Samantha, a 74-year-old woman with a history of rheumatic fever while in her twenties, presented to her physician with complaints of increasing shortness of breath ("dyspnea") upon exertion. She also noted that the typical swelling she's had in her ankles for years has started to get worse over the past two months, making it especially difficult to get her shoes on toward the end of the day. In the past week, she's had a decreased appetite, some nausea and vomiting, and tenderness in the right upper quadrant of the abdomen.On physical examination, Samantha's jugular veins were noticeably distended. Auscultation of the heart revealed a low-pitched, rumbling systolic murmur, heard best over the left upper sternal border. In addition, she had an extra, "S3" heart sound. A chest X-ray reveals a normal cardiac silhouette that is normal in diameter, but her physical examination reveals hepatomegaly and ascites, as well as pitting edema in her ankles. She is advised to wear support stockings and given a prescription for digoxin. Two weeks later she returns to the office for a follow-up visit; upon physical examination, she still has significant hepatomegaly and pitting edema, and is significantly hypertensive (i.e. she has high blood pressure). Her physician prescribes a diuretic called furosemide (or "Lasix").

1. What is causing the low-pitched, rumbling murmur (both in general and specific anatomical and physiological terms)? Why is it heard best over the left upper sternal border? Which valve is involved?

2. What is causing the "S3" heart sound? What portion of the cardiac cycle will it be heard in and why?

3. Is Samantha's history of rheumatic fever relevant to the current symptoms? Why or why not? What causes rheumatic fever and what might it cause in Samantha years after her infection? Why is the diagnosis of the specific valve involved in the systolic murmur important?

4. Does the normal diameter of the heart on X-ray rule out a possible cardiac diagnosis? What is meant by the term “concentric hypertrophy” and why might it be happening in Samantha’s heart?

5. What is meant by the terms “hepatomegaly” and “ascites” and why are they happening? Why are her jugular veins distended? Be specific in terms of blood pressure and Starling forces.

6. What is pitting edema and what is causing it?

7. Why is she advised to wear support stockings? If she had atherosclerosis or blockage of a femoral artery, would this be an advisable diagnosis? Why or why not?

8. Is the stress being placed on Samantha’s heart pre-load or after-load and why?

9. What is the general diagnosis for Samantha’s condition? What would the diagnosis be if there were pulmonary edema instead of systemic edema?

10. Why is Samantha started on digoxin? How does it work? State your answers in terms of chronotropism and inotropism, the Na+/K+ ATPase, cytoplasmic Ca++ concentrations, and the proteins in a cardiomyocyte’s sarcomere.

11. What happened to Samantha in the two weeks before her follow-up visit? In other words, how did her body begin to compensate for decreased stroke volume? Utilize cardiac output, sympathetic nervous system, vasoconstriction to “less vital” organs (including the kidney) the renin-angiotensin-aldosterone (R-A-A) axis, Angiotensin II, ADH, pre-load and after-load, the Frank-Starling law, and the actions of digoxin.

12. Why was she given Lasix medication, and how does it work?

An equally weighted portfolio consists of 74 assets which all have a standard deviation of 0.252. The average covariance between the assets is 0.091. Compute the standard deviation of this portfolio. Please enter your answer as a percentage to three decimal places (i.e. 12.345% rather than 0.12345 -- the percent sign is optional).

Mary has a heart rate of 72 beats per minute, a blood pressure of 118/74, a hemoglobin concentration of 152 g/l, a cardiac output of 5.4, an arterial SO2 of 97% and a venous SO2 of 76%. What is Marys A-V O2 diff?

What is Marys oxygen consumption?

What is Marys stroke volume?

CASE STUDY: PARKINSON’S DISEASE

Miss Rose is a 74 year old female, who is a retired widow and lives with her son for the past five years. Both enjoy planting seedlings and own a community agriculture store. She does not suffer with hypertension or diabetes and has an active lifestyle. She is also not known to have any psychiatric illnesses. Over the past six months Miss Rose’s son and herself noticed physical changes and decided to visit her General Practitioner. At her visit she mentioned to the doctor that she was having difficulty rising up from a sitting position after grooming her plants or turning from one table to another when she has customers. Documentation on her clinic file noted that she previously complained of difficulty walking and falling when coming out of bed. She was sent for an X-ray but there were no clinical findings. The physician asked her to describe what happened when she fell. Miss Rose verbalized that when she got up from bed and starting walking she started moving forward and backward then stooped forward with small fast steps and then she fell. Her son mentioned to the doctor that he has noticed that when she is pruning her plants she has abnormal rhythmic movement of the upper and lower limbs. She occasionally has a slight limp and her handwriting has become smaller over the past months. This has stopped her from doing her daily yoga exercises and she has been very disturbed about it. Miss Rose then further explained that the movement started on the distal part of both upper limbs at the same time. She also expressed that during rest she noticed the movement in her limbs and as she started her tasks the movements became more aggravated. Urinary incontinence is also a problem for Miss Rose and she is having difficulty in her swift movements to her bathroom. The patient was later diagnosed with Parkinson’s disease.

After the assessment and interview of Miss Rose the Physician documented the following:

Physical Assessment Vital Signs: BP- 130/74 mmHg Temperature - 36.7 C, Pulse- 78 bpm regular and bounding Respiration- 20 bpm Height- 5ft 7 in Weight- 70 kg Facial expression- Masklike Gait- Shuffling gait with tendency to fall forward and backward CNS Examination Alert and oriented to time, person and place Level of consciousness GCS- 15/15 Sleeping patterns- normal Swallowing gag reflex- normal Cogwheel rigidity present Tremor present Bradykinesia present Dysphonia present Instructions:

a) Briefly discuss the Anatomy and Physiology of this disease.

b) Briefly discuss the pathophysiology of the disease process. .

c) Discuss what home care activities can be implemented to ensure the patient’s health and safety.

d) State the medications used to treat this disease and its therapeutic effects it has on the patient.

You are valuing Soda City Inc. It has $139 million of debt, $74 million of cash, and 189 million shares outstanding. You estimate its cost of capital is 9.1%. You forecast that it will generate revenues of $731 million and $769 million over the next two years. Projected operating profit margin is 36%, tax rate is 22%, reinvestment rate is 51%, and terminal exit value multiple at the end of year 2 is 10. What is your estimate of its share price? Round to one decimal place. ​[Hint: Compute projected FCFF for years 1 and 2 based on info provided, compute terminal value using the exit multiple method, discount it all to find EV, walk the bridge to Equity, divide by number of shares outstanding.]

Medwig Corporation has a DSO of 22 days. The company averages $4,000 in sales each day (all customers take credit). What is the company's average accounts receivable? Assume a 365-day year. Round your answer to the nearest dollar.

Medwig Corporation has a DSO of 20 days. The company averages $3,750 in sales each day (all customers take credit). What is the company's average accounts receivable? Assume a 365-day year. Round your answer to the nearest dollar.

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Market subject:

Amazon is one of the Web’s most recognizable marketers. Visit the company’s website and describe FIVE main ways the company adds value to its customers’ buying experience with your detailed explanations and relevant examples supporting your answer.