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Serious liver disease cheap 250 mg zithromax fast delivery infection 1 mind games, usually in the form of cirrhosis buy cheap zithromax 250 mg online antibiotic 50s, occurs in 5% to 10% of adults with α1-antitrypsin deficiency and may provide a clue to the underlying enzyme deficiency in some patients. A 67-year-old man presents to your clinic for evaluation of dyspnea. He reports that his breathing has been worsening for years. He has a 100-pack-year history of cigarette smoking. His physical examination is notable for obesity, prolonged expiratory phase with faint wheezing, jugular veinous distention to the mandible, hepatosplenomegaly; and 2+ bilateral lower extremity edema. Which of the following would NOT be characteristic of this patient with type B COPD? Mild to moderate hypoxia with normal to slightly decreased arterial carbon dioxide tension (PaCO2) B. Progression to cor pulmonale; abnormal depression of arousal responses to hypoxia and hypercapnia during sleep D. Increased resistance to airflow in both phases of the respiratory cycle Key Concept/Objective: To know the clinical factors for differentiating and identifying COPD type A patients (pink puffers) from type B patients (blue bloaters) Type A patients exhibit dyspnea with only mild to moderate hypoxemia (arterial oxy- gen tension [PaO2] levels are usually > 65 mm Hg) and maintain normal or even slight- ly reduced PaCO2 levels. These patients are sometimes referred to as pink puffers; they tend to be thin, to experience hyperinflation at total lung capacity, and to be free of signs of right heart failure. Type B patients have marked hypoxemia and peripheral edema resulting from right heart fail- ure. These patients, who are sometimes called blue bloaters, typically exhibit cough and sputum production. They have frequent respiratory tract infections, experience chron- ic carbon dioxide retention (PaCO2 > 45 mm Hg), and have recurrent episodes of cor pul- monale. The blue bloater may also have pathologic evidence of severe emphysema; in addition, the blue bloater suffers from inflammation of large and small airways and 14 RESPIRATORY MEDICINE 9 possible defects in ventilatory control. A 67-year-old man with a history of emphysema presents with a complaint of worsening dyspnea and cough that is productive of yellow-colored sputum. Arterial blood gas measurements were performed several months ago. The baseline value for PaO2 was 53 mm Hg, and the carbon dioxide tension (PCO2) on room air was normal. There is evidence showing improved survival for which of the following interventions (in addition to smoking cessation)? Bronchodilator therapy Key Concept/Objective: To understand that only smoking cessation and long-term administra- tion of supplemental oxygen have been definitively shown to change the natural history of emphysema Reviews and guidelines on the treatment of CAO have been published, but they disagree on recommendations. Suboptimal prescription of and adherence to appropriate thera- pies further complicate the management of CAO. Of the therapeutic measures available for patients with chronic bronchitis and emphysema, only smoking cessation and long- term administration of supplemental oxygen to the chronically hypoxemic patient have been definitively shown to favorably alter the natural history of the disease. A variety of other therapies offer potential relief of symptoms in patients with CAO. These include the use of bronchodilators; anti-inflammatory therapy; the administration of antibiotics during acute purulent exacerbations; pulmonary rehabilitation programs, including physical exercise and respiratory muscle training; and, for patients with cor pulmonale, the use of diuretics. A randomized, multicenter clinical trial comparing lung volume reduction surgery with continued medical treatment in 1,218 patients with severe emphysema found that the surgery increased the chance of improved exer- cise capacity but did not confer a survival advantage, except in patients who had both predominantly upper lobe emphysema and low exercise capacity after rehabilitation. Broad-spectrum antibiotics, corticosteroids, and bronchodilators help improve symp- toms, not long-term survival. A 40-year-old man presents to your clinic for evaluation of dyspnea. The patient is a nonsmoker and reports a slow progression of breathlessness. He also reveals that several of his family members were diag- nosed with emphysema early in life, but he is confused because they were nonsmokers.

