrhage: - results from erosions of the mucosa. Epigastric fullness, heaviness after meal with severe case of obstruction vomiting of undigested food. The presence of an over night gastric residual of 50ml of undigested food indicates severee obstruction. Perforation: - occurs when an ulcer erodes through all the layers of the stomach or duodenal wall. Causes o the cause of intestinal obstruction could be categorized under two headings: 1. Mechanical obstruction Classifications o Extrinsic factor: Adhesions of peritoneum Hernias 146 Pathophysiology Volvulus (Twisting of the bowel lumen) o Intrinsic factors, which encroach on the patency of the bowel. The l e s c o p i n g o f the b o w e l (intussusceptions) Fecal impaction Stricture of the bowel Tumors Ascariasis bolus Types of mechanical obstructions: o There are 3-types of Mechanical obstruction Simple flow Strangulated in blood flow Closed in both ends. It occurs early in the course of peritonitis and can result from chemical irritation caused by bile, bacterial toxins, electrolyte imbalance (hypokalemia) & vascular insufficiency. Intestinal obstruction interfiles with reabsorption of 7 to 8 liters of electrolyte rich extra cellular fluid in small bowel. Lost in the vomitus of 7 liters to 8 liters which represent about half of the extra cellular fluid volume of an average adult can occur in 24hours or less following acute intestinal obstruction. If untreated, the distention resulting from bowel obstruction tends to perpetuate itself by causing atony of the bowel & further distension is aggravated by the accumulation of gases. Clinical Manifestations of Intestinal Obstructions the manifestation of intestinal obstruction depends on the degree of obstruction and its duration. With acute obstruction the onset is usually sudden and dramatic but with chronic one onset is more gradual. It is due to increased peristalsis as the intestine attempts to move the content forward. A b d o m i n a l d i s t e n t i o n: - d u e t o g a s e s accumulations and atonia of the Smooth muscles in the intestinal lumen 4. Signs of Gangrenous Changes or Strangulations:If an acute intestinal obstruction left untreated for long duration, usually above 72 hours, strangulations and gangrenous change is the rule. The following are clinical signs of gangrenous changes:The patient becomes weak and prostrated. Development of fever Tachycardia Absence of peristalsis (bowel sound) Increased abdominal tenderness. Structural classification Hormones have diverse structures ranging from single modified amino acids (epinephrine and thyroxine), poly peptides (growth hormone and insulin), and glycoproteins (follicle-stimulating hormone and luteinizing hormone) to lipids (steroid hormones such as cortisol). Function Hormones do not initiate reactions; rather they are modulators of body and cellular responses. For example, thyrotropin acts selectively on the thyroid gland, where as epinephrine affects the function of many body systems. Synthesis Protein and peptide hormones are synthesized in the rough endoplasmic reticulum and stored in granules or vesicles within the cytoplasm of the cell until secretion is required. The lipid-soluble steroid hormones are released as they are synthesized (smooth endoplasmic reticulum). Transport 154 Pathophysiology Hormones are delivered from cells of the endocrine gland to target cells: 1. Paracrine Metabolism Hormones secreted by endocrine cells must be continuously inactivated to prevent their accumulation. Both intracellular and extra cellular mechanisms participate in the termination of hormone function.

