CPM

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Session 9 IA-9(1)

Given the network plan that follows, compute the early, late, and slack times answer the following:

1. What is the project duration?

2. Using any approach you wish (e.g., trial and error) develop a loading chart for resource resources Carpenters (C) and Electricians (E). Assume only one Carpenter is available and two Electricians are available. 

3. Given your resource schedule, compute the early, late, and slack times for your project.

4. Which activities are now critical? 

5. What is the project duration now?

Use the templates provided below to construct your charts/tables.

ANSWER:  

          2       4          
          C       E          
0 1       3       3       6  
  C                       C  
  3       3       5       2  
          C       2-E          
          1       4          

ANSWER:

Carpenter                            
                             
Electrician                            
    0 1 2 3 4 5 6 7 8 9 10 11 12 13
                               

  ANSWER:

ID/RES ES LS EF LF SL
1-C          
2-C          
3-C          
4-E          
5-2-E          
6-C          
 
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Finance

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  • Show work/explanation. Answers without any work may earn little, if any, credit. You may type or write your work in your copy of the quiz, or if you prefer, create a document containing your work. Scanned work is acceptable also; a single file in pdf format is preferred.  In your document, be sure to include your name and the assertion of independence of work (see top of the page).

NOTE:  In financial analyses, the amounts to be reported should be rounded to the nearest cent.

  1. Showing your work,
  • (4 points) When subject to an annual simple interest rate of 2%, how long will it take a present value (principal) to “grow” by 50%?
  • (2 points) Does the “growth” in Part (a) depend on the principal?  Support your answer by a brief explanation or computation.
  • ( 4 points) What would be the growth (percent increase) in a principal if it were left in an account subject to an annual interest rate of 2% compounded annually for the length of time found in Part (a)? 
  • (25 points) Consider the following academic problem, involving four independent “savings accounts” A, B, C, and D:

At the end of August,

  1. A deposit of $200.00 is made into a no-interest-bearing account (Account A) and also $200 is deposited into the account at the end of each following month for the rest of the year.
  2. A one-time deposit of $800.00 is made into Account B, subject to an annual simple interest rate of 12%.
  3. A one-time deposit of $800.00 is made into Account C, subject to an annual compound interest rate of 12%, compounded monthly.
  4. A deposit of $200.00 is made into Account D and also $200 is deposited into the account at the end of each following month for the rest of the year, subject to an annual compound interest rate of 12%, compounded monthly.

Showing your work and rounding the answers to two decimal places,

  •  Populate the following table, to show the amount at the end of each month for each of the four accounts and the total interest earned at the end of November.

Amount (Future Value) at the end of each month after each end-of-the-month deposit

Account End of August End of September End of October End of November Grand Total Interest Earned at the End of November
A              
B              
C              
D              
  • Which of the above accounts would be a “Piggy Bank”? Support your answer briefly
  • As a “Financial Analyst” in our MATH 106 class, what would you name or label Account D?
  • (15 points) When Matthew was born, his grandparents deposited $6000 into a special account for Matthew’s college education.  The account earned 7.3% interest compounded daily.
  • How much will be in the account when Matthew is 18?
  • If, upon becoming 18, Matthew arranged for the monthly interest to be sent to him, how much would he receive each 30-day month?
  • (15 points) A manufacturing company needs a piece of equipment to be replaced in 5 years at a cost of $900,000.

To have this money available in 5 years, a sinking fund is established requiring making equal monthly payments (at the end of each month; no withdrawals) into an account paying 6.6% compounded monthly.

  • How much should each payment be?
  • How much interest is earned during the last year?
  • (15 points)Kira buys a refrigerator for her big family for $2,400 and agrees to pay for it in 18 equal monthly payments at an annual interest rate of 18% on the unpaid balance.
  • How much are Kira’s payments?
  • How much interest will she pay?
  • A family purchased a home 10 years ago for $160,000, paying 20% down and signing a 30-year mortgage at 9% on the unpaid balance.
  • (10 points) How much is the unpaid loan balance after making 120 monthly payments?
  • For Extra Credit (2 points):  If equity in a home is defined as

Equity = (current net market value) – (unpaid loan balance), find the equity in the family’s home if its market value is $210,000.

7. (10 points) Effective yield, which is also called annual percentage yield [APY], effective interest rate, or true interest rate, is, in effect, the compounded interest on a one-dollar investment after one year.

Following the above interpretation of the effective yield, and invoking the compound interest formula, write the formula for the effective yield for each of the following cases and show your work.  In other words, subtract 1 dollar from the future value of one dollar for each case, having been subjected to a compounding interest for one year.

Calculate the effective yield for the following interest rates:

(a) 4.93% compounded monthly

(b) 4.95% compounded daily

(c) 4.97% compounded quarterly

(d) 4.94% compounded continuously

 
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Origins of prejudice

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Origins of prejudice

Integrated Threat Theory (ITT) developed by Stephan, Stephan, Demitrakis, Yamada, and Clason, (2000) best describes the relationship between our attitudes and our behavior. Do you think that there might be an umbrella theory that can be developed which take the best from the others and explain what needs to be explained? [2 References 2 In text Citations needed. Original Writings only. No ESL writing.]

