Excelsior College. T. Cronos, MD: "Order Azathioprine online - Cheap online Azathioprine no RX".
To help identify management and disease-related Has the bird had other medical problems? Anamnesis What potential aerosols is the bird exposed to (household chemicals purchase azathioprine 50 mg visa spasms in abdomen, disinfectants purchase azathioprine us muscle relaxant medication prescription, hair sprays)? Have any changes recently occurred in the home (new en- closure generic azathioprine 50 mg with amex muscle relaxant gi tract, different diet generic azathioprine 50mg without prescription spasms coughing, painted house, changed carpet, Clinically evaluating an avian patient involves com- moved to a new location, new pet or strange people in the bining information collected from the history, physi- house, moved bird to a new location in the house)? Recently obtained birds (within the last year) are Developing the Anamnesis more likely to be suffering from problems associated with infectious disease or stress, while long-term When and where was the bird obtained? Birds pets are more likely to have problems with malnutri- obtained from traveling dealers are frequently ex- tion or chronic systemic diseases. New birds can invariably be izing in domestically raised hand-fed chicks, which a source for previously unencountered pathogens. A generally have fewer medical problems and make bird obtained from a breeder whose flock is closed to much better companions than their wild-caught con- new birds and is constantly being monitored for sub- specifics (see Chapter 30). Frequent exposure to fresh air and sunlight is important for a bird’s overall health. Medical prob- lems are more common in birds that are restricted to indoor environments. Drafts have no effect on healthy birds that are acclimated to normal tempera- ture fluctuations. Determining if the indoor envi- provide valuable information about the condition of an avian ronment is contaminated with toxins can help with patient. In this Canary-winged Parakeet, the abnormal white-col- an immediate diagnosis and guide suggested ored feathers, abundance of pin feathers, overgrown nails and hyperkeratotic rhamphotheca were caused by an inadequate diet changes to prevent future problems. Commonly encoun- chlamydia), is less likely to have an infectious dis- tered, but infrequently discussed, toxins that could ease than a bird obtained from a source that mixes have a dramatic effect on the health of a bird include birds from different locations (eg, substandard pet cigarette smoke, fumes from disinfectants (eg, Clo- retailers, brokers, bird shows, quarantine stations). Discussion of a bird’s previous medical prob- Has there been a change in food or water con- lems, and how they were diagnosed and treated, may sumption? Subtle increases or decreases in food or provide important information to the clinician. It is referral cases, all available records should be care- important to distinguish between the food offered to fully reviewed. Young immune system and encouraging the proliferation of birds are more susceptible to malnutrition and will secondary bacterial or fungal pathogens. Knowing develop acute signs of disease, while mature birds which antibiotics have been administered will influ- are more likely to suffer from chronic malnutrition. Unfortunately, Changes in behavior that should be noted include many of these birds will be switched by the new excessive sleeping, resting in a fluffed condition and owners to a seed-based diet, which induces obvious a decrease in talking, singing or playing. Personality changes, including pets or family members are ill, the clinician should increased aggression, screaming, intolerance of consider a common etiologic agent (infectious disease strangers or biting the enclosure or toys also may or exposure to an environmental toxin). To overcome this problem, the crouched copulatory stance and masturbatory ac- examination room should be free of extraneous tions with certain family members, toys, mirrors, noises and interruptions, and a bird should be accli- other animals or inanimate objects are suggestive of mated to the examination room for five to ten min- breeding behavior. Reproductively active cocka- ity level of the bird should be determined while it toos, especially Umbrella Cockatoos, may pant rap- remains securely within its enclosure. Some birds, especially the observed at a distance are more likely to feel un- larger macaws, may incubate balls or other round threatened and exhibit changes associated with leth- objects and will defend stuffed toys as if they were argy and depression (Color 8. Single cockatiel hens can lay 20 to 40 eggs a birds can best be initially viewed from a distance year for several years then gradually reduce, and with the aid of binoculars. These birds may continue to Observational clues that a patient is seriously ill go through the behavioral motions of egg laying and include ruffling