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Issues and Testimonies in the Case of Lucy v Zehmer Report Paper

Issues and Testimonies in the Case of Lucy v Zehmer Report Paper.

LUCY v. ZEHMERSupreme Court of Appeals of Virginia. 1954196 Va. 493, 84 S.E.2d 516.BUCHANAN, JUSTICE. This suit was instituted by W.O. Lucy and J.C. Lucy, complainants, against A.H. Zehmer and Ida S. Zehmer, his wife, defendants, to have specific performance of a contract by which it was alleged the Zehmers had sold to W.O. Lucy a tract of land owned by A.H. Zehmer in Dinwiddie county containing 471.6 acres, more or less, known as the Ferguson farm, for $50,000. J.C. Lucy, the other complainant, is a brother of W.O. Lucy, to whom W.O. Lucy transferred a half interest in his alleged purchase.The instrument sought to be enforced was written by A.H. Zehmer on [Saturday] December 20, 1952, in these words: We hereby agree to sell to W.O. Lucy the Ferguson Farm complete for $50,000.00, title satisfactory to buyer,” and signed by the defendants, A.H. Zehmer and Ida S. Zehmer.The answer of A.H. Zehmer admitted that at the time mentioned W.O. Lucy offered him $50,000 cash for the farm, but that he, Zehmer, considered that the offer was made in jest; that so thinking, and both he and Lucy having had several drinks, he wrote out the memorandum” quoted above and induced his wife to sign it; that he did not deliver the memorandum to Lucy, but that Lucy picked it up, read it, put it in his pocket, attempted to offer Zehmer $5 to bind the bargain, which Zehmer refused to accept, and realizing for the first time that Lucy was serious, Zehmer assured him that he had no intention of selling the farm and that the whole matter was a joke. Lucy left the premises insisting that he had purchased the farm.Depositions were taken and the decree appealed from was entered holding that the complainants had failed to establish their right to specific performance, and dismissing their bill. The assignment of error is to this action of the court.The defendants insist that the evidence was ample to support their contention that the writing sought to be enforced was prepared as a bluff or dare to force Lucy to admit that he did not have $50,000; that the whole matter was a joke; that the writing was not delivered to Lucy and no binding contract was ever made between the parties.It is an unusual, if not bizarre, defense. When made to the writing admittedly prepared by one of the defendants and signed by both, clear evidence is required to sustain it.In his testimony Zehmer claimed that he “was high as a Georgia pine,” and that the transaction was just a bunch of two doggoned drunks bluffing to see who could talk the biggest and say the most.” That claim is inconsistent with his attempt to testify in great detail as to what was said and what was done. It is contradicted by other evidence as to the condition of both parties, and rendered of no weight by the testimony of his wife that when Lucy left the restaurant she suggested that Zehmer drive him home. The record is convincing that Zehmer was not intoxicated to the extent of being unable to comprehend the nature and consequences of the instrument he executed, and hence that instrument is not to be invalidated on that ground. C.J.S. Contracts, §, 133, b., p.483; Taliaferro v. Emery, 124 Va. 674, 98 S.E. 627. It was in fact conceded by defendants’ counsel in oral argument that under the evidence Zehmer was not too drunk to make a valid contract.The evidence is convincing also that Zehmer wrote two agreements, the first one beginning “I hereby agree to sell. Zehmer first said he could not remember about that, then that “I don’t think I wrote but one out.” Mrs. Zehmer said that what he wrote was `I hereby agree,” but that the “I” was changed to “We” after that night. The agreement that was written and signed is in the record and indicates no such change. Neither are the mistakes in spelling that Zehmer sought to point out readily apparent.The appearance of the contract, the fact that it was under discussion for forty minutes or more before it was signed; Lucy’s objection to the first draft because it was written in the singular, and he wanted Mrs. Zehmer to sign it also; the rewriting to meet that objection and the signing by Mrs. Zehmer; the discussion of what was to be included in the sale, the provision for the examination of the title, the completeness of the instrument that was executed, the taking possession of it by Lucy with no request or suggestion by either of the defendants that he give it back, are facts which furnish persuasive evidence that the execution of the contract was a serious business transaction rather than a casual jesting matter as defendants now contend..If it be assumed, contrary to what we think the evidence shows, that Zehmer was jesting about selling his farm to Lucy and that the transaction was intended by him to be a joke, nevertheless the evidence shows that Lucy did not so understand it but considered it to be a serious business transaction and the contract to be binding on the Zehmers as well as on himself. The very next day he arranged with his brother to put up half the money and take a half interest in the land. The day after that he employed an attorney to examine the title. The next night, Tuesday, he was back at Zehmer’s place and there Zehmer told him for the first time, Lucy said, that he wasn’t going to sell and he told Zehmer “You know you sold that place fair and square.” After receiving the report from his attorney that the title was good he wrote to Zehmer that he was ready to close the deal.Not only did Lucy actually believe, but the evidence shows he was warranted in believing, that the contract represented a serious business transaction and a good faith sale and purchase of the farm.In the field of contracts, as generally elsewhere, “We must look to the