 
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Accounting

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Accounting

No less than 4 sentences to each bullet.

“Self Constructed Assets and Nonreciprocal Transfers” Please respond to the following:

  • Imagine you are the senior accountant in the Fixed Assets department at your organization, and management is undecided as to whether it should construct its fixed assets or purchase such assets from an outside source. You are responsible for preparing a report to management, highlighting the advantages and disadvantages of self-constructed assets. Suggest to management two (2) advantages of purchasing the assets from an outside organization, as opposed to constructing the assets internally. Justify your response.
  • Imagine that management is considering a nonreciprocal transfer of an old asset. Determine the key arguments for and against the accounting treatment of a nonreciprocal transfer. Select a position for or against the accounting treatment, and explain the method that reflects the best accounting practice.

“Impaired Assets and Depreciation Methods” Please respond to the following:

  • Summarize the authoritative guidance for asset impairments under IFRS. Give at least two (2) examples of events that could cause an asset to be tested for impairment, and recommend the best method to determine the fair value of an impaired asset. Explain the rationale for your recommendation.
  • Differentiate between the decreasing-charge depreciation methods and the special depreciation methods, and suggest the method that would result in the highest depreciation during the first year of operations. Imagine you are a manager at Delta Airlines and are giving a presentation to the Board of Directors concerning the best depreciation method to use for the purchase of twenty-five (25) new aircrafts. Explain to the Board the method that would result in the highest depreciation charge for the next five (5) years.
 
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Finance Discussion

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Pick 5 stocks for Finance Discussion Question

As the basis of your Play Money Paper, you are to pick your stocks this week and submit them here in the week 5 discussion conference to get everyone’s feedback. Please keep in mind the following points:

You have a total of $10,000 to invest

You must invest in at least FIVE stocks

Submit your stock portfolio in this conference for others to give you feedback, and then you will follow your portfolio per the instructions given under this week’s TDL.  Give a reason why you chose the stocks.

Include your stock portfolio in the form of a table that includes:  the name of the company, the ticker symbol, the price at which you “bought” the stock, the quantity of each stock purchased, and its beta.  In addition, you must provide a brief explanation for each of your investments and the total market value of the portfolio as of a certain date in week 5.  The initial market value of the portfolio cannot exceed $10,000

 
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E-Marketing

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Econ 210 You Decide excercise

E-Marketing

Scenario

Scenario description

Role

What is Your Role in this scenario?

Players

Learn more about the Key Players in this scenario.

Deliverable

What would you to resolve this scenario?

Scenario

You are an e-commerce expert and you have some friends who own their own local bookstore. The husband and wife team have owned this company for 20 years and have built an amazing business that is very successful to the local community and is known to have an amazing collection of rare and exotic books. However, due to the World Wide Web, bookstores have had challenges, as Amazon and Barnes and Noble and other online companies have hurt their business. You have been hired by the owners to help craft an e-marketing strategy to improve their local sales and introduce the ability to sell their books online.

Role

You are an e-marketing and e-commerce consultant. Mary and Joe Johnson, the owners of Book Bunker, have hired you to help them improve their sales both online and in their store. The Johnsons do not currently have a website, and are unaware of social media. They have asked you to develop an online strategy to create advertising to improve the number of walk-ins into their store as well as the ability for anyone that has access to their site and purchase books. You will need to write a 5 page (2,500 words minimum) business report outlining your ideas and strategies to improve their online business and increase their advertising via the World Wide Web.

Players

Mary Johnson

Co-Founder of Book Bunker

Joe Johnson

Co-Founder of Book Bunker

Deliverable

Given the scenario, your role and the information provided by the key players involved, it is time for you to make a decision.



If you are finished reviewing this scenario, close this window and begin working on your report.



You can return and review this scenario again at any time.

Your Assignment

You are an e-marketing and e-commerce consultant. Mary and Joe Johnson, the owners of Book Bunker, have hired you to help them improve their sales both online and in their store. The Johnsons do not currently have a website, and are unaware of social media. They have asked you to develop an online strategy to create advertising to improve the number of walk-ins to their store as well as to create the ability for anyone to access to their site and purchase books online.

YOU DECIDE

Activity or Assignment

Assignment

For this assignment, you will generate a Microsoft Word report. You will need to write a 5-page (2,500 words minimum) business report outlining your ideas and strategies to improve their online business and increase their advertising via the Web.

You will submit your work to the Week 3 You Decide Dropbox.