of feathers, partially closed eyes, develop egg-related peritonitis (eg, depression, ano- frequent blinking, tucking the head under a wing, rexia, swollen abdomen) weeks to months after ceas- labored breathing, sitting on the bottom of the enclo- ing oviposition. Birds that are stressed may shiver, causing a rapid movement of the body feathers. A bird that is de- pressed and lethargic will respond poorly to external Physical Examination stimuli when disturbed and then return to a calm, detached state (Color 8. Abnormalities in body function may include lame- The physical examination can be viewed as a three- ness, wing droop, standing on one leg, shifting weight part process: observing a bird’s response to its envi- from one leg to another, resting on the sternum or ronment, examining the bird’s environment and sys- standing on the metatarsus rather than the foot. A bird that is hot or excited A mental picture of a free-ranging bird (slick, solidly may hold the wings out from the body, yet still in a colored feathers; clear, dry skin; bright inquisitive symmetrical position. One drooping wing is an indi- attitude) should serve as a comparative model for cation of an abnormality (eg, fracture, arthritis, ten- evaluating the condition of avian patients (Color 8. Small birds have higher respira- Evaluating the Bird in its Environment tory rates; large birds have lower respiratory rates. Some avian species (notably Amazon parrots and Birds that are stressed will frequently alter their Pionus spp. This physiologic response should not be misinterpreted as is particularly true while a patient is in the examina- disease-induced dyspnea. A bird that the client signs are best detected while the bird is in its enclo- describes as listless at home may appear bright, alert sure. Except in pied and pearl mutations, males over Weight (Rest) (Restraint) (Rest) (Restraint) one year of age lose these horizontal bars, while 25 g 274 400-600 60-70 80-120 females do not. In pieds, some or all of the gray 100 g 206 500-600 40-52 60-80 feathers are white. Pearls will have a splotched, 200 g 178 300-500 35-50 55-65 repeated pattern of interspaced grey and white feath- 300 g 163 250-400 30-45 50-60 ers. This pearl pattern is retained in the adult female 400 g 154 200-350 25-30 40-60 and lost in the adult male. A lutino is characterized 500 g 147 160-300 20-30 30-50 by the replacement of gray feathers with white feath- 1000 g 127 150-350 15-20 25-40 ers that contain various shades of yellow. Hepatitis, 1500 g 117 120-200 20-32 25-30 chlamydiosis or heredity should be considered in 2000 g 110 110-175 19-28 20-30 cockatiels that are dark yellow (Color 8. A young 5000 g 91 105-160 18-25 20-30 pied has stripes in the central tail feathers, which are 10 kg 79 100-150 17-25 20-30 retained in the mature female but replaced with 100 kg 49 90-120 15-20 15-30 solid-colored central tail feathers in the mature male. In these birds, endoscopic breathing, neck stretching, yawning, extending the or genetic testing for gender is required. The male tends to have Dyspnea associated with the upper respiratory tract a “halo” or lighter colored ring around the nares. As or lungs is frequently accompanied by open-mouthed the male matures, the cere turns from light pink to breathing. Sexually maturing females develop a brown lems are usually associated with a rhythmic jerking cere. The color varieties with excessive fluid production may cause gurgling are more difficult to visually sex. Behavior can Dyspnea induced by protracted respiratory disease is indicate gender in some species. For example, male usually associated with other clinical signs including finches tend to sing and perform a mating ritual weight loss, depression, ocular or nasal discharge, dance when stimulated by a receptive hen. Acute dyspnea in an appar- ently healthy bird usually results from exposure to Important genetic information can be obtained by de- aerosolized toxins, dislocation and movement of tra- termining the phenotype of a bird. For example, a blue cheal plaques (from malnutrition or infectious budgerigar (or any color other than wild-type green) agents) or aspiration of foreign bodies (particularly would clinically be expected to have a substantially seed husks or enclosure substrates).