outward expression of a person as manifesting his intention rather than to his secret and unexpressed intention. `The law imputes to a person an intention corresponding to the reasonable meaning of his words and acts.'” First Nat. Exchange Bank of Roanoke v. Roanoke Oil Co., 169 Va. 99, 114, 192 S.E. 764, 770.At no time prior to the execution of the contract had Zehmer indicated to Lucy by word or act that he was not in earnest about selling the farm. They had argued about it and discussed its terms, as Zehmer admitted, for a long time. Lucy testified that if there was any jesting it was about paying $50,000 that night. The contract and the evidence show that he was not expected to pay the money that night. Zehmer said that after the writing was signed he laid it down on the counter in front of Lucy. Lucy said Zehmer handed it to him. In any event there had been what appeared to be a good faith offer and a good faith acceptance, followed by the execution and apparent delivery of a written contract. Both said that Lucy put the writing in his pocket and then offered Zehmer $5 to seal the bargain. Not until then, even under the defendants’ evidence, was anything said or done to indicate that the matter was a joke. Both of the Zehmers testified that when Zehmer asked his wife to sign he whispered that it was a joke so Lucy wouldn’t hear and that it was not intended that he should hear.The mental assent of the parties is not requisite for the formation of a contract. If the words or other acts of one of the parties have but one reasonable meaning, his undisclosed intention is immaterial except when an unreasonable meaning which he attaches to his manifestations is known to the other party. Restatement of the Law of Contracts, Vol. I, § 71, p.74..An agreement or mutual assent is of course essential to a valid contract but the law imputes to a person an intention corresponding to the reasonable meaning of his words and acts. If his words and acts, judged by a reasonable standard, manifest an intention to agree, it is immaterial what may be the real but unexpressed state of his mind. C.J.S. Contracts, §32, p. 361; 12 Am.Jur., Contracts, §19, p. 515.So a person cannot set up that he was merely jesting when his conduct and words would warrant a reasonable person in believing that he intended a real agreement…Whether the writing signed by the defendants and now sought to be enforced by the complainant was the result of a serious offer by Lucy and a serious acceptance by the defendants, or was a serious offer by Lucy and an acceptance in secret jest by the defendants, in either event it constituted a binding contract of sale between the parties. .The complainants are entitled to have specific performance of the contract sued on. The decree appealed from is therefore reversed and the cause is remanded for the entry of a proper decree requiring the defendants to perform the contract in accordance with the prayer of the bill.Reversed and remanded.Write about:Who (plaintiff) is suing whom (defendant)?Plaintiff Defendant Citation:Procedural Posture:How did the case get to the court? Where is this case being heard? Case History: What happened at the trial court level?Case Brief Description:What type of case is it? A contract dispute? A negligence claim? Facts of the Case These are the underlying facts — not who sued whom or what the trial court did, but what happened to create the dispute in the first place. What do the plaintiffs or defendants want?Issues: The issue should state the question before the court in a manner that captures the procedural posture, but also reflects the facts of the case. For example: “Did the trial court make error?”Decision and Analysis: The holding or decision is the answer to the question posed in the “Issue” statement. It is the reason, or the justification, for the court’s conclusion that the plaintiff or defendant ought to prevail on appeal. It is, more generally, a rule that explains how a case with similar facts should be decided. A court may answer the issue presented in the following way: “If the defendant produces evidence that the plaintiff had been drinking while making the contract does that matter?What did the court hold and why? Is there a contract? Why or Why not?Is there a dissent? What are you supposed to learn from reading the case?What are the important concepts?
Issues and Testimonies in the Case of Lucy v Zehmer Report Paper

Leadership And Change Management At Mcdonalds Business Essay

Leadership And Change Management At Mcdonalds Business Essay. “McDonalds started his business in 1940 with 1st restaurant opened in San Bernardino, California by Richard. It was the result of the thoughts of two young brothers, Mac McDonald’s and Dick who introduced a new revolutionary restaurant “Speedee Service System” in 1948 which was established on principles of the modern fast-food restaurant. Speedee completely replaced with Ronald McDonald’s by 1967. McDonald’s as Trade Mark is time used on May 4, 1961, with the description of “Drive In Restaurant Services” and still continues until end of June, 2010. The logo “M” with double arched overlapping as trademark was introduced in Sep 13 1961. The double overlapped as trade mark symbol “M” as logo temporarily disfavoured by September 6, 1962. The modern double arched “M” symbol started in November 18, 1968. “(McDonalds, 25 August, 2010, http://www.mcdonalds.co.uk ) “Big Mac started in 1968, Egg McMuffin started in 1973, Happy Meal for children started in 1979 and Chicken McNuggets started in 1983 .At the present time, McDonald’s have more than 31,000 restaurants in 119 different countries of the world of which a lot are franchised”. (www.mcdonals.com.uk) “McDonald’s vision is to become world’s best and quick service experience restaurant for this purpose McDonald’s delivering outstanding quality, service, cleanliness, and value, so that