Grading Rubric

Category Points Description
Criteria/Creativity 75 Demonstrate a strong grasp of the problem at hand. Demonstrate understanding of how the course concepts apply to the problem. Be sure to include the basic concepts and criteria required by the owners of the bookstore. Your idea must be detailed, compelling, and creative.
Understanding 25 Be sure to include all the elements required when creating your business report. Be sure to listen carefully to the You Decide audio, so that you answer the questions Joe and Mary have in detail.
Execution 25 Make sure your report is clear and succinct, using strong organization and proper grammar. Use citations correctly. You must include a cover page and an executive summary as well as answer the specific questions put forward by Joe.
Total 125 A quality report will meet or exceed all of the above requirements. The paper should be at least 5 pages (2,500 words minimum) in length and can include graphs and pictures to enhance the paper. Hi, I am so glad to see you. As you already know, I am Mary Johnson, co-founder of Book Bunker. My husband Joe and I have run this store for 20 years and we need your help. I plan to tell you all about our background and why we are special, and in a little bit my husband will fill you in on what we need. First off, as you know, we started 20 years ago in a small store in the suburbs that specialized in rare and used books. As we grew in notoriety and customers, we started to expand our business. Over the past twenty years we have moved to two different locations as we grew and today we are located in the middle of downtown with a very nice sized store. We still specialize in buying and selling rare books, but we also offer mainstream novels and audio books. Simply put, you can get any book you want in our store that is offered by our major competitors, such as Barnes and Noble or Amazon, but we ALSO have the ability to find and sell rare books. We are proud of our niche. And we have found that people come from around the country to ask us about a book. I get a few international phone calls a week looking for a rare text. Simply put, we have a great reputation… but we are certain not enough people know about us. Locally we are the leading bookstore in our city… but we have seen sales dip due to people buying books online. With this in mind, Joe and I thought we needed to speak with an expert to discuss creating a website… yes, I know, we should have one already, but we don’t… and developing an e-marketing strategy to improve our local sales as well as begin selling online. I have given you some basic information about our company, now I will turn you over to Joe to talk about the specifics of our marketing needs. Hello, I am Joe Johnson. Nice to meet you. I see you that you spoke to my wife in great length about our store and history. We are very proud of our niche market of rare books, but we also know that we can and do compete well with the larger stores that sell contemporary books. With that said, we have seen a 20% drop in sales over the last two years and we need to address this immediately. Simply put, we are in the dark ages when it comes to e-commerce and we need a plan. We would like for you to help us develop an e-marketing strategy to increase our sales. We are looking for recommendations on the following: 1. Even though we don’t have a website today, I would like to understand various features we should have on our website. 2. Help us decide where we should advertise online, should we use banner ads? What sites should we choose to ad? What keywords and adwords should we choose? 3. Give me a report on the ability to advertise on the internet locally vs. globally. We want to sell books everywhere, but we also want to increase our foot traffic into our local store too. 4. Lastly, we have heard about customer relationship management systems. Could you describe what these are and tell us how we could utilize this new technology to improve our sales? Please note, my wife and I are not completely comfortable with social media, so please do not include any recommendations for social network sites. I hope this is a good start. My wife and I are very anxious to join the 21st century with our store, and hope that we can leverage e-commerce to improve our business and increase sales. Thanks for your time.
 
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PHYSICS

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PHYSICS 
[1pt] 
 A 50-kg shell is fired from a gun with a muzzle velocity 75 m/s at 74o above the horizontal. At the top of the trajectory, the shell explodes into two fragments of equal mass. One fragment, whose speed immediately after the explosion is zero, falls vertically. What is the horizontal speed of the other fragment?

Answer:  



2.[1pt] 
Two identical steel balls, each of mass 2.9 kg, are suspended from strings of length 29 cm so that they touch when in their equilibrium position. We pull one of the balls back until its string makes an angle theta = 31owith the vertical and let it go. It collides elastically with the other ball. How high will the other ball rise above its starting point?

Answer:  



3.[1pt] 
Suppose that instead of steel balls we use putty balls. They will collide inelastically and remain stuck together after the collision. How high will the balls rise after the collision?

Answer:  



4. [1pt]
A bullet of mass m= 3.40×10-2kg is fired along an incline and imbeds itself quickly into a block of wood of mass M= 1.45kg. The block and bullet then slide up the incline, assumed frictionless, and rise a height H= 1.25m before stopping. Calculate the speed of the bullet just before it hits the wood. 

Answer:  


5.[1pt] 
A car, mass m1 is moving to the right on a frictionless air track. It collides with a second car, mass m2, which is initially at rest. Which of the following statements are true? (If A and E are true, and the others are not, enter TFFFT).

A) If car 1 is much lighter than m2, and the collision is perfectly elastic, car 1 will continue heading to the right with nearly its original speed after the collision.
B) If car 1 sticks to car 2, the car1-car2 system must move to the right after the collision.
C) If car 1 sticks to car 2, the final total kinetic energy of the car1-car2 system is less than the initial total kinetic energy of the two cars.
D) If the collision is elastic, car 1 must always come to a stop after the collision.
E) Suppose (for this statement only) that car 2 was NOT initially at rest, but was instead heading towards car 1 with equal (but opposite) momentum before the collision. After the collision, the cars must both be at rest.

Answer:  



6.[1pt] 
A ball of mass 4.0 g with a speed of 29.2 m/s strikes a wall at an angle 28.0o and then rebounds with the same speed and angle. It is in contact with the wall for 41.0 ms. What is the magnitude of the impulse associated with the collision force?

 
 
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Art

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All of these questions must be answered in your report in the order that they appear here..