Calcium absorption from the intestinal tract A benign or malignant tumor of chromaffin tissue is reduced after administration of betamethasone may cause hypersecretion of epinephrine or no- and cortisol discount azathioprine 50 mg on line spasms baby. Corticosterone increases the glomerular repinephrine purchase azathioprine with a visa muscle relaxant end of life, which in man is known to lead to hy- filtration rate which purchase cheapest azathioprine muscle relaxant 2631, together with glucosuria quality azathioprine 50 mg spasms just under rib cage, may pertension and associated symptoms such as profuse be recognized as polyuria and polydipsia. A pheochromocy- toma of the adrenal gland in a 14-week-old broiler Iatrogenic Secondary Hypoadrenocorticism 15 pullet has been reported. Glucocorticoids exert a negative feedback influence The only obvious abnormality was an enlarged left at the hypothalamo-hypophyseal level and suppress adrenal gland measuring 15 mm in diameter. Fail- ure of the adrenal gland to respond to stress factors may result in adrenocortical insufficiency. Many stressors are known to induce corticosterone secre- tion in birds: extreme environmental temperatures, Endocrine Control handling, immobilization, anesthesia, infection, frus- tration, fear, housing, noise, food and water depriva- of Feather Formation tion and hypovitaminosis A. Adrenocortical failure and shock may occur in birds exposed to one or more stressful situation following iatrogenic glucocorticoid administration. Exposure to high doses over a pro- turbances in feather formation of unknown etiology. Replacement therapy is indicated in length, which controls the neurohumoral factors. Neural control of feather formation has been demon- strated by growth retardation of feathers when de- Stress Marks nervation occurs. The metabolic processes that un- A common disorder of developing feathers is the sym- derlie feather formation are regulated by the thyroid metrical development of stress marks or hunger and the gonads. The presence of thyroid hormone, however, is essential for the growth, differ- In some birds (eg, Galliformes, Passeriformes, An- entiation of structure and formation of feather pat- seriformes), feather color and pattern vary with the tern. The importance of thyroid hormone for feather age, gender and season, and these characteristics are formation is generally similar in young and mature governed by hormonal influences of the gonads. In some birds, this thyroid dependence affects these birds, the adult plumage, unlike the juvenile the rate of feather growth and formation of vane plumage, develops under the influence of at least two structure and in others, it affects the pigmentation endocrine glands. In these birds the plumage does not change under influence of In thyroidectomized birds, the lower parts of the plasma concentrations of sex hormones but is gov- feather are underdeveloped, while in hyperthyroid- erned by the autosome: sex chromosome ratio and ism, these parts develop most vigorously. The roidism, the vanes of the feathers are narrower and influence of sex hormone in the former group in each there is a partial reduction of the barbs. In a number feather-forming process is realized only at a defini- of fowl breeds, hypothyroidism is accompanied by tive level of metabolism that is maintained by thy- partial or complete replacement of black eumelanin roid hormone (female plumage does not develop in by brown pheomelanin, while in hyperthyroidism thyroidectomized birds given estrogen). The black pig- bird is adequately saturated with thyroid and sex ment can be formed in the bird’s body at only a hormones, the feathers that develop should be certain concentration of thyroid hormone. Under conditions of hypothyroidism or athyreosis, the feathers that de- Molting is possible only as the result of complex velop are uniform in structure and should be termed hormonal influences. Molting occurs during a period the athyreoid type of plumage (and consequently also of depressed sexual activity. The male plumage is potentially an attribute of both genders, and the female hormones play the principal When the duration of light is decreased, or a long role in gender differences in the plumage of Gallifor- period of artificial daylight is suddenly replaced by a mes and Anseriformes. When a rooster, drake or cock short one, sexual activity declines or ceases and molt- pheasant is castrated, no changes are produced in the ing begins. When a ods of daily light associated with declining sexual castrated rooster or a neutered hen undergoes an activity are needed for the proliferation of feather ovarian transplant, female-type plumage develops. Sudden transi- tion to darkness after prolonged exposure to length- ened periods of daily light produces vigorous molting in various birds. It should be remembered that many avian species Diabetes Mellitus must be exposed to natural photoperiods to allow a normal hypothalamic-pituitary control of the molt- ing process. Improper photoperiods may be an impor- Spontaneous diabetes mellitus has been reported in tant cause of feathering disorders in companion birds a variety of granivorous avian species, including the kept indoors. One case of spontaneous diabetes ment requires that appropriate nutrients for feather 103 mellitus has been reported in a raptor. A tentative diagno- body’s increased requirements of thyroid hormone in sis can be made by demonstrating glucosuria while a connection with the development of new feathers. Glucocorticoids, epinephrine, There are some striking differences between birds glucagon and growth hormone can all induce hyper- and