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Red hair pheomelanosomes contain a vesicular matrix quit smoking free patches nicotinell 35mg discount, but melanin is deposited irregularly quit smoking coupons cheap 35 mg nicotinell with amex, in blotches quit smoking jail order nicotinell 17.5 mg without a prescription. Of interest quit smoking 40 days ago 35mg nicotinell visa, both eumelanogenic and pheomelanogenic melanosomes can coexist in the same human cell (316), but not within the same pathway. These structural principles apply to follicular melanocytes and also probably to human epidermal melanocytes and rodent cutaneous melanocytes (181, 515). It was recently proposed that late endosomes may be the initial sites of stage I melanosome formation (333, 335, 456, 608); further maturation would be driven by delivery of structural and enzymatic proteins, and by their activation followed by substrate delivery. Others believe that formation of melanosomes is driven by independent, but overlapping, mechanisms (384). One suggests that the enzymatic proteins required for melanogenesis are delivered via coated vesicles to melanosomes that originate from the endoplasmic reticulum and Golgi (335). Melanogenesis commences when tyrosinase and other relevant enzymes are cleaved, and initiation of activity may depend on an acidic environment provided by proton pumps (454, 601). Proteomic analysis of early melanosomes has provided new information on the recruitment of organelle specific proteins and on membrane remodeling crucial for melanosome formation, movement, and transfer. The recently cloned pink-eyed dilution mouse gene (p) and its human P homolog encode a melanosomal protein with 12 transmembrane domains with partial homology to a tyrosine specific transporter protein in Esch- erichia coli (204, 620). This would be consistent with the homology of the P protein to the tyrosine specific transporter (204, 620), and with the proposed regulatory role for P protein in the assembly of the melanogenic apparatus (539). The mechanism of pheomelanosome formation is less precisely defined than for eumelanosomes. The process of pheomelanogenesis depends on the presence of tyrosinase activity, which is comparatively low, and on the availability of cysteine to conjugate dopaquinone formed by tyrosinase action (515, 597, 598). Because melanosomes are metabolically active organelles, their activity is bound to affect the function of the host melanocyte or keratinocyte (746). The presence of pigment granules that can regulate intracytosolic calcium concentration, or reversibly bind cations or bioregulatory compounds such as catecholamines, serotonin, and prostaglandins, may also affect the function of the host cell (736, 746). Based on this, it has been further proposed that melanosomes could serve as an accurate indicator for cellular responses to the environment (262). Results of proteomics analyses appear to support the notion that melanosomes are complex organelles. Introduction to melanogenesis Cutaneous pigmentation is under complex genetic control regulated by more than 150 alleles spread over 90 loci (262, 263, 328, 385, 515, 673, 708). Protein products of these loci acting as enzymes, structural proteins, transcriptional regulators, transporters, receptors, and growth factors have a wide array of functions and cellular targets (263, 515). The availability of L-tyrosine for enzymatic oxidation is a central component of melanogenesis, regulated at the The type of melanin produced is determined by the enzymatic library available and its prevalent metabolism. It is nevertheless unclear whether oxidation of catecholamines in substantia nigra with transformation into neuromelanins is catalyzed enzymatically or whether it is dependent on physicochemical factors. The involvement of macrophage inhibitory factor in the formation of neuromelanin has been already demonstrated (262, 467, 638, 664), but not the involvement of peroxidase (930). Therefore, the presence and actual activity in the melanocyte of antioxidant enzymes such as catalase, superoxide dismutases, glutathione peroxidase, glutathione reductase, and thioredoxin reductase/thioredoxin would modify quantitatively or qualitatively the melanogenic pathway (664). When concentration of sulfhydryl compounds is low, dopaquinone is converted to dopachrome, initiating the eumelanogenic pathway. High concentrations of cysteine and glutathione lead to their conjugation with dopaquinone and corresponding formation of cysteinyldopa (5-S-cysteinyldopa is the major isomer while 2-S-cysteinyldopa, 6-S-cysteinyldopa, and 2,5dicysteinyldopa are minor isomers) and glutathionyldopa (597, 598). The velocity of the postcysteinyldopa steps of pheomelanogenesis is increased by peroxidase and tyrosinase through oxidative transformation