  • When and where was the photographer born?
  • Did he or she study photography or were they self-taught?
  • Describe the genres the photographer worked with primarily; landscape, portraiture, etc. Where were the photos taken?
  • Describe the style of the photographer’s work. Did they emphasize particular elements or principles of design? Describe camera angles, lighting and other style elements particular to the photographer.
  • Explain any technical information about the photographs: film or digital? Cameras and equipment used by the artist.
  • Why does the work of this photographer inspire you?

  Assemble your responses in a paper that is at least two pages in length, double spaced. 

Step 2: Choose at least two photographs by the photographer and explain why they are successful. Critique the photos using formal terms of design such as balance, unity, texture, value and focal point.

Photographer: Helmut Newton

 
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Corporate Finance

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It is likely that:
 A) prudent managers have a detailed knowledge of the composition of their shareholders.
 B) mixing asset purchase and financing decisions could cause managers to make good decisions.
 C) none of the above.
 D) A and B.
The present value of a cash flow allows an investor to assess:
 A) the present value of a future cash flow.
 B) the value of a stream of cash flows in terms of the best and most certain alternative.
 C) what equivalent present payment would be equally acceptable in lieu of the investment under consideration.
 D) A and B.
 E) A, B, and C.
In a stable, predictable industry, an average of the previous ten years’ sales growth figures probably provides a less accurate forecast than assuming the same level of sales next year as in the current year.
 True
 False
Which of the following would be included among the investment numbers of a capital budget?
 A) Purchase price of the asset.
 B) Trade-in value of an asset being replaced.
 C) Investment tax credit from acquisition.
 D) Installation costs of the machinery.
 E) All of the above.
If projected assets exceed liabilities and owners’ equity, it is assumed that the difference is funded through short-term or long-term debt.
 True
 False
For capital budgeting purposes, an asset’s depreciable life is:
 A) always equal to the time horizon of an evaluation.
 B) equal to the asset’s useful life.
 C) equal to the asset’s economic life.
 D) an arbitrary period dictated by GAAP.
 E) none of the above.
The most accurate pro formas do not necessarily contain the most detail.
 True
 False
Analysts within a company are less likely to fall into the ‘false accuracy trap’ when they develop pro formas than would external analysts because insiders have access to more detailed information.
 True
 False
Which of the following statements record a firm’s financial situation on a single day?
 A) Statement of financial position.
 B) Income statement.
 C) Statement of cash flows.
 D) All of the above.
 E) Both A and B.
Residual cash flows are estimated when:
 A) the useful lives of alternatives are different.
 B) one asset has a shorter economic life than its alternatives.
 C) one asset has a longer economic life than its alternatives.
 D) A and B.
 E) A, B, and C.
The cost of capital can be defined as:
 A) the weighted average cost of attracting investors to the firm.
 B) the price of obtaining funding for the firm, weighted according to target ratios in the capital structure.
 C) less than the weighted average return that investors in the firm require.
 D) A and B.
 E) A, B, and C.
It is not possible for stock appreciation to offset a dividend reduction and create value for shareholders.
 True
 False
Dividends are not the sole source of returns for shareholders.
 True
 False
If managers do not foresee investment opportunities in the coming year that are as attractive as they have seen in the past, it is not necessarily appropriate to raise the dividend to the level that mature companies pay.
 True
 False
If an investment’s IRR is higher than the firm’s chosen hurdle rate, then the investment:
 A) has a positive NPV.
 B) is of greater risk than the overall risk of the firm.
 C) should be qualitatively considered before selection.
 D) A and C.
 E) A, B, and C.
A differential analysis:
 A) can be used to compare an alternative to the status quo.
 B) can be used to compare any set of alternatives.
 C) is easier to comprehend if a consistent frame of reference is employed.
 D) B and C.
 E) A, B, and C.
Flexibility issues are those which:
 A) deal with a company’s financing reserves.
 B) impact the debt capacity that a firm should maintain.
 C) All of the above.
As the interest rate used to discount future cash flows is decreased, present value of the future cash inflows:
 A) increases.
 B) decreases.
 C) stays the same.
A firm with substantial fixed costs such as a manufacturing overhead will have a lower degree of risk in the trough of a business cycle than will a firm with high variable costs and limited fixed costs.
 True
 False
The qualitative portion of a financial analysis is analogous to the hypothesis-forming stage of scientific investigation because:
 A) assumptions are not tested until the numbers are run.
 B) false hypotheses (assumptions) may be formed.
 C) empirical measurement is not performed later.
 D) A and B.
 E) A, B, and C.
‘Other’ issues normally do not cause managers to assign more importance to one FRICTO element than the others.
 True
 False
The risk-free rate of return used to determine a firm’s cost of capital will not vary depending upon the financial and operating risk level of the firm.
 True
 False
Timing issues involve:
 A) the costs of the alternative forms of capital.
 B) sequencing the alternatives, once funding amounts are known.
 C) none of the above.
 D) A and B.
If a company consistently uses hurdle rates that are higher than its marginal cost of capital, then:
 A) it will certainly increase its earnings.
 B) it may have fewer and fewer investment alternatives.
 C) the risk of the firm will decrease.
 D) A and C.
 E) B and C.
The risk of illiquidity is more pronounced for share owners than it is for debt holders in a public company.
 True
 False
FRICTO analysis does not point out poor investments.
 True
 False
A valuation determines whether a merger should occur; legalities determine what form the business combination should be.
 True
 False
The ‘efficient market’ theory seems to be reasonable because:
 A) there are fewer financial analysts valuing securities.
 B) there are hundreds of investors trying to make money from improperly valued securities, and the market forces which result drive stock prices to a fair value.
 C) statistical assessments are becoming increasingly important in financial analysis.
 D) B and C.
 E) A, B, and C.
It is best when evaluating mergers to rely on several quantitative methods.
 True
 False
It is not impossible for the acquisition price of a target firm ever to fall below book value.
 True
 False
Present value calculations allow managers to:
 A) choose assets which create the most value, even if their cash flows are timed differently.
 B) express present values in terms of future cash flows.
 C) create value for the firm.
 D) A and C.
 E) A, B, and C.
The final step(s) in using pro formas are to:
 A) test the assumptions.
 B) compare the results of the sensitivity analysis to the decision maker’s risk tolerance in the current situation.
 C) create best- and worst-case scenarios.
 D) A and C.
 E) A, B, and C.
Qualitative comparisons may be as important as the numerical comparisons in financial analysis.
 True
 False
When performing sensitivity analysis:
 A) statistical methods should not be employed.
 B) electronic spreadsheets can save time.
 C) assumptions should be changed one at a time.
 D) all of the above.
 E) B & C.
Management can improve its ROA by increasing investments in property, plant, and equipment.
 True
 False
A payment of dividends reduces the cash balance.
 True
 False
Compound rates are used in an attempt to:
 A) screen out weak investments.
 B) quantify the firm’s opportunity costs.
 C) quantify the firm’s risk.
 D) A and B.
 E) none of the above.
More detail in a pro forma doesn’t necessarily mean greater accuracy.
 True
 False
Synergy between two companies:
 A) is the complimentary situation where value is created in the joining of the firms.
 B) may result in the improvement of the acquirer’s bottom line.
 C) could be defined by purely qualitative benefits.
 D) A and C.
 E) A, B, and C.
The utility of sensitivity analysis is as great in merger valuations as it is in capital budgeting.
 True
 False
 
