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, swelling, 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 aspirated for culture and a search for urate crystals. Diagnostic Test The gold standard diagnostic test for gout is an arthrocentesis. The American College of Rheumatology has established 12 clinical criteria, 6 of which a patient must have for diagnosis. * Maximum joint inflammation within 1 day * More than one attack over time * Monoarticular arthritis (although gout can be polyarticular) * Redness of joint * Great metatarsophalangeal pain or swelling * Unilateral great metatarsophalangeal involvement * Unilateral tarsal involvement * Suspected tophus * Hyperuricemia * Asymmetrical swelling within the joint on x-ray * Subcortical cysts without erosion on x-ray * Joint fluid culture negative for organisms during attack Treatment and Management The gold of treating gout is to minimize or eliminate the urate crystals from the joints and other structures associated with them. Several aspects must be taken into consideration and each treatment regiment is varied from patients to patients. The three main objectives that FNP take into consideration are treatment for the acute attacks, prophylaxis against recurrent attacks, and management of hyperurecemia. Asymptomatic hyperurecemia: urate-lowering drugs is not recommended to treat patients with asymptomatic hyperurecemia. If hyperurecemia is identified, underlying causes such as obesity, hypercholesterolemia, alcohol consumption, and hypertension should be addressed. Acute gout: NSAIDs are being used as first-line therapy. Indomethacin (Indocin), ibuprofen (Motrin), naproxen (Naprosyn), sulindac (Clinoril), piroxicam (Feldene) are also effective against gout. Corticosteroids: intra-articular, intravenous, intramuscular or oral corticosteroids are effective in acute gout. When one or two joints are involved, intra-articular injection of corticosteroid can be used. Intramuscular triamcinolone acetonide is as effective as indomethacin in relieving acute gouty arthritis. Triamcinolone acetonide is especially useful in patients with contraindication to NSAIDs. Oral prednisone: is an option when repeat dosing is anticipate. Prenisone, 0.5 mg per kg on day 1 and tapered by 5 mg each day is effective. Cochicine is also effective treatment for acute gout. However, majority of patients experience gastrointestinal side effects, including nausea, vomiting, and diarrhea. Patient Education If they are obese, they should be advised to begin a concerted program of supervised weight reduction (see Chapter 233), but to avoid starvation or very low calorie diets that may only exacerbate the risk of gout. Drinkers should be warned against binges. Maintenance of good hydration needs to be stressed to those at risk for nephrolithiasis. On the other hand, patients will find it comforting to know that severe dietary restrictions are unnecessary. Fasting should be avoided because it may precipitate an attack. The importance of treating an acute attack at the first sign of illness also needs to be stressed. For the patient with interval gout, a discussion of the risks and benefits of prophylactic therapy and the importance of compliance is indicated. Those taking allopurinol should be warned of the risk of a hypersensitivity reaction and advised to cease intake immediately and call the physician at the first sign of a rash, fever, or other manifestation. Pain management is the pri mary concern during acute phase of and attack. The patient should be advised to take analgesic medications as schedule. The joint should be rested as much as possible in a position of comfort. Ice, not heat, may help with reducing discomfort. Conclusion Gout is one of the most causes of acute monoarticular arthritis. Primary gout runs in families and follows multifactorial inheritance. The expanded use of agents that decrease uric acid excretion has significantly increased the incidence of secondary gout. The Fremingham Study suggested that almost half of new cases were associated with thiazide use. The FNP should be able to properly diagnose acute gout, treat it, prevent recurrence, and minimize the chances for the development of chronic gouty arthritis. Patients who present with asymptomatic hyperuricemia should be further investigated to prevent complications from this disorder.