we make every customer in every restaurant smile. In mission statements includes best employer or our people in each community around the world, excellent operational for delivery to customers and enduring profitable growth by expanding the brand and leveraging strength of McDonald’s through innovation and technology” McDonald Corporation ,2010) Change and Resistance to Change: “According to Rev Sharon Patterson that which people want to changes are babies who have wet diapers. We can be explained that change is the pain full processes in the place of work towards real physically changes are consists exciting incentives.” (Bernerth, 2004) Change Process Model “Though we all know and believe that success is change so every one want and need success because everyone want earning profit and want to hold this success but on the other hand we don’t forget that every change have some resistances and resistance only in the response of change. (Duck, 1993)” According to Duck (1993) bluntly he pointed out that “Changes are strongly personal”. “According to Petersen (2002) many people consider that change basically factor of “Fear and uncertainly and some Doubts”. (Peterson, 2002)” “As change broadly accepted all over the world as usual from top management to down management and its also brings high management and those people who are in the capacity of manage by any management they always show resistances against the change before application of change or before forward change its duty of manager to make a such type framework which should be overcome over all resistance before implementation”. (Peterson, 2002) “Resistance to change can be defined as it’s an apparent attitude of organization employees or members who are declined to admit any change within organization”. (Cheng and Petro Vic Lazar Vic, 2004). “James Hunt says Resistance isn’t an indication that something is wrong with what you are trying to change. It is an indication that something is happening”. “Ansoff defined Resistance as its only cause of creation unexpected delays and different types of costs or losses which create instabilities into the process of costs and instabilities into the process of planned change” (Ansoff, 1988) “Resistance is any employee behaviour trying to stop or delay in any change”. (Bemmels and Reshef 1991) Real example of the change process and its implementation. British Airways. “Past in 1981, British Airways hired on board of Directors a new chairperson. When this chairperson joined, he noticed that the company was very unproductive and was wasting a lot of valuable resources in useless activities. To make the organization efficient and increasing the profit ratio he decided to restructure the entire organization. He realized that Change Methodology Management Plan is the best way to serve that purpose”. (Jean Scheid, 2010) “Systematically, the British airways started reducing workforce. But, before started this, through his change management leadership, the chairman gave the all reasons for the restructuring and privatization of the company in order to prepare them for the future change. He directed his company through a hard time that could have been terrible without effective change management resistance communication just only through his LeadershipLeadership And Change Management At Mcdonalds Business Essay

In Sickness and in Health I Contain Multitudes by Ed Yong Chapter Summary

term paper help In Sickness and in Health I Contain Multitudes by Ed Yong Chapter Summary.

Read the Material I provided in attachment files: I Contain Multitudes Chapter 5(only Chapter 5!!!)Here are the main criteria for the essay reflections for I Contain Multitudes:At least a five hundred word essay & 12 point font & double spaced*Write about 3 to 6 interesting ideas that you learned about in the chapter and explain why you found them interesting.Or how they apply to what we are learning.Or how they reveal the way scientists work. Or any other aspect you find relevant to comment on.Or something you read that contradicts what you thought about a certain topic or science idea.Or describe a new technique or form of technology that is being described in the chapter.Or anything that surprised you in the reading and why it surprised youOr did the reading correct a misconception about something you had learned earlier in your life?Or Summarize the chapter, each example story or research would have 1-2 paragraphs.Usually the essay is 1.5 to 2.5 pages long.Remember I need to “hear” YOUR voice in the essay.Try to use simple words (avoid to high level english vocab) as possible as you can
In Sickness and in Health I Contain Multitudes by Ed Yong Chapter Summary

Issue of Tariffs on Sugar Imports in China

China sugar industry to obby government on extension on hefty tarrifs on sugar imports The plan to request an extension of the tariffs was discussed at a meeting organized by the China Sugar Association on Thursday. Beijing’s trade measures on sugar imports, set to expire on May 21, 2020, “have played an effective role in safeguarding the interest of the domestic industry, and promoting healthy and stable development of the sector,” said the draft document that was dated Sept. 5. China’s domestic sugar sector has struggled to compete with foreign rivals due to higher production costs. Chinese white sugar prices CSRc1 also plunged in 2018, amid a global supply surplus, pushing many producers into the red. The Guangxi Sugar Association, in China’s top producing region for the sweetener, will submit the application for the extension of the tariffs on behalf of the entire domestic sugar industry, according to the document. A source familiar with the matter confirmed that the industry group is consulting lawyers and experts, and drafting the application to be submitted to the government. It is not clear when the Guangxi association will submit the