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Pathophysiology

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Instructions

  • This week’s case study will introduce concepts related to the pulmonary system and shock states. Read the scenario and thoroughly complete the questions. Some of the answers will be short answers and may not require a lot of details. For example: what is the most common organism to cause a hospital acquired infection? The answer is pseudomonas aeruginosa. Answers to questions that relate to the pathogenesis of a disease must include specific details on the process. For example: How does hypoxia lead to cellular injury? Simply writing that a lack of blood flow, causes a lack of oxygen available to the cell and the cell cannot function without oxygen is not sufficient. This type of response is NOT reflective of an advanced understanding of the concept or graduate level work. This answer should discuss the cascade of events leading to the lack of oxygen and how it specifically impairs cellular function. All answers to these type of questions should address the effects at the cellular level, then the effects on the organ and then the body as a whole. Additionally describing the normal anatomical and/or physiologic processes underlying the pathogenesis will be necessary to thoroughly answer the question.

It is very likely that you will need to reference multiple sources to answer the questions thoroughly. Your text book will not necessarily have all the answers. Only professional sources may be used to complete the assignment. These include text books, primary and secondary journal articles from peer reviewed journals, government and university websites, and publications from professional societies who establish disease management guidelines and recommendations. Sources such as Wikipedia or other generic websites are not considered professional references and should not be used to complete the case studies.

  • Reason for Consultation:
    Desaturation to 64% on room air 1 hour ago with associated shortness of breath.

History of Present Illness:
Mrs. X is 73-year-old Caucasian female who was admitted to the general surgery service 3 days ago for a leaking j-tube which was surgically replaced 2 days ago. This morning at 07:30, the RN reported that the patient was sleeping and doing fine, then the CNA made rounds at 0900 and Mrs. X was found to be mildly dyspneic.  Vital signs were checked at that time and were; temperature 38.6, pulse 120, respirations 20, blood pressure 138/38.  O2 sat was 64% on room air.  The general surgeon was notified by the nursing staff of the hypoxia, an order for a chest x-ray and oxygen therapy were given to the RN. The O2 sat is maintaining at 91-92% on 4L NC. The patient was seen and examined at 10:10 a.m.  She reported that she has had mild dyspnea for 2 days that has progressively gotten worse. She does not use oxygen at home.  Her respiratory rate at the time of this visit was 20 and she feels short of breath. She has felt this way in the past when she had pneumonia.  She is currently undergoing radiation treatment for laryngeal cancer and her last treatment was 1 to 2 weeks ago.  She reported that she has 2 to 3 treatments left.  She denied any chest pain or previous history of CHF. Review of her vital signs showed that she had been having intermittent fevers since yesterday morning.  Of note, she was admitted to the hospital 3 weeks ago for an atrial fibrillation with RVR for which she was cardioverted and has not had any further problems.  The cardiologist at that time said that she did not need any anticoagulation unless she reverted back into A-fib. 