The Cost of Solar Cells to Harvest Energy Essay -- Power Environment R

Solar Cells - Energy of the Future Solar cells have been around since 1883, when the first solar cell was created. Even though they have been around for so long, many people still wonder why they have not been implemented into wide-scale usage already. Solar cells today are highly efficient and can provide enough energy to power many cities today. But what is holding them back from being used in developing countries that have a chance to base their society around them, or in already developed countries? Simply put- the cost. Before I go in to detail about usage and implementation of solar cells, let me explain just how they work. Solar cells, also known as photovoltaic cells (Photo= light Voltaic=electricity) capture photons, convert them into electrons, and use these electrons to transfer energy to whatever you want to power. To do this, solar cells are made with a material called a semiconductor, which, for solar cells is almost always silicon. When light hits this material, it causes electrons to break loose and flow throughout the material. By placing metal plates on the solar cell, we can capture this flow of electrons, otherwise known as current. Using the equation Power= Volts * Current, you can calculate the voltage output of a cell, which, using silicon, is about 1.1 volts- a 25% or so efficiency. There are currently three types of solar cells- first generation, second generation, and third generation, where each generation aims to address a certain problem with solar cells. First generation cells aim to make as many cells as possible, second generation aim to make highly effective solar panels, and third generation cells try to create the most cost efficient solar panels. In this paper, I will address how and w... ...vernment. Energy Information Administration. Retrieved on 2007-10-02. Government, US. "Government Solar Facts." Multiband Solar Panels. 29 July 2008 . How Stuff Works. "Solar Cells." How Stuff Works. 29 July 2008 . Inc., Energy, comp. "Purchase a Solar Cell." Purchase a Solar Cell Today. 29 July 2008 . Irock23. "Yahoo Answers." Yahoo Answers. 29 July 2008 . James, Stuart. "Http://articles.latimes.com/2007/sep/01/local/me-heat1." La Times 29 July 2008: 15-16. Online, Chemistry, ed. "Solar Powering the World." Solar Energy (Photovoltaic Cells). 29 July 2008 .

The Golden Lily Chapter 5

WORD OF MY UPCOMING DATE spread fast. I could only presume Trey had told Kristin and Julia, who had in turn told Jill and Eddie and God only knew who else†¦. So, I shouldn't have been surprised when I got a call from Adrian just after dinner. He started talking before I could even say hello. â€Å"Really, Sage? A date?† I sighed. â€Å"Yes, Adrian. A date.† â€Å"A real date. Not, like, doing homework together,† he added. â€Å"I mean like where you go out to a movie or something. And a movie that's not part of a school assignment. Or about something boring.† â€Å"A real date.† I figured I wouldn't give him the specifics on the Shakespeare play. â€Å"What's the lucky guy's name?† â€Å"Brayden.† There was a pause. â€Å"Brayden? That's his real name?† â€Å"Why are you asking if everything's real? You think I'd make any of this up?† â€Å"No, no,† Adrian assured me. â€Å"That's what's so unbelievable about it. Is he cute?† I glanced at the clock. It was time for me to meet my study group. â€Å"Gee, maybe I should just send you a picture to review?† â€Å"Yes, please. And a full background check and life history.† â€Å"I have to go. Why do you care so much anyway?† I finally asked in exasperation. His answer took a long time, which was uncharacteristic. Adrian was usually ready with a dozen witty quips. Maybe he couldn't decide which one to use. When he finally responded, it was in that usual sarcastic way of his – though the levity sounded a little forced. â€Å"Because it's one of those things I never expected to see in my lifetime,† he told me. â€Å"Like a comet. Or world peace. I'm just used to you being single.† For some reason, that bothered me. â€Å"What, you don't think any guy would ever be interested in me?† â€Å"Actually,† said Adrian, sounding remarkably serious, â€Å"I can imagine lots of guys being interested in you.† I was certain he was teasing me and had no time for his jokes. I said goodbye and headed off to my study group, which, thankfully, was pretty dedicated and got a lot of work done. But when I met up with Trey at the library later, he was less than focused. He couldn't stop going on and on about how brilliant he was in getting Brayden and me together. â€Å"This date hasn't even happened, and I'm already tired of it,† I said. I spread Trey's lab paperwork out on the table before us. The numbers and formulas were comforting, far more concrete and orderly than the mysteries of social interaction. I tapped the lab assignment with my pen. â€Å"Pay attention. We don't have a lot of time.