By R. Cyrus. Whitman College.

Although there are no known copies of an incarnation of Lord Shiva cheap 2.5mg methotrexate visa, he was born in 509 the work remaining buy 2.5mg methotrexate with visa, the information imparted B. Legend has it that a crocodile grabbed young (Goraksanatha is a Sanskrit form of Gorakhnath), Shankara’s foot while he bathed in a river. When she niyama (disciplines), which precede asana in Patan- agreed, he uttered a mantra. According to Bengal lit- Govinda, a realized sage, and attained self-realiza- erature, he was born of the matted hair of the god tion (samadhi). As the purest and strongest of ies called Mutts, which exist today throughout yogis, he put the goddess Durga to shame with his India. Gorakhnath has been For studies of logic and metaphysics Shankara’s described as the most influential Indian since work is highly recommended. Ramakrishna Paramhansa As in the Yoga-Sutra, there is no mention of an Ramakrishna Paramhansa (1836–86) was a scholar author. He did not found any mantras, prayers, and psalms dealing with religious organization or claim to know a new path to salva- ceremony and ritual. He grew to realize that different religions lead Sama-Veda, Yajur-Veda, and Artharva-Veda. He was known to say, “As many According to the introduction in the book’s trans- faiths, so many paths” and “Man’s upliftment is the lation by Swami Paramananda, these scriptures main goal in life. The first Eng- master used to say that such names as Hindu, lish translation was that of Raja Ram Mohun Roy Christian, etc. They have all lost their man, the universal reality of consciousness, and the good powers and now only stand as baneful influ- identity of brahman with the inner essence (atman) ences under whose black magic even the best of us of the human being. Well, we will have to work philosophical schools of Vedanta, which is based pri- hard and we must succeed. Adi Shankara (also known as Samkara), one of Swami Vivekananda India’s greatest sages, wrote Advaita Vedanta, the When Swami Vivekananda was born, January 12, Vedanta treatise, among other texts. He became a disciple of Sri Rama- eternal which is beyond the pale of the sense krishna Paramhansa, who renamed him Swami which his reason cannot grasp. There is nothing higher humanitarianism and service to God through ser- than this. He who has achieved it, shall not be vice to others rather than on dogma, as well as on moved by the greatest sorrow. In 1897 this pio- meaning of Yoga—a deliverance from contact with neer of the Vedanta movement in the United States pain and sorrow. Various chapters of so appreciated that he is known as the “patron the Gita deal with renunciation and meditation. Union with The author, poet, and teacher Swami Paramananda God can be achieved by following a divine set of was the youngest monastic disciple of Swami guidelines that fall under the categories of hatha Vivekananda, founder of the Ramakrishna Order, (physical practice), jnana (knowledge), karma the most widely known religious and philanthropic (right action), bhakti (devotion), raja (control of the organization in India. The Hatha Yoga Pradipika He wrote several books, including Change Your Although the Yoga-Sutra is revered by all practi- Mind, A Practical Guide to Buddhist Meditation. A few more Bhagavad-Gita asanas (postures) are described in what is consid- The title of this book-length Sanskrit poem, Bha- ered the bible of the physical component of yoga, gavad-Gita, means “song of the Lord. This 500-page text was gavad Gita is the most widely read scripture in written by Sri Yogindra Svatmarama in the 14th India. Also known as the Gita, it is part of the century and provided the first textual evidence of Mahabharata (Great India), a religious classic of asanas. The story spotlights Lord Krishna and first explains yamas (restraints on behavior), niya- Prince Arjuna on the eve of the battle of Kuruk- mus (observances), asanas (postures), and nutrition. Krishna persuades Arjuna to fight his fear of The second discusses pranoyama (control or the opposing army with the armor of spiritual wis- restraint of energy) and the shatrurmas (internal dom attained through yoga (union with God). The third part talks about mudras (hand In chapter 6 of the Gita, considered the most gestures), bandhas (locks), the nadis (channels of important authority of yoga philosophy, Krishna energy through which prana flows), and the kun- advises Arjuna, “When his mind, intellect and self dalini power. The fourth describes pratyahara (with- (ahamkara) are under control, freed from restless drawal of the senses), dharana (concentration), desire, so that they rest in the spirit within, a man dhyana (meditation), and samadhi (absorption). A lamp does not flicker in a place where no winds Krishnamacharya blow; so it is with a yogic, who controls his mind, Tirumalai Krishnamacharya (1888–1989) receives intellect and self, being absorbed in the spirit much credit for shedding new light on what is now within him. By age intellect and self is stilled through the practice of 12 he was already a serious student of the Vedas. In Yoga, the yogic by the grace of the Spirit within 1924 he opened a school of yoga in Mysore, India. Desikachar, founded yoga 167 the Krishnamacharya Yoga Mandiram, a center for rule, he was jailed in 1909 for terrorist activities. One secret was that yoga can help walls that I was imprisoned; no, it was Vasudeva control the heartbeat. He believed that yoga is most [the father of the Vedic gods Krishna and authentic and useful when adapted to suit the indi- Balarama] who surrounded me.