plan or what Beijing’s response will be, as other major sugar exporters continue to pressure China to drop the trade measure to curb imports. “The safeguard measures are a very complicated issue. Application is still only an plan. It is not easy to extend (the measures),” said one of the sources who was briefed on the plan. Separately, China Sugar Association will also look into the possibility of an anti-dumping and anti-subsidy investigation into imported sugar products, according to a second draft document discussed at the Thursday meeting. Some sugar exporting countries and regions have exported sugar products at below cost prices, or with subsidies, which has damaged China’s domestic sugar industry, the document said. The draft does not outline proposed tariff rates if the safeguard measures are extended. China in May 2017 hit major exporting nations with hefty tariffs on sugar shipments after years of lobbying by domestic mills. Beijing started to levy extra tariffs on out-of-quota sugar imports from all origins last August. China’s sugar industry plans to request the Chinese government to extend the 2017 hefty tariffs on sugar imports. Due to a global supply surplus in 2018, Chinese white sugar prices decreased drastically, which has negatively impacted many domestic producers. A tariff is defined as an import duty, a tax levied per unit on the price of imported goods and are considered the most common form of trade restriction. Tariffs are used to protect a domestic industry from competition (protective tariff) or to raise revenue for the government (a revenue tariff). Figure 1, shows that under free trade, China accepts the world price Pw, where it produces quantity Q1 , demands Q4 ,and imports Q4 – Q1. With imposed tariffs from 2017, the price of imported goods rises to P w T, causing the domestic price of goods to rise above the world price by the amount of the tariff, to P w T. At P w T, the domestic quantity supplied increases from Q1 to Q2, domestic quantity demanded falls from Q4 to Q3, and the quantity of imports falls to Q3 – Q2. The impact of the tariffs is negative on both the Chinese consumers and foreign producers. However, it is beneficial for domestic producers, as they receive a higher price, P w T, and sell a larger quantity Q2(rather than Q1). The government also gains tariff revenues as per the yellow box. However, the decrease in consumption and the shift of production away from more efficient foreign producers, to more inefficient domestic producers indicate that there is an increase in misallocation of resources both domestically and globally (represented by the orange Deadweight loss triangles in figure 1). Figure 2 shows that some countries, are producing more than their domestic consumption due to subsidies. Before the subsidy, domestic production is at Q1, domestic consumption is at Q2, and import are Q2 – Q1. The subsidy shifts the domestic supply curve from Sd to S ds. Hence, the new quantity of domestic production is Q3 which is greater than Q2. As the excess capacity produced, Q3 – Q2 cannot be absorbed by the local markets, it is dumped on international markets by the producers, i.e. sold at a price which is below the cost of production. The effect of dumping has dire consequences on the Chinese sugar industry, as local producers cannot compete with these low prices. Dumping is considered ‘unfair’ by the World Trade Organization (WTO). This organization promotes fair trade competition as one of its main functions. Hence, it is highly recommended that China involves the WTO to investigate these low prices and resolve this issue, by imposing an anti-dumping tariffs in order to limit imports of the subsidized, or dumped goods. Moreover, it is recommended that the sugar industry evaluates subsidies from the government. Subsidies in the case of trade protection are the payments per unit of sugar output granted by the government to domestic firms that compete with imports. Figure 3 shows that under free trade, China produces Q1 of sugar, the quantity demanded is Q2. The excess demand is Q2 – Q1 will be catered to by imports. By granting subsidies (a determinant of supply) to the local producers, the domestic supply Sd will shift to S ds. The sugar domestic production moves from Q1 to Q3 and continue to sell at Pw. This will reduce the imports from Q2 – Q1 to Q2 – Q3, Thus, under this scenario, the consumption of sugar will remain unchanged at Q2, at price Pw. Consumers will purchase more local sugar, which is beneficial for the local economy in the short term. Therefore, in the long term, it will ensure a steady circular flow of economic activity. Hence, the domestic producers will sell locally at Pw (per unit), but they will receive Ps (per unit) as the government will subsidize their cost of production per unit. The production will increase from Q1 to Q3, which will benefit the producers in the short term. For the long term this shift of production from efficient to inefficient producers will affect negatively economies due to the misallocation of resources. Moreover, the downside of these subsidies in the short term, will have a negative effect on the government budget as the amount of the subsidy (Ps – Pw) multiplied by Q3 must be paid by tax revenues that could have been used in merit goods. Therefore, in the long term will allow an increase in domestic employment as the quantity produced expands from Q1 to Q3 keeping the consumption unaffected which is beneficial for the local economy. References https://www.reuters.com/article/us-china-sugar-imports-exclusive/exclusive-china-sugar-industry-to-lobby-government-for-extension-of-hefty-tariffs-on-imports-sources-idUSKCN1VR1N4

Walden University Knowledge Check Questions Paper

Walden University Knowledge Check Questions Paper.

I’m working on a writing question and need an explanation to help me understand better.