of benzothiazinylalanines (597, 598). It must be noted that enzymatically nonfunctional tyrosinase proteins can be expressed in nonmelanocytic cells of neural crest origin (254, 826). Proteolytic cleavage of the transmembrane portion of the newly synthesized enzyme generates two soluble molecular forms: a 53-kDa unmodified protein, or a 65-kDa glycosylated tyrosinase, which N and C are the amino and carboxy protein terminus, respectively; Cy-rich, cysteinerich segments; Cu or Me, Cu or metal binding domains; t, transmebrane segment. The higher molecular mass forms of tyrosinase (140, 655, 720, 722, 741) may represent dimmers, tight complexes with other melanogenic proteins (542), or high-molecular-weight tyrosinase proteins. It is still unclear how or when copper ions (necessary for enzymatic activity) are integrated into apotyrosinase. The catalytic site of tyrosinase is represented by two copper atoms ligated to six histidine residues. In addition to mutations in hot spots (copper binding domains), virtually the entire coding sequence of the gene is susceptible to mutations. These include missense, nonsense, frameshift, and splicing abnormalities (524) Thus the stability, folding, and activation of tyrosinase are critically controlled by redox conditions. Activation of inactive enzyme (mettyrosinase) involves the reduction of its two Cu2 sites to two Cu1 centers (fully active form; deoxytyrosinase) requiring a two-electron reduction step. A similar mechanism may be responsible for the reduction in lag period for tyrosine hydroxylation by catecholamines, by reduced tri- and diphosphopyridine nucleotides, and by high concentrations of tetrahydropteridine (587). Tyrosinase activity can also be inhibited by interactions with cysteine, by chelation of copper ions, by competitive occupancy of the catalytic site (for example, by L-phenylalanine), by feedback inhibition by intermediates of melanogenesis, and by direct inactivation by melanin pigment.

Capitalize official titles quit smoking zyban treatment purchase nicotinell 17.5 mg fast delivery, including separate political entities such as East St quit smoking inspirational quotes discount 35 mg nicotinell with visa. The preferred form for the section of a city is lowercase: the west end quit smoking 3 months ago women nicotinell 17.5mg online, northern Los Angeles quit smoking results timeline buy discount nicotinell 17.5mg. But capitalize widely recognized names for the sections of a city: South Side (Chicago), Lower East Side (New York). To avoid confusion, use resident, not citizen, in referring to inhabitants of states and cities. Citizen is also acceptable for those in the United Kingdom, or other monarchies where the term subject is often used. National is applied to a person residing away from the nation of which he or she is a citizen, or to a person under the protection of a specified nation. The term describes a group of radio frequencies set aside by the Federal Communications Commission for local use at low power by individuals or businesses. Lowercase elsewhere: a Texas city; the city government; the city Board of Education; and all city of phrases: the city of Boston. Capitalize when part of a formal title before a name: City Manager Francis McGrath. Lowercase when not part of the formal title: city Health Commissioner Frank Smith. Lowercase in other uses: the council, the Boston and New York city councils, a city council. Use the proper name if the body is not known as a city council: the Miami City Commission, the City Commission, the commission; the Louisville Board of Alder- 50 men, the Board of Aldermen, the board. Use city council in a generic sense for plural references: the Boston, Louisville and Miami city councils. A union shop requires workers to join a union within a specified period after they are employed. An agency shop requires that the workers who do not want to join the union pay the union a fee instead of union dues. A guild shop, a term often used when the union is the Newspaper Guild, is the same as a union shop. See the right-to-work entry for an explanation of how some states prohibit contracts that require workers to join unions. Whenever practical, use a phrase such as closing debate or ending debate instead of the technical term. Civil actions generally involve a charge that a contract has been breached or that someone has been wronged or injured. A criminal case is one that the state or the federal government brings against an individual charged with committing a crime. Cooperate, coordinate and related words are exceptions to the rule that a hyphen is used if a prefix ends in a vowel and the word that follows begins with the same vowel. Capitalize when referring to regions of the United States lying along such shorelines: the Atlantic Coast states, a Gulf Coast city, the