† He shrugged off my concerns. â€Å"Can't you just finish it?† â€Å"No! I left enough time so that you could do it yourself. I'll help, but that's it.† Trey was intelligent enough to figure out most of it on his own. Using me was just another way for him to dodge looking smart. He let the date go and focused on the work. I thought I was free of Brayden interrogation until, just as were wrapping up, Jill and Micah came strolling by, hand in hand. They were with a group of other people, which didn't surprise me. Micah was easygoing and popular, and Jill had inherited a large circle of friends by going out with him. Her eyes sparkled with happiness as someone in the group told a funny story that made them all laugh. I couldn't help a smile myself. This was a far cry from when Jill had first come to Amberwood and been treated as an outcast for unusual looks and odd behaviors. She was thriving with this new social status. Maybe it would help her embrace her royal background. My smile faded when Jill pulled Micah away from the group and hurried over to our table. Her eager expression worried me. â€Å"Is it true?† she asked. â€Å"Do you have a date?† â€Å"For the love of – you know it's true! And you told Adrian, didn't you?† I gave her a pointed look. Their psychic bond wasn't active 100 percent of the time, but something told me she knew about his earlier phone call to me. When the bond was â€Å"on,† she could see into his mind, observing both his feelings and actions. It only worked one way, however. Adrian had no such insight. She turned sheepish. â€Å"Yeah†¦ I couldn't help it when Micah told me†¦Ã¢â‚¬  â€Å"I heard it from Eddie,† Micah added quickly, as though that might get him off the hook. He had red hair and blue eyes that were always cheerful and friendly. He was one of those people you couldn't help but like, which made it harder to undo the tangled web Jill had woven by dating him. â€Å"Hey, I did not tell Eddie,† said Trey defensively. I turned my gaze on him. â€Å"But you told other people. And they told Eddie.† Trey gave a half shrug. â€Å"I might have mentioned it here and there.† â€Å"Unbelievable,† I said. â€Å"What's this guy like?† asked Jill. â€Å"Is he cute?† I thought about it. â€Å"Pretty cute.† She perked up. â€Å"Well, that's promising. Where's he taking you? Somewhere good? Night on the town? Fancy dinner? Micah and I had an awesome time at Salton Sea. It's so pretty. You could go there, have a romantic picnic.† Her cheeks turned pink and she stopped for breath, as if realizing she was talking too much. Rambling was one of Jill's most endearing traits. â€Å"We're going to see Shakespeare in the park,† I said. That got me silence. â€Å"Antony and Cleopatra. It's good.† I suddenly felt the need to defend myself. â€Å"A classic. Brayden and I both appreciate Shakespeare.† â€Å"His name is Brayden?† asked Micah in disbelief. â€Å"What kind of a name is that?† Jill frowned. â€Å"Antony and Cleopatra†¦ is that romantic?† â€Å"Kind of,† I said. â€Å"For a while. Then everyone dies in the end.† Jill's horrified expression told me that I wasn't really improving matters. â€Å"Well,† she said. â€Å"I hope you have, um, fun.† A few moments of awkwardness ensued, then her eyes lit up again. â€Å"Oh! Lia called me tonight. She said you two talked about me modeling for her again?† â€Å"She what?† I exclaimed. â€Å"That's not quite how I'd put it. She asked if you could do some print ads. I said no.† â€Å"Oh.† Jill's face fell a little. â€Å"I understand. From what she said†¦ I just thought. Well. I thought maybe there was a way†¦Ã¢â‚¬  I gave her a meaningful look. â€Å"I'm sorry, Jill. I wish there was a way. But you know why you can't.† She nodded sadly. â€Å"I understand. It's okay.† â€Å"You don't need a modeling campaign to be beautiful to me,† said Micah gallantly. That brought a smile back to her face that faded when she saw a nearby clock. Her transient moods reminded me of Adrian's, and I wondered if some of that was the effect of the bond. â€Å"Ugh. Curfew's coming. We'd better head out. You coming, Sydney?† I glanced at Trey's lab. It was complete and, I knew, absolutely perfect. â€Å"I'll leave in just a couple minutes.† She and Micah left. Glancing over at Trey, I was surprised to find him staring at her retreating figure intently. I nudged him. â€Å"Hey. Don't forget to put your name on this, or it was all for nothing.† It still took him several seconds to drag his gaze away. â€Å"That's your sister, isn't it?† His dismal tone made it sound more like a statement than a question, as though he were revealing some unfortunate fact. â€Å"Um, yeah. You've seen her like a hundred times. She's gone to this school for a month.† He frowned. â€Å"I just never thought much about it†¦ never got a good look at her before. I don't have any classes with her.