A 67-year-old Caucasian woman was brought to the clinic by her son who stated that his mother had become slightly confused over the past several days. She had been stumbling at home and had fallen once but was able to ambulate with some difficulty. She had no other obvious problems and had been eating and drinking. The son became concerned when she forgot her son’s name, so he thought he better bring her to the clinic. PMH-Type II diabetes mellitus (DM) with peripheral neuropathy x 20 years. COPD. Depression after death of spouse several months ago Social/family hx – non contributary except for 30 pack/year history tobacco use. Meds: Metformin 500 mg po BID, ASA 81 mg po qam, escitalopram (Lexapro) 5 mg po q am started 2 months ago Labs-CBC WNL; Chem 7- Glucose-92 mg/dl, BUN 18 mg/dl, Creatinine 1.1 mg/dl, Na+120 mmol/L, K+4.2 mmol/L, CO237 m mol/L, Cl-97 mmol/L. The APRN refers the patient to the ED and called endocrinology for a consult for diagnosis and management of syndrome of inappropriate antidiuretic hormone (SIADH). Question: Define SIADH and identify any patient characteristics that may have contributed to the development of SIADH. 1 points QUESTION 2 A 43-year-old female presents to the clinic with a chief complaint of fever, chills, nausea and vomiting and weakness. She has been unable to keep any food, liquids or medications down. The symptoms began 3 days ago and have not responded to ibuprofen, acetaminophen, or Nyquil when she tried to take them. The temperature has reached as high as 102˚F. Allergies: none known to drugs or food or environmental Medications-20 mg prednisone po qd, omeprazole 10 po qam PMH-significant for 20-year history of steroid dependent rheumatoid arthritis (RA). GERD. No other significant illnesses or surgeries. Social-denies alcohol, illicit drugs, vaping, tobacco use Physical exam Thin, ill appearing woman who is sitting in exam room chair as she said she was too weak to climb on the exam table. VS Temp 101.2˚F, BP 98/64, pulse 110, Resp 16, PaO2 96% on room air. ROS negative other than GI symptoms. Based on the patient’s clinical presentation, the APRN diagnoses the patient as having secondary hypocortisolism due to the lack of prednisone the patient was taking for her RA secondary to vomiting. Question: Explain why the patient exhibited these symptoms? 1 points QUESTION 3 A 64-year-old Caucasian female presents to the clinic with vague symptoms of non- specific abdominal pain, myalgias, constipation, polyuria, and says she feels “fuzzy headed” much of the time. She had about of kidney stones a few weeks ago and she fortunately was able to pass the small stones without requiring lithotripsy or other interventions. She was told by the urologist to follow up with her primary care provider after the kidney stones has resolved. The APRN examining the patient orders a Chem 7 which revealed a serum Ca++ of 13.1 mg/dl. The APN believes the patient has primary hyperparathyroidism and refers the patient to an endocrinologist who does a complete work up and concurs with the APRN’s diagnosis. Question: What is the role of parathyroid hormone in the development of primary hyperparathyroidism? 1 points QUESTION 4 A 64-year-old Caucasian female presents to the clinic with vague symptoms of non- specific abdominal pain, myalgias, constipation, polyuria, and says she feels “fuzzy headed” much of the time. She had a fracture of her right metatarsal without trauma and currently is wearing a walking boot. She also had a bout of kidney stones a few weeks ago and she fortunately was able to pass the small stones without requiring lithotripsy or other interventions. She was told by the urologist to follow up with her primary care provider after the kidney stones has resolved. The APRN examining the patient orders a Chem 12 which revealed a serum Ca++ of 13.1 mg/dl. The APRN believes the patient has primary hyperparathyroidism and refers the patient to an endocrinologist who does a complete work up and concurs with the APRN’s diagnosis. Question 1 of 2: Explain the processes involved in the formation of renal stones in patients with hyperparathyroidism. 0.5 points QUESTION 5 A 64-year-old Caucasian female presents to the clinic with vague symptoms of non- specific abdominal pain, myalgias, constipation, polyuria, and says she feels “fuzzy headed” much of the time. She had a fracture of her right metatarsal without trauma and currently is wearing a walking boot. She also had a bout of kidney stones a few weeks ago and she fortunately was able to pass the small stones without requiring lithotripsy or other interventions. She was told by the urologist to follow up with her primary care provider after the kidney stones has resolved. The APRN examining the patient orders a Chem 12 which revealed a serum Ca++ of 13.1 mg/dl. The APRN believes the patient has primary hyperparathyroidism and refers the patient to an endocrinologist who does a complete work up and concurs with the APRN’s diagnosis. Question 2 of 2: Explain how a patient with hyperparathyroidism is at risk for bone fractures. — Font family — Andale Mono Arial Arial Black Book Antiqua Comic Sans MS Courier New Georgia Helvetica Impact Symbol Tahoma Terminal Times New Roman Trebuchet MS Verdana Webdings Wingdings — Font size — 1 (8pt) 2 (10pt) 3 (12pt) 4 (14pt) 5 (18pt) 6 (24pt) 7 (36pt) — Format — Heading Sub Heading 1 Sub Heading 2 Paragraph Formatted Code — Font family — — Font size — Path: p Words:0 0.5 points QUESTION 6 A 64-year-old Caucasian female who is 4 weeks status post total parathyroidectomy with forearm gland insertion presents to the general surgeon for her post-operative checkup. She states that her mouth feels numb and she feels “tingly all over. The surgeon suspects the patient has hypoparathyroidism secondary to the parathyroidectomy with delayed vascularization of the implanted gland. She orders a Chem 20 to determine what electrolyte abnormalities may be present. The labs reveal a serum Ca++ of 7.1 mg/dl (normal 8.5 mg/dl-10.5 mg/dl) and phosphorous level of 5.6 mg/dl (normal 2.4-4.1 mg/dl). Question: What serious consequences of hypoparathyroidism occur and why? 1 points QUESTION 7 A 17-year-old boy is brought to the pediatrician’s office