West Coast, the East Coast. Capitalize the Coast when standing alone only if the reference is to the West Coast. The label itself, the dictionary says, "does not indicate substandard or illiterate usage. In some countries of Africa, it is used to denote individuals of 53 mixed racial ancestry. Whenever the word is used, place it in quotation marks and provide an explanation of its meaning. Three other former republics ~ Latvia, Lithuania and Estonia ~ became independent nations earlier in 1991. Do not capitalize committee in shortened versions of long committee names: the Special Senate Select Committee to Investigate Improper Labor-Management Practices, for example, became the rackets committee. The members of this free association of sovereign states recognize the British sovereign as head of the Commonwealth. The members are: Antigua and Barbuda, Australia, Bahamas, Bangladesh, Barbados, Belize, 54 Botswana, Brunei, Cameroon, Canada, Cyprus, Dominica, Fiji, Gambia, Ghana, Grenada, Guyana, India, Jamaica, Kenya, Kiribati, Lesotho, Malawi, Malaysia, Maldives, Malta, Mauritius, Namibia, Nauru, New Zealand, Nigeria, Pakistan (suspended after the 1999 military coup), Papua New Guinea, St. Vincent and the Grenadines, Samoa, Seychelles, Sierra Leone, Singapore, Solomon Islands, South Africa, Sri Lanka, Swaziland, Tanzania, Tonga, Trinidad and Tobago, Tuvalu, Uganda, United Kingdom, Vanuatu, Western Samoa, Zambia and Zimbabwe. Communications Workers of America the shortened form Communications Workers union is acceptable in all references. Use compared with when juxtaposing two or more items to illustrate similarities and/or differences: His time was 2:11:10, compared with 2:14 for his closest competitor. Constitute, in the sense of form or make up, may be the best word if neither compose nor comprise seems to fit: Fifty states constitute the United States. Use include when what follows is only part of the total: the price includes breakfast. Compliment is a noun or a verb that denotes praise or the expression of courtesy: the captain complimented the sailors. It is best used only in the active voice, followed by a direct object: the Unit- composition titles Apply the guidelines listed here to book titles, computer game titles, movie titles, opera titles, play titles, poem titles, song titles, television program titles, and the titles of lectures, speeches and works of art. The guidelines, followed by a block of examples: -Capitalize the principal words, including prepositions and conjunctions of four or more letters. In addition to catalogs, this category includes almanacs, directories, dictionaries, encyclopedias, gazetteers, handbooks and similar publications.

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Clinical features include: perineal quit smoking 4th week buy nicotinell 17.5 mg cheap, sacral or suprapubic pain dysuria and frequency varying degrees of obstructive symptoms which may lead to quit smoking 003 order nicotinell 35 mg amex urinary retention sometimes fever acutely tender prostate on rectal examination the condition may be chronic quit smoking 6 month benefits generic 17.5mg nicotinell otc, bacterial or non-bacterial quit smoking on your own order nicotinell 35mg with visa, the latter usually being assessed when there is failure to respond to antibiotics. Urinary retention with a distended bladder may be present in the absence of severe symptoms, therefore it is important to palpate for an enlarged bladder during examination. For patients presenting with urinary retention, insert a urethral catheter as a temporary measure while patient is transferred to hospital Remove drugs that prevent urinary outflow. As the axial skeleton is the most common site of metastases, patients may present with back pain or pathological fractures. Referral All patients with suspected cancer (For more detail refer to the Malignant diseases section) 2. It is important, however, to differentiate between nocturnal enuresis and enuresis during daytime with associated bladder dysfunction. Secondary causes of enuresis include: diabetes mellitus urinary tract infection physical or emotional trauma Note: Clinical evaluation should attempt to exclude the above conditions. Referral Suspected underlying systemic illness or chronic kidney disease Persistent enuresis in a child 8 years or older Diurnal enuresis 2. Organic causes include neurogenic, vasculogenic, endocrinological as well as many systemic diseases and medications. General measures Thorough medical and psychosexual history Physical examination should rule out gynaecomastia, testicular atrophy or penile abnormalities. Clinical features of obstructing urinary stones may include: Sudden onset of acute colic, localized to the flank, causing the patient to move constantly. Investigation: Examine the pinna; using