mammals with respect to pancreatic control of glycemia and impaired glucose tolerance. The insulin content of the duction of these hormones may occur with tumors of pancreas of granivorous birds is about one-sixth that the hormone-producing cells or paraneoplastic syn- of mammalian pancreata, while the glucagon content dromes (“ectopic” hormone production). Circulating plasma concentrations of glucagon are 10 to 50 times higher In man, hyperglucagonemia may be associated with in birds than in mammals. In mammals, pancreatec- bacterial infections, trauma, congestive heart fail- tomy results in diabetes mellitus. Reported effects of ure, azotemia and functioning tumors of the α-cells pancreatectomy in birds are controversial. However, of the islets of the pancreas or of the gastrointestinal recent experiments performed on granivorous birds tract (eg, glucagonoma). The few reported pancreatec- secondary invasion usually via serosal implantation tomies performed on carnivorous birds have always on the duodenal loop of tumors arising in the female reproductive tract. The limited data available on was identified as an α-cell adenoma has been de- spontaneous diabetes mellitus in granivorous birds scribed. The cellular There are several case reports of successful treat- origin of the tumor was not identified, but it was ment of spontaneous diabetes mellitus in birds with suggested that it could be an α-cell tumor. Glucagon concentrations on the The normal avian pancreas contains extremely high other hand were extremely high or extremely low. Neoplasms associated with this syn- may have previously laid eggs and then stopped be- drome include lung carcinoma (oat cell and small cause of the egg-related peritonitis. Numerous cases suggest that any carci- noma may induce an ectopic endocrine syndrome. Experimental administration of pro- raptorial bird was associated with markedly vacuo- lactin to Mallard Ducks results in a decreased urine lated B-cells indicative of excessive stimulation. In chickens, an increase in plasma pro- Further findings were four fluid-filled cysts on the lactin concentrations has been observed after infu- kidneys and mildly enlarged adrenals. The liver had variable-sized, randomly scat- When water intake is restricted in these birds, the tered foci of lipidosis. A water deprivation Apparent psychogenic poly- pigeons) test may be useful in documenting a primary polydip- dipsia Liver disease sia or compulsive water drinking. In these patients, Medications (corticos- Renal disease water restriction results in disappearance of the teroids, diuretics, progester- (Hypercalcemia? Glucosuria is not always associated with hyperglyce- The pathophysiologic mechanism for these clinical mia, and the two should occur together to warrant a changes has not been defined. Glucosuria without hyperglycemia in man is associated with the Fanconi syndrome, which is caused by inherited or acquired Products Mentioned in the Text damage to the proximal convoluted tubules of the 105 a. New York, Harper and Row, tion to Molecular and Cellular Princi- terone to chickens. J Pathol & Bact 92:77-90, therapy: Mechanisms of action and heiten [Avian Diseases]. Philadelphia, the excretion of oocysts on normal rhythm of corticosterone in laying and immunosuppressed racing pi- hens and the influence of egg laying. New York, to total protein and albumin in Afri- Van de Water D: Normal thyroid val- and young chickens (Gallus domesti- Springer Verlag, 1986, pp 303-325; can grey (Psittacus erithacus) and ues for common pet birds. Thesis, Rotterdam, Erasmus function in the mallard (Anas geons (Columba livia domestica).
Funding will be contingent upon the resident being in good standing by the Program Director buy azathioprine in india muscle relaxer 86 62. If the resident is on a rotation that requires resident service purchase 50 mg azathioprine otc spasms around the heart, it is the responsibility of the resident to find coverage for the service (as approved by the Chief Residents and Program Director) trusted 50mg azathioprine spasms throughout my body. In such cases order generic azathioprine online spasms on right side, the strength of the scientific project will be reviewed by the Department of Pathology Research Committee or Resident Education Committee and final approval will be determined by the Department Chair based upon availability of funds. Resident Educational Funds Each academic year each resident will be allocated $750 for educational development. Additionally, these funds may be applied to cover expenses related to attending pre- approved medical conferences and workshops. American Board of Pathology application fees and permanent license fees are not covered. Funding will be contingent upon the resident being in good standing (including adequate conference attendance) as deemed by the Program Director. During the year that a resident serves as Chief Resident, the allocation is increased to $1,250. Funding