Review of Systems: 
Constitutional:  Negative for diaphoresis and chills.  Positive for fever and fatigue.
HEENT:  Negative for hearing loss, ear pain, nose bleeds, and tinnitus.  Positive for throat pain secondary to her laryngeal cancer.  
Eyes:  Negative for blurred vision, double vision, photophobia, discharge and redness.  
Respiratory:  Positive for cough and shortness of breath. Negative for hemoptysis and wheezing.  
Cardiovascular:  Negative for chest pain, palpitations, orthopnea, leg swelling and PND.  
Gastrointestinal:  Negative for heartburn, nausea, vomiting, abdominal pain, diarrhea, constipation, blood in stool and melena.  
Genitourinary:  Negative for dysuria, urgency, frequency, hematuria and flank pain.  
Musculoskeletal:  Negative for myalgias, back pain and falls. 
Skin:  Negative for itching and rash.  
Neurological:  Negative for dizziness, tingling, tremors, sensory change and speech changes.  
Endocrine/hematologic/allergies:  Negative for environmental allergies or polydipsia.  Does not bruise or bleed easily.  
Psychiatric:  Negative for depression, hallucinations and memory loss.

Past Medical History: 

1.    Diabetes mellitus that was diagnosed 12 years ago with neuropathy. This resolved after gastric bypass surgery, which she had approximately 3 years ago.

2.    Laryngeal cancer

3.    Hypertension

4.    Hypercholesterolemia  

5.    Pneumonia

6.    Arthritis

7.    Hypothyroidism

8.    Atrial fibrillation  

9.    Acute renal failure

10.Chronic kidney disease, stage IV – 4 months ago a renal biopsy was completed, which showed focal acute tubular necrosis and patchy tubular atrophy, moderate to severe interstitial fibrosis with patchy acute and chronic interstitial nephritis, normal cellular glomeruli with no white microscopic evidence of a primary glomerulopathy. Baseline creatinine is 1.9.

11.Peptic ulcer disease

12.Skin cancer

13.Anemia

14.Osteoporosis

Past Surgical History:

15.Gastric bypass 4 years ago

16.Closure of mesenteric defect.

17.Radical neck resection on 1 year ago.

Family History:

18.Mother had diabetes diagnosed at age 55 and high blood pressure. Deceased.

19.Father had heart disease diagnosed at age 60. Deceased.

20.She had a sister with diabetes, thyroid disease, CKD, on dialysis, with unknown etiology.

Social History:
She denies any smoking or alcohol use.  She denies any drug use.

Medications:

21.Calcitriol 0.5 mcg PO every other day

22.Vitamin B12 2500 mcg sublingual every Monday and Thursday

23.Docusate sodium 100 mg PO BID

24.Fentanyl patch 100 mcg every 72 hours

25.Gabapentin 800 mg PO BID

26.Levothyroxine 50 mcg daily

27.Multivitamin 1 PO Daily

28.Oxybutynin 5 mg PO BID

29.Hydrocodone 5/325 1-2 tablets every 6 hours PRN pain

Allergies:
She is allergic to Cipro, which causes Uticaria and hives, contrast dye, honey and bee venom, adhesive, and sulfas, which causes hives

Physical Examination: 
Vital signs:  38.6, 120, 20, 138/38, 64% on room air.  She is maintaining O2 sat of 91 to 92 on 4 liters nasal cannula.  
Constitutional:  She is somnolent.  Oriented to person and place.  Appears ill and mildly dyspneic.
Head:  Normocephalic and atraumatic.  Nose:  Midline, right and left maxillary and frontal sinuses are nontender bilaterally. 
Oropharynx:  Clear and moist. No uvula swelling or exudate noted.  
Eyes:  Conjunctivae, EOM and lids are normal.  PERL. Right and left eyes are without drainage or nystagmus.  No scleral icterus.
Neck:  Normal range of motion and phonation.  Neck is supple.  No JVD.  No tracheal deviation present.  No thyromegaly or thyroid nodules.  No cervical lymphadenopathy noted bilaterally.
Cardiovascular:  rapid rate, S1 and S2 without murmur or gallop.  Brachial, radial, dorsalis pedis, and posterior tibial are 2+/4+ bilaterally.
Chest: Respirations are regular and even with mild dyspnea. Lungs are coarse and with some rales in the posterior bases.
Abdomen:  Soft.  Bowel sounds are active, nontender, no masses noted.  No hepatosplenomegaly noted.  No peritoneal signs.  
Musculoskeletal:  Full range of motion of the bilateral shoulders, wrists, elbows.
Neurologic:  Somnolent.  Cranial nerves II-XII are intact.
Skin:  Warm and dry.  
Psychiatric:  Mood and affect are normal.  Calm and cooperative.  Behavior, judgment is intact.