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It can lead to hypovolemic shock and can significantly reduce vital capacity if it is not recognized buy methotrexate 2.5 mg online. Hemorrhage from injured lung parenchyma is the most common cause of hemothorax cheap 2.5mg methotrexate with visa, but this tends to be self-limiting unless there is a major laceration to the parenchyma. A hemothorax is treated with chest thoracostomy (chest tube) that is generally placed in the fourth or fifth intercostal space at the anterior or midaxillary line, over the superior portion of the rib. The tube should be directed superior and posterior to allow it to drain blood from the dependent portions of the chest. Indications for thoracotomy include: • Initial chest tube drainage of 1000 to 1500 cc of blood (a and b). In general, if the patient remains hemodynamically unstable after 40 cc/kg of crystal- loid administration (approximately 2-3 L), then a blood transfusion should be started. Fully cross-matched blood is preferable; however, this is generally not available in the early resuscitation period. Therefore, type- specific blood (type O, Rh-negative or type O, Rh-positive) is a safe alternative and is usually ready within 5 to 15 minutes. Type O, Rh-negative blood is typically reserved for women in their childbearing years to prevent Rh sensitization. Type O, Rh-positive blood can be given to all men and women beyond their childbearing years. Epinephrine is used if the patient is in cardiopulmonary arrest and no longer has a pulse. If the patient remains hypotensive despite resuscitation, then definitive measures need to take place, such as an exploratory laparo- tomy to stop the hemorrhage. It is important to focus the primary examination on the patient and evaluate the fetus in the secondary examination. Cardiotocographic observation of the viable fetus is recommended for a minimum of 4 hours to detect any intrauterine pathology. The minimum should be extended to 24 hours if, at any time during the first 4 hours, there are more than three uterine contractions per hour, persistent uterine tenderness, a non-reassuring fetal monitor strip, vaginal bleeding, rupture of the membranes, or any serious maternal injury is present. Shielding of the uterus in head and chest scans allows for an acceptable radiation exposure level. The mother with no obvious abdominal injury or even normal laboratory values still requires monitoring. Because of the central location of the disk herniation, symptoms are often bilateral and involve leg pain, saddle anes- thesia, and impaired bowel and bladder function (retention or inconti- nence). On examination, patients may exhibit loss of rectal tone and display other motor and sensory losses in the lower extremities. Patients, however, should not exhibit altered bowel and bladder function, or have decreased rectal tone. If so, the condition is likely cauda equina syndrome and is a neurologic emergency. Hyperventilation is a temporary maneuver and should only be used for a brief period of time during the acute resuscitation and only in patients demonstrating neuro- logic deterioration. Mannitol has the addi- tional benefit of expanding volume, initially reducing hypotension, and improving the blood’s oxygen-carrying capacity. Secondary to the gunshot, air has entered the pleural space, sec- ondary to the gunshot, and caused the right lung to collapse. This air cannot escape and pressure continues to increase, pushing the right lung into the mediastinum, causing the trachea to shift to the left. If this process is not cor- rected, venous return and cardiac output can be compromised and the patient will die. Classic symptoms of tension pneumothorax include dyspnea, tachypnea, tracheal deviation to the uninjured side, absent breath sounds on the injured side, and hypotension. Air should come out of the catheter and the patient’s clinical con- dition should improve. While intubation (b) is generally helpful for patients in respiratory distress, it can be dangerous in the setting of a tension pneumothorax. Positive pressure ventilation worsens the tension pneumothorax leading to further cardio- vascular compromise. This patient will likely require surgical management and the surgical team (d) should be called; however, needle decompression and tube thoracostomy are core emergency medicine skills and should be performed immediately by the emergency physician. On physical examination, he has tenderness to palpation in the mid-thoracic spine, and decreased strength in the upper extremities bilaterally, with nor- mal range of motion. Ordinarily, the patient is high functioning: she is ambulatory, cooks for herself, and walks on a treadmill 30 minutes a day. On examination, the patient has dry mucous membranes, but is otherwise unremarkable. Which of the following is the next most appropriate course of action to manage this patient with early-goal-directed therapy? Physical examination reveals a tender left testicle with a firm nodu- larity on the posterolateral aspect of the testicle.

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