will also be provided for travel expense, lodging, food, and meeting registration, not to exceed $1,200 (receipts are required for reimbursement) for each resident to attend a board review course during either the third or fourth year of the residency program. Such residents may petition the residency education committee for consideration of extension of contract to allow them time to take the examination again. Initial Application Screening The initial screening of applicants is done by the residency program coordinator or program directors. If greater than 10 years, the type of work the candidate has been engaged in since graduation from medical school is noted. Experience, either by education or work experience, in the field of pathology is noted. The program directors read the applicant’s personal statement and evaluate it based on the following: • Command of the English language • Stated genuine interest in Pathology • Overall quality of the statement • Dean’s Letter • Medical Transcripts • Letters of reference • Any potential items for concern Additional Screening If the program director is unable after the secondary screening to make a decision on whether or not to invite a candidate, the application will be sent to one of the other program director or another member of the Resident Education Committee for their review. After receiving feedback from the committee reviewer, the program director will decide whether or not to extend an invitation to the candidate. Each candidate that is selected for interview will be invited via email by the residency program coordinator. Once the applicant is schedule, they will be sent an email with an interview confirmation and instructions for the interview day. Interview Process Six to 8 interview dates are selected and up to 8 candidates may be interviewed per interview day. At the beginning of each interview day an overview of the institution and program is presented. Five faculty members, including the two program directors and one chief resident interview the applicants. Each interviewer is given all application materials for each applicant to be interviewed in their scheduled day. Each interviewer is asked to complete a resident candidate evaluation form and also an individual ranking Pathology Resident Manual Page 20 form for each candidate they interview. Interviewers are asked to assign them a quartile based on every applicant they have ever interviewed. In February an annual ranking meeting is held with all faculty and resident interviewers and any other faculty who wish to attend. After initial grouping into ‘Upper, Middle, or Lower Thirds’, the final rank list determined by the committee. A list of faculty members who will evaluate residents on each rotation has been developed and a tracking mechanism is used to insure that all evaluations have been obtained. Resident evaluations are reviewed by the Program Director and are summarized for the Resident Education Committee Meeting and at least annually at a meeting attended by all clinical faculty members. If a problem with performance is identified for any resident, the Program Director or designee immediately meets with the resident to discuss the issues and develop a plan of action. If there are no problems with the performance, the residents review and sign their evaluations at the time of evaluation release or at the six- month review meeting with the Program Director. Clinical faculty members meet at the end of the academic year to decide on promotion for each resident. All evaluations, performance on exams, attendance at conferences and overall performance are discussed with each resident at the 6-month evaluation meetings with the Program Director. At that time, residents are asked to write a self-assessment and goals for the following 6 months. Each resident is asked at every 6 month evaluation to provide suggestions for program improvement. The Program Director completes a summative evaluation for each resident finishing the program. The final evaluation summarizes all aspects of the resident’s education and training, verifies that the resident is competent in the six general competencies and confirms that the resident has the ability to practice without direct supervision. Pathology Resident Manual Page 21 Faculty Evaluations Near the end of each month each resident receives electronically a rotation and a faculty evaluation form. If problems are identified, they are discussed immediately with the appropriate faculty member. Faculty members are given an overall assessment including the following: • clinical teaching • commitment to educational program • clinical knowledge • professionalism • scholarly activity The annual assessment is signed by the Department Chair and a copy is sent to the faculty member. Program Evaluations A formal resident training quality improvement program addresses individual resident performance improvement, faculty development and overall training program improvement