Laboratories and Diagnostics: 
WBC 7.2, Neutrophil 63% 
Creatinine 2.0, BUN 45, Na 144, Potassium 4.4 
BNP 242
Lactate 1.0
All other labs are unremarkable
Chest x-ray: Right lower lobe infiltrate 
EKG: NSR, no ST or T wave changes 

One hour after your saw Mrs. X, you get a call from the RN to report that her BP is now 75/40, pulse is 140, RR is 34 and dyspneic, temperature is 39.6 and she is minimally responsive.  Mrs. X is transferred to the MICU. 

Upon re-evaluation of Mrs. X you note that she is obtunded, struggling to breath, using accessory muscles and O2sats are 85% on a Non-rebreather. She is intubated and placed on a ventilator. A central line is placed and confirmation obtained via CXR. A foley is placed and fluid resuscitation has begun. 

WBC 20
Hgb 12
HCT 36
Platelets 98,000
Na 148
Chloride 110
Potassium 5.6
Glucose 190
Creatinine 3.0
BUN 68
Albumin 3.0
Anion Gap 21
Lactate 5.2
Procalcitonin 15, INR is 1.0, aPTT 23
ABG (prior to intubation) pH 7.28, PCO2 36, HCO3 17

EKG: Atrial Fibrillation with RVR at 156
CVP 3

Answer the following questions:  

30.What are 4 plausible differential diagnoses for Mrs. X’s hypoxemia that are specific to her clinical scenario? How would each diagnosis cause a hypoxemia?

31.What is your final diagnosis for the hypoxemia?

32.What are the most likely organisms to cause the diagnoses you identified in question 2?

33.Upon initial evaluation what category of sepsis was Mrs. X?

34.Upon re-evaluation what category of sepsis was Mrs. X?

35.Why is a gram negative bacteremia more serious than one caused by a gram positive organism?

36.What is the most likely source of Mrs. X sepsis?

37.What is a CVP and what does a value of 3 indicate? Why is Mrs. X CVP 3?

38.What is a Procalcitonin and what is its purpose?  

Hypoxemia: Causes, Symptoms, and Treatment
Hypoxemia is a medical condition which is characterized by a reduction in the levels of partial pressure of oxygen in the arterial blood. Scroll down to learn about the causes and symptoms of hypoxemia along with the treatment options.
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Our body needs oxygen to carry out the functions like cellular respiration and energy metabolism which are essential for its survival. One is therefore most likely to experience distressing symptoms in event of a decrease in the levels of oxygen. The term ‘hypoxemia’ refers to a medical condition that is characterized by a decrease in the partial pressure of oxygen in the arterial blood (PaO2). PaO2 is measured in millimeters of mercury (mm Hg or Torr). It refers to the pressure exerted by oxygen in a mixture of other gases. Arterial Blood Gas (ABG) testing helps measure PaO2.

Though these medical conditions are in some way related to reduction in the levels of oxygen in the body, these are distinct medical conditions. Here’s some information that will help you distinguish hypoxemia from the rest of the aforementioned conditions.

What is Hypoxemia?

This condition occurs when the pulmonary alveoli (microscopic sacs in lungs where exchange of oxygen and carbon dioxide takes place) are starved of oxygen. In this condition, a substantial decrease is observed in the levels of partial pressure of arterial oxygen. Under normal circumstances, partial pressure of oxygen in arterial blood should be within 95 to 100 mmHg. When the partial pressure of arterial oxygen in the blood falls below 80 mmHg, one is diagnosed with severe hypoxemia.

Also referred to as oxygen desaturation, hypoxemia should not be confused with medical conditions such as anoxia, asphyxia, hypoxia or anemia. Hypoxemia refers to a condition that is characterized by low oxygen content and low partial pressure of oxygen in arterial blood. The term ‘hypoxia’ refers to the deficiency of oxygen in the body as a whole or in some specific part of the body. ‘Asphyxia’ is a condition that is characterized by the absence of oxygen along with the accumulation of carbon dioxide. ‘Anoxia’ refers to the absence of oxygen in the body tissues or in the arterial blood. This implies extremely low levels of oxygen in the body. ‘Anemia’ is another medical condition that is characterized by a decrease in the number of red blood cells or low levels of hemoglobin in the blood. While the oxygen content in the arterial blood is low in people who are anemic, the partial pressure of oxygen in the arterial blood doesn’t decrease.

Arterial Oxygen Content

The arterial oxygen content can be calculated with the help of the following equation:

Arterial Oxygen Content = (Hgb x 1.36 x SaO2) + (0.0031 x PaO2)

In the equation given above, Hgb stands for the hemoglobin, SaO2 is the percentage of hemoglobin saturated with oxygen and (PaO2) refers to the partial pressure of arterial oxygen.

Symptoms

The symptoms of hypoxemia will vary depending on the extent to which the partial pressure has fallen.

Symptoms of Mild Hypoxemia

Restlessness
Anxiety
Disorientation, confusion, lassitude, and listlessness
Headaches

Symptoms of Acute Hypoxemia

Cyanosis (Skin appearing bluish due to insufficient oxygen)
Cheyne-Stokes respiration (irregular pattern of breathing)
Elevated blood pressure
Apnea (temporary cessation of breathing)
Tachycardia (increased rate of heartbeat, more than 100 per minute)
Hypotension (abnormally low blood pressure, below 100 diastolic and 40 systolic. Here, as an effect of an initial increase in cardiac output and rapid decrease later.)
Ventricular fibrillation (irregular and uncoordinated contractions of the ventricles)
Asystole (severe form of cardiac arrest, heart stops beating)
Polycythemia (abnormal increase in the number of red blood cells. The bone marrow may be stimulated to produce excessive RBCs in case of patients suffering from chronic hypoxemia)
Coma

Causes

Hypoxemia is usually triggered off by respiratory disorders.