an otoscope carefully examine the external auditory canal and the tympanic membrane 175 P a g e I. Acute suppurative otitis media It is acute purulent exudates in the middle ear cavity with an ear discharge (perforated tympanic membrane) of not more than 12 weeks duration Diagnosis Discharge of pus from ear Perforated tympanic membrane Treatment of Acute otitis media & acute suppurative otitis media Acute otitis media should be treated with analgesics, antibiotics and/or paracentesis. Culture of a discharge (if any) could be of a great help to identify the causative bacteria. Foul smelling ear discharge Mastoiditis "Ear Children" Otitis in the normal (or better hearing) ear combined with permanent hearing loss in the other ear. Mastoiditis with subperiosteal abcess It is due to infection of the mastoid air cells in the middle ear, a complication of otitis media. Secretory otitis media It is a multifactorial non-purulent inflammatory condition in the middle ear with serous or mucous discharge. Diagnosis Little or no pain Gradual loss of hearing No ear discharge often discovered by chance Treatment Close follow-up Nasal drops, oral decongestants and antihistamines have no demons ratable effect on this condition Secretory otitis with hearing loss that does not improve should be referred to a specialist 2. Acute sinusitis starts with obstruction of the sinus ostium due to mucosal edema from a viral infection, followed by reduced sinus ventilation, retention of mucous in the sinus and bacterial multiplication. The bacteria most often causing purulent sinusitis are pneumococci and Haemophilus influenzae which in some studies are shown to be equally common. Total 400 micrograms (8 sprays) daily; when symptoms controlled, dose reduced to 50 micrograms (1 spray) into each nostril twice daily Oral drugs to reduce swelling of the mucous membrane, antihistamines and antibiotics are not indicated. Erythromycin etc) are not suitable because of poor effect on Haemophilus influenza. Treatment duration of less than 2 weeks will result in treatment failure Referral to specialist Children with ethmoiditis presenting as an acute periorbital inflammation or orbital cellulitis must be hospitalized immediately Adults with treatment failure and pronounced symptoms If sinusitis of dental origin is suspected Recurrent sinusitis (>3 attacks in a year) or chronic sinusitis (duration of illness of >12 weeks) 2. Antibiotics can hinder the spread of infection and reduce the risk of complications. Shorter treatment involves increased risk of therapy failure Refer the patient to the specialist with tonsillitis if Chronic tonsillitis Recurrent tonsillitis (>3 attacks in a year or 5 or more attacks in 2 years) Obstructive tonsillitis (causing an upper airway obstruction) 4. Etiological agents include viruses (for acute laryngitis), bacteria, fungi, laryngeal reflux disease, thermal injuries, cigarette smoking, trauma (vocal cord abuse), and granulomatous conditions (for chronic laryngitis). The picture of the disease is different in children and adults due to the small size of the larynx in children. Acute subglottic laryngitis (pseudocroup) occurs mainly in children under the age of seven, it is a viral infection. Edema of the mucous membrane of the subglottic space causes breathing difficulties, especially on inspiration. Put the patient in a sitting position, put on a gown, glasses, and head light, sterile gloves. Remove a foreign body; cauterize septal varisces using a silverex stick 182 P a g e If the patient is still bleeding do an anterior nasal packing by introducing as far posterior as possible sterile vaseline gauzes (or iodine soaked gauzes if not available) using a dissecting forcep (if bayonet forcep is not available). Put dry gauze on the nose to prevent necrosis and fix the catheter on the nose with an umbilical clamp. Put the patient on oral antibiotics (Amoxycillin 500mg 8 hourly for 5 days), analgesics (Paracetamol 1g 8 hourly for 5 days) and trenaxamic acid 500mg 8 hourly for 3 days. Put an ice cube on the forehead, extending the neck or placing a cotton bud soaked with adrenaline in the vestibule will not help Referral If the patient is still bleeding repack and refer immediately Failure to manage the underlying cause, refer the patient 8. In a simpler way, it is when some one fails to count fingers at a distance of 3 meters in the eye that is considered good with the best available corrective/distance spectacles. The definition is the same to children and infants though there are different methods for testing vision in young children until when they are at pre school age when normal visual acuity chart can be used. The common causes of blindness are Cataract, Glaucoma, Trachoma, and Vitamin A Deficiency, Diseases of the Retina, uncorrected Refractive Errors and Low Vision.