as described below. Overall Goals of Resident Training Quality Improvement Program The Pathology Resident Training Quality Improvement Program provides a process for individual resident performance improvement as well as overall program improvement. Measurement tools are used to identify individual residents in need of remediation early in the program. A general remediation program has been developed and is tailored for the individual needs of each resident. In addition, several measurement tools are used to monitor and identify areas of potential improvement within the overall training program. The Resident Education Committee, consisting of six faculty members, the two Chief Residents, and the Program Director, is responsible for ensuring the quality of resident education in Anatomic and Clinical Pathology. Failure to attend at the required level is considered a problem with competency in professionalism. Specific areas of weakness identified by any of the above performance tools may result in repeating a rotation. More global unsatisfactory performance areas may result in placement on remediation. Examples of quality monitors and outcome measurement tools used to evaluate the quality of the training program include the following: • American Board of Pathology Specialty Exam – Outcome data over a 5 year period for different areas of pathology broken down into different areas of pathology are provided to the program annually. For each category the board reports if residents from the individual program performed in the upper, middle or lower third compared to all residents taking the boards.
Incisions These wounds are caused by sharp cutting implements generic azathioprine 50 mg on-line kidney spasms after stent removal, usually bladed weapons buy azathioprine in united states online spasms from dehydration, such as knives and razors azathioprine 50 mg sale spasms in spanish, but sharp slivers of glass cheap 50 mg azathioprine visa infantile spasms 4 year old, the sharp edges of tin cans, and sharp tools, such as chisels, may also cause clean-cut incised injuries. Axes, choppers, and other similar instruments, although capable of cutting, usually cause lacerations because the injury caused by the size of the instrument (e. Mixed wounds are common, with some incised element, some laceration, bruising, and swelling and abrasion also present. Machetes and other large-blade implements are being used, pro- ducing large deep cuts known as slash or chop injuries. They Injury Assessment 141 gape, and the deeper tissues are all cut cleanly in the same plane. If the blade of the weapon is drawn across the skin while it is lax, it may cause a notched wound if the skin creases. The direction of travel of the blade of the weapon is not always easy to decide, but usually the deeper part of the wound is near the end that was inflicted first, the weapon tending to be drawn away toward the end of the wound. In an attempt to ward off the assailant, the arms are often raised in a protective gesture and incisions are then often seen on the ulnar borders of the forearms. If the blade of the weapon is grasped, then incised wounds are apparent on the palmar surfaces of the fingers. Incised wounds may be a feature of suicide or attempted suicide (see Subheading 3. They are usually located on the wrists, forearms, or neck, although other accessible areas on the front of the body may be chosen. The incisions usually take the form of multiple parallel wounds, most of them being tentative and superficial; some may be little more than simple linear abrasions. Stab Wounds Stab wounds are caused by sharp or pointed implements and wounds with a depth greater than their width or length. They are usually caused by knives but can also be inflicted with screwdrivers, pokers, scissors, etc. Although the external injury may not appear to be particularly serious, damage to vital struc- tures, such as the heart, liver, or major blood vessels, can lead to considerable morbidity and death, usually from hemorrhage. In those individuals who survive, it is common for little information to be present about the forensic description of the wound because the priority of resuscitation may mean that no record is made. If operative intervention is undertaken, the forensic signifi- cance of a wound may be obliterated by suturing it or using the wound as the entry for an exploratory operation. In such cases, it is appropriate to attempt to get a forensic physician to assess the wound in theatre or subsequently. Stab wounds are rarely accidental and occasionally suicidal, but usually their infliction is a result of criminal intent. In the case of suicide, the wounds are usually located on the front of the chest or upper abdomen and, as with self- inflicted incisions, may be associated with several superficial tentative punc- ture wounds (see Subheading 3. When deliberately inflicted by an assailant, stab wounds may be associated with defense injuries