† â€Å"She was front and center in that fashion show.† â€Å"She had a mask on.† His dark eyes studied me. â€Å"You guys don't look alike at all.† â€Å"We get that a lot.† Trey still looked troubled, and I had no idea why. â€Å"You're smart to keep her out of modeling,† he said at last. â€Å"She's too young.† â€Å"It's a religious thing,† I said, knowing Trey wouldn't quiz me for many details on our â€Å"faith.† â€Å"Whatever it is, keep her out of the public eye.† He scrawled his name on the lab and shut his textbook. â€Å"You don't want her plastered all over magazines or something. Lots of creepy people out there.† Now I was the one left staring. I agreed with him. Too much exposure meant the Moroi dissidents could find Jill. But why would Trey feel that way, too? His claims that she was too young were sound, I supposed, but there was something vaguely unsettling about the exchange. The way he'd watched her walk away was too weird. But then, what other reason aside from concern could he have? The normality of the next couple of days was welcome – normality being relative around here, of course. Adrian kept sending me e-mails, asking me to rescue him (while also offering unsolicited dating advice). Ms. Terwilliger continued her passive aggressive attempts to teach me magic. Eddie continued in his fierce dedication to Jill. And Angeline continued her not-sosubtle advances on Eddie. After watching her â€Å"accidentally† spill her water bottle all over her white T-shirt at practice with him one day, I knew something would have to be done, no matter what Eddie had said about his personal life. Like so many awkward and unpleasant tasks in our cohort, I had a feeling I was the one who would have to do it. I figured this would be some sort of stern, heart-to-heart talk about the proper way to solicit someone's attention, but on the night of my date with Brayden, it was soon made clear to me that I was apparently the last person who should be giving dating advice. â€Å"You're wearing that?† demanded Kristin, pointing an accusing finger at the outfit I'd neatly set out on my bed. She and Julia had taken it upon themselves to inspect me before I went out. Jill and Angeline had tagged along without invitation, and I couldn't help but notice that everyone seemed a lot more excited about this than I was. Mostly I was a tangle of nerves and fear. This was what it must feel like to go into a test without having studied. It was a new experience for me. â€Å"It's not a school uniform,† I said. I'd had enough sense to know wearing that would be unacceptable. â€Å"And it's a color. Kind of.† Julia held up the top I'd selected, a crisp cotton blouse with short sleeves and a high, button-up collar. The whole thing was a soft shade of lemon yellow, which I thought would score me points with this group since everyone accused me of not wearing colors. I'd even combined it with a pair of jeans. She shook her head. â€Å"This is the kind of shirt that says, ‘You're never getting in here.'† â€Å"Well, why would he?† I demanded. Kristin, sitting cross-legged in my desk chair, tilted her head thoughtfully as she studied the shirt. â€Å"I think it's more like a shirt that says, ‘I'm going to have to end this date early so I can go prepare my Power Point presentation.'† That sent them into fits of laughter. I was about to protest when I noticed Jill and Angeline going through my closet. â€Å"Hey! Maybe you should ask before doing that.† â€Å"All your dresses are too heavy,† said Jill. She pulled out one made of soft, gray cashmere. â€Å"I mean, at least this is sleeveless, but it's still too much for this weather.† â€Å"Half my wardrobe is,† I said. â€Å"It's made for four seasons. I didn't really have a lot of time to switch to all summer stuff before coming here.† â€Å"See?† exclaimed Angeline triumphantly. â€Å"Now you know my problem. I can cut a couple inches off of that, if you want.† â€Å"No!† To my relief, Jill put the dress away. A few moments later, she produced a new find. â€Å"What about this?† She held up a hanger carrying a long white tank top made of light, crinkly material with a scoop neckline. Kristin glanced at Angeline. â€Å"Think you could make the neckline lower?† â€Å"The neckline's low enough already. And that's not a shirt you wear on its own,† I protested. â€Å"It's meant to be tucked in under a blazer.† Julia rose from the chair. She tossed her hair; this was serious business. â€Å"No, no†¦ this might work.† She took the shirt from Jill and laid it across the jeans I'd set out. She studied it for a few moments and then returned to my closet – which was apparently free game for everyone. After a quick search, she pulled out a skinny leather belt with a tan snakeskin pattern. â€Å"I thought I remembered you wearing this.