by his parents who are concerned about their son’s weight loss despite eating more, frequent urination, unquenchable thirst, and fatigue that is interfering with his school/work activities. He had been seemingly healthy until about 3 months ago when his parents started noticing these symptoms but put these symptoms down to his busy schedule including a part time job. He admits to sleeping more and tires very easily. He denies any other symptoms. PMH-noncontributory. No surgeries or major medical problems. Usual colds and ear infections as a child Allergies-none know Family history- maternal uncle with “some kind of sugar diabetes problem” but parents unclear on the exact disease process Social-denies alcohol, tobacco or illicit drug use. Not sexually active. Junior at local high school and works in a fast food store after school and on weekends. Labs in office: random glucose 220 mg/dl. Based on his symptoms and the glucose level, the pediatrician makes a tentative diagnosis of Diabetes Mellitus type 1 and refers the boy and his parents to an endocrinologist for further work up and management plan. Question 1 of 6: The patient exhibited classic signs of Type 1 diabetes. Explain the pathophysiology of “polydipsia.” 1 points QUESTION 8 A 17-year-old boy is brought to the pediatrician’s office by his parents who are concerned about their son’s weight loss despite eating more, frequent urination, unquenchable thirst, and fatigue that is interfering with his school/work activities. He had been seemingly healthy until about 3 months ago when his parents started noticing these symptoms but put these symptoms down to his busy schedule including a part time job. He admits to sleeping more and tires very easily. He denies any other symptoms. PMH-noncontributory. No surgeries or major medical problems. Usual colds and ear infections as a child Allergies-none know Family history- maternal uncle with “some kind of sugar diabetes problem” but parents unclear on the exact disease process Social-denies alcohol, tobacco or illicit drug use. Not sexually active. Junior at local high school and works in a fast food store after school and on weekends. Labs in office: random glucose 220 mg/dl. Based on his symptoms and the glucose level, the pediatrician makes a tentative diagnosis of Diabetes Mellitus type 1 and refers the boy and his parents to an endocrinologist for further work up and management plan. Question 2 of 6: The patient exhibited classic signs of Type 1 diabetes. Explain the pathophysiology of “polyuria.” 1 points QUESTION 9 A 17-year-old boy is brought to the pediatrician’s office by his parents who are concerned about their son’s weight loss despite eating more, frequent urination, unquenchable thirst, and fatigue that is interfering with his school/work activities. He had been seemingly healthy until about 3 months ago when his parents started noticing these symptoms but put these symptoms down to his busy schedule including a part time job. He admits to sleeping more and tires very easily. He denies any other symptoms. PMH-noncontributory. No surgeries or major medical problems. Usual colds and ear infections as a child Allergies-none know Family history- maternal uncle with “some kind of sugar diabetes problem” but parents unclear on the exact disease process Social-denies alcohol, tobacco or illicit drug use. Not sexually active. Junior at local high school and works in a fast food store after school and on weekends. Labs in office: random glucose 220 mg/dl. Based on his symptoms and the glucose level, the pediatrician makes a tentative diagnosis of Diabetes Mellitus type 1 and refers the boy and his parents to an endocrinologist for further work up and management plan. Question 3 of 6: The patient exhibited classic signs of Type 1 diabetes. Explain the pathophysiology of “polyphagia.” 1 points QUESTION 10 A 17-year-old boy is brought to the pediatrician’s office by his parents who are concerned about their son’s weight loss despite eating more, frequent urination, unquenchable thirst, and fatigue that is interfering with his school/work activities. He had been seemingly healthy until about 3 months ago when his parents started noticing these symptoms but put these symptoms down to his busy schedule including a part time job. He admits to sleeping more and tires very easily. He denies any other symptoms. PMH-noncontributory. No surgeries or major medical problems. Usual colds and ear infections as a child Allergies-none know Family history- maternal uncle with “some kind of sugar diabetes problem” but parents unclear on the exact disease process Social-denies alcohol, tobacco or illicit drug use. Not sexually active. Junior at local high school and works in a fast food store after school and on weekends. Labs in office: random glucose 220 mg/dl. Based on his symptoms and the glucose level, the pediatrician makes a tentative diagnosis of Diabetes Mellitus type 1 and refers the boy and his parents to an endocrinologist for further work up and management plan. Question 4 of 6: The patient exhibited classic signs of Type 1 diabetes. Explain the pathophysiology of “weight loss.” 0.5 points QUESTION 11 A 17-year-old boy is brought to the pediatrician’s office by his parents who are concerned about their son’s weight loss despite eating more, frequent urination, unquenchable thirst, and fatigue that is interfering with his school/work activities. He had been seemingly healthy until about 3 months ago when his parents started noticing these symptoms but put these symptoms down to his busy schedule including a part time job. He admits to sleeping more and tires very easily. He denies any other symptoms. PMH-noncontributory. No surgeries or major medical problems. Usual colds and ear infections as a child Allergies-none know Family history- maternal uncle with “some kind of sugar diabetes problem” but parents unclear on the exact disease process Social-denies alcohol, tobacco or illicit drug use. Not sexually active. Junior at local high school and works in a fast food store after school and on weekends. Labs in office: random glucose 220 mg/dl. Based on his symptoms and the glucose level, the pediatrician makes a tentative diagnosis of Diabetes Mellitus type 1 and refers the boy and his parents to an endocrinologist for further work up and management plan. Question 5 of 6: The patient exhibited classic signs of Type 1 diabetes. Explain the pathophysiology of “fatigue.” 