to the arms and hands. The appearance of the skin wound will vary depending on the weapon used and can easily be distorted by movement of the surrounding skin. If the blade is double- edged, such as that of a dagger, the extremities of the wound tend to be equally pointed. A stab wound from a single-edged blade, such as a kitchen knife, will usually have one extremity rounded, squared-off, or fish-tailed (caused by the noncutting back of the blade). When blunt weapons are used—a pair of scissors, for example—the wound tends to be more rounded or oval, with bruising of its margins (see Fig. Scissor wounds can sometimes have a cross-shape caused by the blade screws or rivets. Notched wounds are often caused by the blade of the weapon being partially withdrawn and then rein- troduced into the wound or twisted during penetration. It is rarely possible from an inspection of the skin wound alone to com- ment usefully on the width of the blade because the skin retracts and the knife is unlikely to have been introduced and removed perfectly perpendicularly. Deliberate Self-Harm Deliberate self-harm refers to any attempt by an individual to harm him- self or herself. When assessing injuries, it is important to understand which factors may indicate the possibility that an injury was caused by deliberate Injury Assessment 143 Table 4 Indicators of Possible Deliberate Self-Harm Injuries • Must be on an area of body accessible to the person to injure themselves. Individuals injure themselves for numerous reasons, including psy- chiatric illness and others, such as attempting to imply events took place that did not or for motives of gain. Self-inflicted injuries have several characteris- tics, which are not diagnostic but that together may give an indication of self- infliction. Table 4 lists features that may assist in the recognition or suspicion that cuts or other injury, such as scratches, are self-inflicted—all or some may be present—their absence does not preclude self-infliction nor does their pres- ence necessarily imply self-infliction (2). As with all injuries within the forensic setting it is essential in these nonfatal cases that the initial appear- ances of the injuries be accurately described and the wounds photographed. This is particularly important because subsequent surgical treatment may dis- tort or completely obliterate the wound characteristics. Furthermore, any frag- ments, bullets, or pellets found within the wounds must be carefully removed and handed over to the appropriate authorities. Smooth-Bore Weapons Shotguns, which fire a large number of small projectiles, such as lead shot, are the most common type of smooth-bore weapons. They are commonly used in sporting and agricultural activities and may be either single or double- barreled. The ammunition for these weapons consists of a plastic or cardboard cartridge case with a brass base containing a percussion cap. Inside the main part of the cartridge is a layer of propellant, plastic, felt, or cardboard wads and a mass of pellets (lead shot of variable size) (see Fig. In addition to the pellets, the wads and/or cards may contribute to the appearance of the wounds and may be important in estimating range and possible direction. Rifled Weapons Rifled weapons are characterized by having parallel spiral projecting ridges (or lands) extending down the interior of the barrel from the breach to the muzzle. The rifling also leaves characteristic scratches and rifling marks that are unique to that weapon on the bullet surface. There are three common types of rifled weapons: the revolver, the pistol, and the rifle. The Injury Assessment 145 revolver, which tends to have a low muzzle velocity of 150 m/s, is a short- barreled weapon with its ammunition held in a metal drum, which rotates each time the trigger is released. In the self-loading pistol, often called “semi-automatic” or erroneously “automatic,” the ammunition is held in a metal clip-type maga- zine under the breach. Each time the trigger is pulled, the bullet in the breach is fired, the spent cartridge case is ejected from the weapon, and a spring mecha- nism pushes up the next live bullet into the breach ready to be fired. The rifle is a long-barreled shoulder weapon capable of firing bullets with velocities up to 1500 m/s. Most military rifles are “automatic,” allowing the weapon to continue to fire while the trigger is depressed until the magazine is empty; thus, they are capable of discharging multiple rounds within seconds. Shotgun Wounds When a shotgun is discharged, the lead shot emerges from the muzzle as a solid mass and then progressively diverges in a cone shape as the distance from the weapon increases. The pellets are often accompanied by particles of unburned powder, flame, smoke, gases, wads, and cards, which may all affect the appearance of the entrance wound and are dependent on the range of fire.
Buy azathioprine us. Pharmacology - Tramadol & Flexeril Drug Interaction.