† She laid the belt over the white shirt and stepped back. After a bit more scrutiny, she gave it a nod of approval. The others crowded in to look. â€Å"Good eye,† said Kristin. â€Å"Hey, I found the shirt,† Jill reminded her. â€Å"I can't wear the shirt alone,† I said. I hoped my protests covered up my anxiety. Had I really been that off on the yellow shirt? I'd been certain it was date-appropriate. How was I going to survive tonight if I couldn't even dress right? â€Å"If you want to put a blazer on over it in this weather, be my guest,† said Julia. â€Å"But I don't think you have to worry about it showing too much. This wouldn't even be worth Mrs. Weathers's notice.† â€Å"Neither would the yellow blouse,† I pointed out. They decided my clothing was a done deal and moved on to hair and makeup advice. I drew the line there. I wore makeup every day – very nice, very expensive makeup applied to make the most of my features in a way that made it look as though I didn't even have makeup on. I wasn't going to change that natural look, no matter how adamantly Julia swore pink eye shadow would be â€Å"hot.† None of them put up much of a fight on my hair. It was currently in a layered cut that went just past my shoulders. There was exactly one way it could be styled, worn down with the layers carefully arranged with a hair dryer. Any other style looked messy, and of course, I already had it in the perfect configuration today. No point messing with a good thing. Besides, I think they were all too excited that I'd agreed to wear the white tank top – once I'd tried it on to verify that it wasn't transparent. My only nod to jewelry was my little gold cross. I fastened it around my neck and said a silent prayer that I'd get through this. Although Alchemists used crosses a lot, we weren't exactly part of any traditional Christian faith or practice. We had our own religious services and believed in God, that He was a great force of goodness and light that infused every bit of the universe. With all that responsibility, He probably didn't care much about one girl going on a date, but maybe He could spare a second to make sure it wasn't too painful. They all traipsed down the stairs with me when the time came for Brayden to pick me up. (Actually, it was a little earlier than the appointed time, but I hated being late.) The girls had all come up with reasons for needing to meet him, from Jill's â€Å"It's a family thing† to Kristin's â€Å"I can spot an asshole in five seconds.† I wasn't confident in that last one, seeing as she'd once speculated that Keith might be a good catch. All of them were also full of unsolicited advice. â€Å"You can split the cost of dinner or the play,† said Julia. â€Å"Not both. He needs to pick up the whole bill on one of them.† â€Å"Better if he pays for everything, though,† said Kristin. â€Å"Still order something, even if you don't want to eat it,† added Jill. â€Å"If he's buying dinner, you don't want to let him off cheap. He's gotta work for you.† â€Å"Where are you guys getting all of this?† I asked. â€Å"What does it matter if I – oh, come on.† We'd reached the lobby and found Eddie and Micah sitting on a bench together. They at least had the decency to look embarrassed. â€Å"Not you guys too,† I said. â€Å"I was just here to see Jill,† said Micah unconvincingly. â€Å"And I was here to, um†¦Ã¢â‚¬  Eddie faltered, and I held up a hand to stop him. â€Å"Don't bother. Honestly, I'm surprised Trey isn't here with a camera or something. I figured he'd want to immortalize every moment of this debacle of a – oh. Hey, over here.† I put on a smile as Brayden stepped into the lobby. Apparently I wasn't the only one who liked to be early. Brayden seemed a little surprised that I had an entourage. I couldn't blame him since I was kind of surprised I had one too. â€Å"It's nice to meet all of you,† said Brayden, friendly, even if a little bewildered. Eddie, while uncomfortable with Angeline's advances, could be perfectly outgoing in less bizarre social situations. He played up the brotherly role and shook Brayden's hand. â€Å"I hear you guys are seeing a play tonight.† â€Å"Yes,† said Brayden. â€Å"Although, I prefer the term drama. I've actually already seen this production, but I'd like to watch it again with an eye toward alternative forms of dramatic analysis. The standard Freytag method can get a little cliched after a while.† This left everyone speechless. Or maybe they were just trying to figure out what he'd said. Eddie glanced at me then back to Brayden. â€Å"Well. Something tells me you guys are going to have a great time together.† Once we were able to extract ourselves from my well-wishers Brayden said, â€Å"You have very†¦ devoted family and friends.† â€Å"Oh,† I said. â€Å"That. They just, uh, happened to all be going out together at the same time we were. To study.† Brayden glanced at his watch. â€Å"Not too late for that, I suppose. If I can, I always do my homework right after school because – â€Å" â€Å"If you put it off, you never know if something unexpected might happen?