0.5 points QUESTION 12 A 17-year-old boy is brought to the pediatrician’s office by his parents who are concerned about their son’s weight loss despite eating more, frequent urination, unquenchable thirst, and fatigue that is interfering with his school/work activities. He had been seemingly healthy until about 3 months ago when his parents started noticing these symptoms but put these symptoms down to his busy schedule including a part time job. He admits to sleeping more and tires very easily. He denies any other symptoms. PMH-noncontributory. No surgeries or major medical problems. Usual colds and ear infections as a child Allergies-none know Family history- maternal uncle with “some kind of sugar diabetes problem” but parents unclear on the exact disease process Social-denies alcohol, tobacco or illicit drug use. Not sexually active. Junior at local high school and works in a fast food store after school and on weekends. Labs in office: random glucose 220 mg/dl. Based on his symptoms and the glucose level, the pediatrician makes a tentative diagnosis of Diabetes Mellitus type 1 and refers the boy and his parents to an endocrinologist for further work up and management plan. Question 6 of 6: How do genetics and environmental factors contribute to the development of Type 1 diabetes? 1 points QUESTION 13 A 17-year-old boy recently diagnosed with Type I diabetes is brought to the pediatrician’s office by his parents with a chief complaint of “having the flu”. His symptoms began 2 days ago, and he has vomited several times and has not eaten very much. He can’t remember if he took his prescribed insulin for several days because he felt so sick. Random glucose in the office reveals glucose 560 mg/dl and the pediatrician made arrangements for the patient to be admitted to the hospitalist service with an endocrinology consult. BP 124/80mmHg; HR 122bpm; Respirations 32 breaths/min; Temp 97.2˚F; PaO297% on RA Admission labs: Hgb 14.6 g/dl; Hct 58% CMP- Na+ 122mmol/L; K+ 5.3mmol/L; Glucose 560mg/dl; BUN 52mg/dl; Creatinine 4.9mg/dl; Cl- 95mmol/L; Ca++ 8.8mmol/L; AST (SGOT) 248U/L; ALT 198U/L; CK 34/35 IU/L; Cholesterol 198mg/dl; Phosphorus 6.8mg/dl; Acetone Moderate; LDH38U/L; Alkaline Phosphatase 132U/L. Arterial blood gas values were as follows: pH 7.09; Paco220mm Hg; Po2100mm Hg; Sao2 98% (room air) HCO3-7.5mmol/L; anion gap 19.4 A diagnosis of diabetic ketoacidosis was made, and the patient was transferred to the Intensive Care Unit (ICU) for close monitoring. Question: The hormones involved in intermediary metabolism, exclusive of insulin, that can participate in the development of diabetic ketoacidosis (DKA) are epinephrine, glucagon, cortisol, growth hormone. Describe how they participate in the development of DKA. 1 points QUESTION 14 A 67-year-old African American male presents to the clinic with a chief complaint that he has to “go to the bathroom all the time and I feel really weak.” He states that this has been going on for about 3 days but couldn’t come to the clinic sooner as he went to the Wound Care clinic for a dressing change to his right great toe that has been chronically infected, and he now has osteomyelitis. Patient with known Type II diabetes with poor control. His last HgA1C was 10.2 %. He says he can’t afford the insulin he was prescribed and only takes half of the oral agent he was prescribed. Random glucose in the office revealed glucose of 890 mg/dl. He was immediately referred to the ED by the APRN for evaluation of suspected hyperosmolar hyperglycemic non ketotic syndrome (HHNKS). Also called hyperglycemic hyperosmolar state (HHS). Question: Explain the underlying processes that lead to HHNKS or HHS. 1 points QUESTION 15 A 32-year-old woman presented to the clinic complaining of weight gain, swelling in her legs and ankles and a puffy face. She also recently developed hypertension and diabetes type 2. She noted poor short-term memory, irritability, excess hair growth (women), red-ruddy face, extra fat around her neck, fatigue, poor concentration, and menstrual irregularity in addition to muscle weakness. Given her physical appearance and history, a tentative diagnosis of hypercortical function was made. Diagnostics included serum and urinary cortisol and serum adrenocorticotropic hormone (ACTH). MRI revealed a pituitary adenoma. Question: How would you differentiate Cushing’s disease from Cushing’s syndrome? 1 points QUESTION 16 A 47-year-old female is referred to the endocrinologist for evaluation of her chronically elevated blood pressure, hypokalemia, and hypervolemia. The patient’s hypertension has been refractory to the usual medications such as beta blockers, diuretics, and angiotensin-converting enzyme (ACE) inhibitors. After a full work up including serum and urinary electrolyte levels, aldosterone suppression test, plasma aldosterone to renin ratio, and MRI which revealed an autonomous adenoma, the endocrinologist diagnoses the patient with primary hyper-aldosteronism. Question: What is the pathogenesis of primary hyper-aldosteronism? 1 points QUESTION 17 A 47-year-old African American male presents to the clinic with chief complaints of polyuria, polydipsia, polyphagia, and weight loss. He also said that his vison occasionally blurs and that his feet sometimes feel numb. He has increased hunger despite weight loss and admits to feeling unusually tired. He also complains of “swelling” and enlargement of his abdomen. Past Medical History (PMH) significant for HTN fairly well controlled with and ACE inhibitor; central obesity, and dyslipidemia treated with a statin, Review of systems negative except for chief complaint. Physical exam unremarkable except for decreased filament test both feet. Random glucose in office 290 mg/dl. The APRN diagnoses the patient with type II DM and prescribes oral medication to control the glucose level and also referred the patient to a dietician for dietary teaching. Question: What is the basic underlying pathophysiology of Type II DM? 1 points QUESTION 18 A 21-year-old male was involved in a motorcycle accident and sustained a closed head injury. He is waking up and interacting with his family and medical team. He complained of thirst that doesn’t seem to go away no matter how much water he drinks. The nurses note that he has had 3500 cc of pale-yellow urine in the last 24 hours. Urine was sent for osmolality which was reported as 122 mOsm/L. A diagnosis of probable neurogenic diabetes insipidus was made. Question: What causes diabetes insipidus (DI)? 