Chronic obstructive pulmonary disease (COPD)
Airway obstruction
Acute respiratory distress syndrome
Pneumonia
Pneumothorax (collapsed lung)
Emphysema
Congenital heart defects
Pulmonary embolism (blood clot in lungs)
Pulmonary edema (fluid in lungs)
High altitude ascension could also lead to low partial pressure of oxygen in the arterial blood.

These are some of the conditions that could cause hypoxemia. Additionally, hypoxemia may also be caused as a result of one or a combination of the following

Hypoventilation: This refers to a condition wherein the oxygen (PaO2) content in the blood decreases and a marked increase in the levels of carbon dioxide is observed. This lowered PaO2 content can cause hypoxemia.

Low Inspired Oxygen: The FiO2 content in the blood is called the fraction of inspired oxygen in the blood. A decrease in this fraction of inspired oxygen may cause hypoxemia.

Right to Left Shunt: A right-to-left shunt refers to a condition in which there is a transfer of blood from the right side of the heart to its left side. An opening between the atria, ventricles, or blood vessels can lead to this. Structural defect or a problem in a heart valve can also result in right to left shunt.

Ventilation-Perfusion Mismatch: This is a condition in which an imbalance between the volume of gas expired by the alveoli (alveolar ventilation) and the pulmonary capillary blood flow is seen. This mismatch may cause hypoxemia.

Diffusion Impairment: In this condition, a marked reduction is seen in the oxygen movement from the alveoli to capillaries. This restricted movement may trigger hypoxemia.

More often than not, it is difficult to decide one single cause of hypoxemia in acute illnesses. It also becomes almost impossible to determine the extent of contribution of the causes of hypoxemia in such cases.

Treatment Options

Now that you have some idea about the circumstances under which one may develop hypoxemia, let’s move on to the treatment options for this pathological condition.

Mechanical Ventilation: Mechanical ventilation is a mechanism by which it is possible to aid or substitute spontaneous breathing mechanically. Continuous Positive Airway Pressure (CPAP) refers to a type of device that forces a steady stream of air into the nasal passage. This flow is set at a pressure that can overcome obstructions, thereby preventing the airway from closing. The pressure to be maintained should be determined through careful observation.

Supplemental Oxygen Therapy: In severe cases, it becomes essential to administer oxygen to the patient. Oxygen may be supplied through oxygen concentrators, cylinders or tanks. However, it is crucial to determine the precise levels of oxygen to be administered. Special care needs to be taken during supplemental oxygen therapy for infants. Supplemental oxygen therapy and CPAP are usually prescribed together as a treatment for hypoxemia. This is particularly effective for treating hypoxemia caused due to hypoventilation.

Transfusion of Packed RBCs: Packed red blood cells refers to the concentrate of red blood cells obtained after the removal of plasma in the blood. Packed red blood cells can be transfused as a treatment option for patients suffering from hypoxemia. This is known to increase the oxygen-carrying capacity of the blood. Sufficient care should be taken during the blood transfusion to avoid infections. This form of treatment cannot be used in case of patients who develop polycythemia (which is characterized by abnormally high RBC count) as a result of chronic hypoxemia.

Increasing Inspired Oxygen: This form of treatment is effective for hypoxemia that develops as a result of hypoventilation or due to the reduction in inspired oxygen.

Since hypoxemia can be caused by serious medical conditions, it is extremely essential to identify the underlying cause. Treating the underlying condition can certainly help to bring back the partial pressure of oxygen in arterial blood to normal. Drug therapy, oxygen therapy and lifestyle modification can certainly help in normalizing the partial pressure of oxygen in arterial blood.
Read more at Buzzle: http://www.buzzle.com/articles/hypoxemia-causes-symptoms-and-treatment.html

Common bacterial causes of sepsis are gram-negative bacilli (for example, E. coli, P. aeruginosa, E. corrodens, and Haemophilus influenzae in neonates). Other bacteria also causing sepsis are S. aureus, Streptococcus species, Enterococcus species and Neisseria; however, there are large numbers of bacterial genera that have been known to cause sepsis. Candida species are some of the most frequent fungi that cause sepsis. In general, a person with sepsis can be contagious, so precautions such as hand washing, sterile gloves, masks, and clothing coverage should be considered depending on the patient’s infection source.

What are the risk factors for sepsis?

The following groups are at increased risk for sepsis:

  • The very young and the elderly are at greatest risk
  • People who are very ill due to an infectious agent
  • People in an intensive-care unit
  • People with weakened or compromised immune systems
  • People with devices such as IV catheters, breathing tubes, or other devices
  • People with extensive burns
  • People with severe trauma
 
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