† â€Å"Exactly,† he said. He smiled at me. I smiled back. I followed him to visitor parking, over to a shiny, silver Ford Mustang. I nearly swooned. Immediately, I reached out and ran my hand along the car's smooth surface. â€Å"Nice,† I said. â€Å"Brand new, next model year. These new ones will never quite have the character of the classics, but they certainly make up for it in fuel economy and safety.† Brayden looked pleasantly surprised. â€Å"You know your cars.† â€Å"It's a hobby,† I admitted. â€Å"My mom is really into them.† When I'd first met Rose Hathaway, I'd had the incredible experience of driving a 1972 Citroen. Now I owned a Subaru named Latte. I loved it, but it wasn't exactly glamorous. â€Å"They're works of art and engineering.† I noticed then that Brayden had come with me to the passenger side. For half a second, I thought he expected me to drive. Maybe because I liked cars so much? But then, he opened the door and I realized he was waiting for me to get in. I did, trying to remember the last time a guy had opened a car door for me. My conclusion: never. Dinner wasn't fast food, but it wasn't anything fancy either. I wondered what Julia and Kristin's opinion would be on that. We ate at a very California type of cafe, that served all organic sandwiches and salads. Every menu item seemed to feature avocado. â€Å"I would've taken you somewhere nicer,† he told me. â€Å"But I didn't want to risk being late. The park's a few blocks away, so we should be able to get a good spot. I†¦ I hope that's okay?† He suddenly looked nervous. It was such a contrast to the confidence he had shown when talking about Shakespeare. I had to admit, it was kind of reassuring. I found myself relaxing a little bit. â€Å"If it's not, I'll find a better place – â€Å" â€Å"No, this is great,† I told him, glancing around the cafe's brightly lit dining room. It was one of those places where we ordered at a counter and then brought a number to our table. â€Å"I'd rather be early, anyway.† He'd paid for all of our food. I tried to make sense of the dating rules my friends had bombarded me with. â€Å"What do I owe you for my ticket?† I asked tentatively. Brayden looked surprised. â€Å"Nothing. It's on me.† He smiled tentatively back. â€Å"Thank you,† I said. So, he was paying. That would make Kristin happy, although it made me a little uneasy – through no fault of his. With the Alchemists, I was always the one picking up the bills and handling the paperwork. I wasn't used to someone else doing it. I guess I just had trouble shaking that feeling that I had to take care of everything because no one else could do it right. Academics had always been a breeze for me. But at Amberwood, learning how to hang out with people my own age in a normal way had been a much more difficult task. I'd gotten better, but it was still a struggle trying to figure out the proper things to say to my peers. With Brayden, there were no such problems. We had an endless supply of topics, both of us eager to put forth all we knew on anything and everything. Most of the meal was spent discussing the intricacies of the organic certification process. It was pretty awesome. Trouble came when, as we were finishing up, Brayden asked if I wanted to get dessert before we left. I froze, suddenly in a dilemma. Jill had said to make sure I ordered enough to not come across as a cheap date. Without even thinking about it, I'd ordered an inexpensive salad – simply because it sounded good. Was I now on the hook to order more so I'd seem like someone Brayden had to work for? Was this worth breaking all my own rules about sugar and dessert? And honestly, what did Jill know about dating etiquette anyway? Her last boyfriend had been homicidal, and her current one was oblivious to the fact that she was a vampire. â€Å"Uh, no thank you,† I said at last. â€Å"I'd rather make sure we get to the park on time.† He nodded as he rose from the table and gave me another smile. â€Å"I was thinking the same thing. Most people don't seem to think punctuality is that important.† â€Å"Important? It's essential,† I said. â€Å"I'm always at least ten minutes early.† Brayden's grin widened. â€Å"I aim for fifteen. To tell you the truth†¦ I really didn't want dessert anyway.† He held the door open for me as we stepped outside. â€Å"I try to avoid getting too much sugar.† I nearly came to a standstill in astonishment. â€Å"I totally agree – but my friends always give me a hard time about it.† Brayden nodded. â€Å"There are all sorts of reasons. People just don't get it, though.