0.5 points QUESTION 19 A 43-year-old female patient presents to the clinic with complaints of nervousness, racing heartbeat, anxiety, increased perspiration, heat intolerance, hyperactivity and palpitations. She states she had had the symptoms for several months but attributed the symptoms to beginning to care for her elderly mother who has Alzheimer’s Disease. She has lost 15 pounds in the last 3 months without dieting. Her past medical history is significant for rheumatoid arthritis that she has had for the last 10 years well controlled with methotrexate and prednisone. Physical exam is remarkable for periorbital edema, warm silky feeling skin, and palpable thyroid nodules in both lobes of the thyroid. Pending laboratory diagnostics, the APRN diagnoses the patient as having hyperthyroidism, also called Graves’ Disease. Question: Explain how the negative feedback loop controls thyroid levels. 1 points QUESTION 20 A 43-year-old female patient with known Graves’ Disease presents to the clinic with complaints of nervousness, racing heartbeat, anxiety, increased perspiration, heat intolerance, hyperactivity and severe palpitations. She states she had been given a prescription for propylthiouracil, an antithyroid medication but she did not fill the prescription as she claims she lost it. She had been given the option of thyroidectomy which she declined. She also notes that she is having trouble with her vision and often has blurry eyes. She states that her eyes seem “to bug out of her face”. She has had recurrent outs of nausea and vomiting. She was recently hospitalized for pneumonia. Physical exam is significant for obvious exophthalmos and pretibial myxedema. Vital signs are temp 101.2˚F, HR 138 and irregular, BP 160/60 mmHg. Respirations 24. Electrocardiogram revealed atrial fibrillation with rapid ventricular response. The APRN recognizes the patient is experiencing symptoms of thyrotoxic crisis, also called thyroid storm. The patient was immediately transported to a hospital for critical care management. Question: How did the patient develop thyroid storm? What were the patient factors that lead to the development of thyroid storm? 1 points QUESTION 21 A 44-year-old woman presents to the clinic with complaints of extreme fatigue, weight gain, decreased appetite, cold intolerance, dry skin, hair loss, and sleepiness. She also admits that she often bursts into tears without any reason and has been exceptionally forgetful. Her vision is occasionally blurry, and she admits to being depressed without any social or occupational triggers. Past medical history noncontributory. Physical exam Temp 96.2˚F, pulse 62 and regular, BP 108/90, respirations. Dull facial expression with coarse facial features. Periorbital puffiness noted. Based on the clinical history and physical exam, and pending laboratory data, the ARNP diagnoses the patient with hypothyroidism. Question: What causes hypothyroidism? 0.5 points QUESTION 22 A 44-year-old woman is brought to the clinic by her husband who says his wife has had some mental status changes over the past few days. The patient had been previously diagnosed with hypothyroidism and had been placed on thyroid replacement therapy but had been lost to follow-up due to moving to another city for the husband’s work approximately 4 months ago. The patient states she lost the prescription bottle during the move and didn’t bother to have the prescription filled since she was feeling better. Physical exam revealed non-pitting, boggy edema around her eyes, hands and feet as well as the supraclavicular area. The APRN recognizes this patient had severe myxedema and referred the patient to the hospital for medical management. Question: What causes myxedema coma? 0.5 points QUESTION 23 A 53-year-old woman presents to the primary care clinic with complaints of severe headaches, palpitations, high blood pressure and diaphoresis. She relates that these symptoms come in clusters and when she has these “spells”, she also experiences, tremor, nausea, weakness, anxiety, and a sense of doom and dread, epigastric pain, and flank pain. She had one of these spells when she was at the pharmacy and the pharmacist took her blood pressure which was recorded as 200/118. The pharmacist recommended that she immediately be evaluated for these symptoms. Past medical history significant for a family history of neurofibromatosis type 1 (NF1). Based on the presenting symptoms and family history of NF1, the APRN suspects the patient has a pheochromocytoma. Laboratory data and computerized tomography of the abdomen confirms the diagnosis. Question 1 of 2: What is a pheochromocytoma and how does it cause the classic symptoms the patient presented with? 0.5 points QUESTION 24 A 53-year-old woman presents to the primary care clinic with complaints of severe headaches, palpitations, high blood pressure and diaphoresis. She relates that these symptoms come in clusters and when she has these “spells”, she also experiences, tremor, nausea, weakness, anxiety, and a sense of doom and dread, epigastric pain, and flank pain. She had one of these spells when she was at the pharmacy and the pharmacist took her blood pressure which was recorded as 200/118. The pharmacist recommended that she immediately be evaluated for these symptoms. Past medical history significant for a family history of neurofibromatosis type 1 (NF1). Based on the presenting symptoms and family history of NF1, the APRN suspects the patient has a pheochromocytoma. Laboratory data and computerized tomography of the abdomen confirms the diagnosis. Question 2 of 2: What are the treatment goals for managing pheochromocytoma? 1 points
Walden University Knowledge Check Questions Paper