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She has had no chest pain quit smoking encouragement generic nicotinell 17.5mg with amex, palpitations quit smoking 17 days cheap nicotinell 17.5mg otc, orthopnea quit smoking 24 hours buy 52.5 mg nicotinell amex, or paroxysmal nocturnal dyspnea quit smoking 2 12 years discount nicotinell 17.5mg amex. Breath sounds are decreased, and faint expiratory wheezes are heard in all lung fields. A 22-year-old woman comes to the physician because of a 10-day history of pain in multiple joints. She first had pain in her right elbow, and then her right shoulder, and now has pain, redness, and swelling in her left knee that began 2 days ago. She is sexually active, and she and her partner use condoms for contraception inconsistently. Examination of the left knee shows warmth, erythema, tenderness, and soft-tissue swelling. The remainder of the examination, including pelvic examination, shows no abnormalities. Arthrocentesis of the knee joint yields 10 mL of cloudy fluid with a leukocyte count of 18,300/mm3 (97% segmented neutrophils). Microscopic examination of the leukocytes within the joint fluid is most likely to show which of the following A 47-year-old woman comes to the physician for a routine health maintenance examination. The most appropriate recommendation is decreased intake of which of the following A 32-year-old man comes to the physician because of a 12-day history of abdominal cramps and bloating, diarrhea, and flatulence. He says that he started a new exercise program 2 weeks ago and has been consuming a high quantity of yogurt bars, peanut butter, and protein- and calorie-enriched milk shakes to "bulk up. A 22-year-old college student comes to student health services because of a 7-day history of low-grade fever, sore throat, fatigue, and general malaise. One month ago, she had a painless vulvar ulcer that resolved spontaneously; she has been otherwise healthy. She is sexually active and has had three partners since the age of 15 years; she uses an oral contraceptive. Examination shows a rash over the palms and soles and mild cervical lymphadenopathy. A 57-year-old woman comes to the physician 1 week after noticing a mass in her left breast during breast self-examination. She was receiving estrogen therapy but discontinued it 6 weeks ago; she has had no menopausal symptoms. Examination shows a 2-cm, palpable, nontender, mobile mass in the upper outer quadrant of the left breast; no nipple discharge can be expressed. A 27-year-old nulligravid woman has had severe pain with menses that has caused her to miss at least 2 days of work during each menstrual cycle for the past year. A 22-year-old woman comes to the physician because of a 2-day history of pain with urination, intense vaginal itching, and a thick discharge. Genitourinary examination shows erythema of the vulva and vagina with an odorless curd-like discharge. A 27-year-old nulligravid woman and her husband have been unable to conceive for 12 months. She had a single episode of pelvic inflammatory disease 4 years ago and was treated with oral antibiotics. A 42-year-old woman, gravida 2, para 2, comes to the physician because of increasingly frequent loss of urine during the past year. She has loss of urine when she coughs, sneezes, exercises, or plays with her children. Her incontinence is never preceded by a sudden urge to void, and she does not have loss of urine at night. During a routine examination, a 25-year-old woman expresses concern about her risk for ovarian cancer because her mother died of the disease. At her 6-week postpartum visit, an 18-year-old woman, gravida 1, para 1, tells her physician that she has a pinkish vaginal discharge that has persisted since her delivery, although it is decreasing in amount. On physical examination, the uterus is fully involuted and there are no adnexal masses. A 32-year-old nulligravid woman comes to the physician because of a 6-week history of persistent foul-smelling vaginal discharge and vaginal itching. Her symptoms have not improved despite 2 weeks of treatment with over-the-counter antifungal medications and fluconazole. She has been sexually active and monogamous with her boyfriend during the past year, and they use condoms consistently. A wet mount preparation of the discharge shows numerous multi-flagellated organisms the size of erythrocytes. The S 2 varies with inspiration, and the pulmonic component is soft; diastole is clear. A 42-year-old woman, gravida 3, para 3, comes to the physician because she has not had a menstrual period for 2 months.

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