† I walked to the park, stunned. No one had ever understood me so quickly and easily. It was like he had read my mind. Palm Springs was a desert city, filled with long stretches of sandy vistas and stark, rocky mountain faces. But it was also a city that mankind had been shaping for a long time, and many places – Amberwood, for example – had been given lush, green makeovers in defiance of the natural climate. This park was no exception. It was a huge expanse of green lawn, ringed with leafy deciduous trees instead of the usual palms. A stage had been set up at one end, and people were already seeking out the best spots. We chose one in the shade that had a great view of the stage. Brayden took out a blanket to sit on from his backpack, along with a worn copy of Antony and Cleopatra. It was marked up with notes and sticky tabs. â€Å"Did you bring your own?† he asked me. â€Å"No,† I said. I couldn't help but be impressed. â€Å"I didn't bring many books from home when I moved here.† He hesitated, as though unsure he should say what he was thinking. â€Å"Do you want to read along with mine?† I'd honestly figured I would just watch the play, but the scholar in me could certainly see the perks of having the original text along. I was also curious about what kind of notes he'd made. It was only after I'd said yes that I realized why he was nervous. Reading along with him meant we had to sit very, very close together. â€Å"I won't bite,† he said, smiling when I didn't move right away. That broke the tension, and we managed to move into positions that allowed us both to see the book with almost no touching. There was no avoiding our knees brushing one another, but we both had jeans on, and it didn't make me feel like my virtue was at stake. Also, I couldn't help but notice he smelled like coffee – my favorite vice. That wasn't a bad thing. Not bad at all. Still, I was very conscious of being so close to someone. I didn't think I was getting any romantic vibes. My pulse didn't race; my heart didn't flutter. Mostly I was aware that this was the closest I'd sat to anyone, maybe in my life. I wasn't used to sharing my personal space so much. I soon forgot about that as the play started. Brayden might not like Shakespeare performed in modern clothing, but I thought they did an admirable job. Following along with the text, we caught a couple of spots where the actors messed up a line. We shot each other secret, triumphant looks, gleeful that we were in on something others didn't know about. I kept up with Brayden's annotations too, nodding at some and shaking my head at others. I couldn't wait until we discussed this on the ride home. We were all leaning forward intently during Cleopatra's dramatic death scene, intensely focused on her last lines. Off to my side, I heard the crinkling of paper. I ignored it and leaned forward further. The paper crinkled again, this time much louder. Looking over, I saw a group of guys sitting nearby who appeared to be about college-aged. Most of them were watching the performance, but one was holding an item wrapped in a brown paper bag. The bag was too big for the object and had been rolled down several times. He glanced around nervously, trying to be discreet and unroll the paper in small batches. It was obvious that was actually making more noise than if he'd just gone for it and unrolled it all at once. This went on for another minute, and by then, a few others nearby were glancing over at him. He finally managed to open the bag and then, still in slow motion, carefully lowered his hand inside. I heard the pop of a cap and the guy's face lit up in triumph. Still keeping the object concealed, he lifted the bag to his mouth and drank out of what was very obviously a bottle of beer or some other alcohol. It had been pretty apparent right away from the bag shape. I clapped a hand over my mouth, in an attempt to smother my laughter. He reminded me so much of Adrian. I could absolutely see Adrian smuggling in alcohol to an event like this and then going to all sorts of pains to be covert, thinking that if he just did everything slowly enough, no one would catch on to him. Adrian, too, would probably have the misfortune of opening the bottle right in the middle of the play's most tense scene. I could even picture a similarly delighted look on his face, one that said, No one knows what I'm doing! When, of course, we all knew. I didn't know why it made me laugh, but it did. Brayden was too focused on the play to notice. â€Å"Ooh,† he whispered to me. â€Å"This is a good part – where her handmaidens kill themselves.† The two of us had plenty to debate and analyze on the way back to Amberwood. I was almost disappointed when his car pulled up to my dorm. As we sat there, I realized we'd come to another critical dating milestone. What was the correct procedure here? Was he supposed to kiss me? Was I supposed to let him? Had that been the real price of my salad? Brayden seemed nervous too, and I braced myself for the worst. When I looked down at my hands in my lap, I noticed they were shaking. You can do this, I told myself. It's a rite of passage. I started to close my eyes, but when Brayden spoke, I opened them quickly. As it turned out, Brayden's buildup of courage wasn't for a kiss, so much as a question. â€Å"Would you†¦ would you like to go out again?† he asked, giving me a shy smile. I was surprised at the mix of emotions this triggered. Relief was foremost, of course. I'd now have time to research books on kissing too. At the same time, I was kind of disappointed that the swagger and confidence he'd shown in dramatic analysis didn't carry through here. Some part of me thought his line should've been more like, â€Å"Well, after that night of perfection, I guess we have no choice but to go out again.† Immediately, I felt stupid for such a sentiment. I had no business expecting him to be more at ease with this when I was sitting there with my hands shaking. â€Å"Sure,† I blurted out. He breathed a sigh of relief. â€Å"Cool,† he said. â€Å"I'll e-mail you.† â€Å"That'd be great.† I smiled. More awkward silence fell, and suddenly, I wondered if the kiss might be coming after all. â€Å"Do you†¦ do you want me to walk you to the door?† he asked. â€Å"What? Oh, no. Thank you. It's right there. I'll be fine. Thank you.† I realized I was on the verge of sounding like Jill. â€Å"Well, then,† said Brayden. â€Å"I had a really nice night. Looking forward to next time.† â€Å"Me too.† He held out his hand. I shook it. Then I left the car and went inside. I shook his hand? I replayed the moment in my head, feeling dumber and dumber. What is wrong with me? As I walked through the lobby, kind of dazed, I took out my cell phone to see if I had any messages. I'd turned it off tonight, figuring if ever there was a time I'd earned peace, this was it. To my astonishment, no one had needed anything in my absence, though there was one text message from Jill, sent about fifteen minutes ago: How was your date with Brandon? What's he like? I unlocked my dorm door and stepped inside. His name is Brayden, I texted back. I pondered the rest of her question and took a long time in trying to decide how to respond. He's just like me.

Infectious Disease Free Essay Example, 1000 words

and subtracting tomorrow increase in individuals recovered bI from it. Next day increase in - I Following same procedures as we did explaining Equation 1 we should express following equation with relation to our independent variable t(time). Once again next day can be represented as: I [t+t] - I [t]. Applying the change we get: I [t+t] = I [t] + ( – I[t]) t Following mathematics rules those equations can be written as: = I [t] + (– I[t]) Dividing by N on both sides to get rid of the denominator: = () – Using mathematics rules we can cancel N’s in denominators: == ) – Setting our limit to 0, because we are dealing with time: == Finally we get what we started with: ) – Equation 3: = In the following equation there is no need to show any working out. The equation represents change in the Recovered class and it is simply calculated by g (recovery rate constant) by number of the Infected people. It represents the people that were recovered from the disease and now healthy (immune for life). Working Example using Ebola spread in Sierra Leone. Lets use data from Sierra Leone to plot those equations and discuss. Applying data from â€Å"WHO situation Report 12 November† we get this data. Assuming that everyone in Sierra Leone is a suspect 620000. Susceptible Infected Recovered T=0 6,192,123 4,523 3,354 N – population of Sierra Leone is 6,200,000 as estimated of 2014. We will write a custom essay sample on Infectious Disease or any topic specifically for you Only $17.96 $11.86/pageorder now - Of Ebola is approximately = ÃŽ ² - Of Ebola is 0.128 SIR equations for Ebola. Using eqn 1 for â€Å"susceptible†: = = Using eqn 2 for â€Å"infected†: ) – – Using eqn 3 for â€Å"recovered†: = = Calculating basic reproductive ratio, R0 is the sum of secondary infections resulting from a single infection entering a population totally made of susceptible population. From this definition, we can derive the equation, in which case is contact rate (ÃŽ ²) divided by recovery rate constant (g).    Hence R0 = 0.128/0.005 = 25.6 Using a computer application we can plot those equations. (http: //www. public. asu. edu/~hnesse/classes/sir. html Graph of Population vs Time for the three group levels Discussion The differentiated values obtained from the above three equations, were entered in a computer simulation program that then gave the above graph. This were used as the variables for the graph, essentially representing the number of people in the three groups. As shown in the calculations, R0 is greater than 1 meaning that the disease can enter a fully susceptible population just as proved by the graph. As shown in the graph, the disease has entered a population and therefore mostly occupied by â€Å"susceptible† individuals as shown by the yellow curve at 6200000.