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Abdominal exami- nation shows mild tenderness in the lower abdomen without rebound order zithromax 250mg antibiotic levofloxacin. Rectal examination shows no masses order zithromax 500 mg on-line bacteria 4 pics 1 word, and the stool is heme-negative. Which of the following is the best step to take next for this patient? Determine serum prolactin and testosterone levels B. Send stool sample to assess for enteric pathogens and ova and parasite D. Reassure the patient that these are common side effects of his chemotherapy E. Arrange for urgent head CT with contrast Key Concept/Objective: To know the common side effects of antiandrogenic chemotherapy The common side effects of antiandrogenic chemotherapeutic agents such as nilutamide include nausea, diarrhea, and constipation. Hormonal effects include gynecomastia, galac- torrhea, breast tenderness, hot flashes, and decreased facial hair. Idiosyncratic reactions associated with nilutamide include delayed dark-light adaptation, interstitial pneumoni- tis, and alcohol intolerance. Thus, in this case, the patient needs to be reassured that these 8 BOARD REVIEW are usual side effects of his regimen. A 55-year-old white man presents to your primary care clinic for his annual physical examination. He underwent a colonoscopy 2 years ago, and an adenomatous polyp was removed. After the examination, the patient mentions that he has been reading about colon cancer and polyps in the news and wants to know his risk of having colon cancer. Which of the following statements regarding the relationship between colon cancer and polyps is false? Most colorectal cancers arise from preexisting adenomas B. Adenomatous polyps, as well as juvenile polyps, hamartomas, and inflammatory polyps, progress to colorectal carcinoma C. Larger polyps, especially those larger than 1 cm, are more likely to contain invasive carcinoma D. On the basis of histology, villous polyps are more likely to contain invasive carcinoma than are tubular polyps E. Fewer than 1% of adenomatous polyps become malignant Key Concept/Objective: To understand the relationship between various types of polyps and colorectal cancer It is thought that most colorectal cancers arise from preexisting adenomas. Such poten- tially premalignant lesions should be distinguished from juvenile polyps, hamartomas, and inflammatory polyps, which are not thought to progress to colorectal cancer. Histologically, adenomatous polyps may be tubular, villous, or both (tubulovillous). The larger the adenoma, the greater the likelihood that a villous component will be present. Villous polyps are more likely to contain invasive carcinoma than are tubular polyps of the same size. Regardless of histologic class, large polyps—especially those larger than 1 cm in diameter—are more likely to contain invasive carcinoma. Fewer than 1% of adenoma- tous polyps ever become malignant. A 45-year-old woman presents to your office to establish primary care. While taking her medical histo- ry, you notice she has a strong family history of colon cancer occurring at a young age. You suspect hereditary nonpolyposis colorectal cancer (HNPCC). Which of the following is NOT a part of the Amsterdam-2 criteria for identifying patients with HNPCC? Histologically documented colorectal cancer (or other HNPCC-related tumor) in at least three relatives, one of whom is a first-degree relative of the other two B. Cases of colorectal cancer in at least two successive generations of the family C.

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Depending on the patient’s presenting history and findings generic zithromax 100mg with visa antibiotics for acne side effects, examination may include other systems generic 100mg zithromax with amex antibiotics nerve damage. Diagnostic Studies For most mouth sores, diagnostic studies are not indicated. However, lesions can be cul- tured to provide definitive diagnosis of candida, herpes simplex, or other infectious causes. Biopsies may be indicated to diagnose or rule out malignancy. Painful Mouth Sores APHTHOUS ULCERS The cause of aphthous ulcers is unclear. A number of theories exist, including infection, stress, and food sensitivities. The ulcers are painful and usually small (less than 1 cm). The patient often has history of previous ulcers, which healed in approximately 1 week. The ulcer is shallow, surrounded by erythema and mild edema. Often only one ulcer is present, although patients may have multiple ulcers. On occasion, patients experi- ence larger ulcers, which take longer to heal and are associated with increased pain. Nursing health assessment: A critical thinking, case studies approach. Occasionally, the ulcers can be cultured to rule out herpes simplex. HERPES SIMPLEX Orolabial ulcers are often caused by herpes simplex type 1 virus. The patient often complains of a history of intermittent mouth sores, with onset as a youth. The ulcers are typically preceded by a prodromal phase of tenderness, followed by edema at the site where an individual or cluster of vesicles forms and progresses to ulcera- tion. The prodromal phase may also include malaise and fever. The vesicles have an ery- thematous base, and the ulcerated lesion often becomes crusted. The vesicles can be cultured for definitive diagnosis; a Tzanck smear can be performed in the office for rapid diagnosis. Herpes Zoster Herpes zoster has been previously described in Chapter 2. Compared with other painful mouth lesions, herpes zoster typically occurs in older individuals. Because the virus affects a dermatome, there are usually extraoral findings and complaints. Chemical and Thermal Burns As with any of the integument, the oral mucosa is at risk for chemical and thermal burns. The history is extremely important to identify whether the patient has been exposed to chemical agents or to a thermal source that would have resulted in the painful lesion. The distribution of the lesion(s) should be consistent with the history of exposure. HAND-FOOT-AND-MOUTH DISEASE Hand-foot-and-mouth disease is caused by a coxsackievirus. Outbreaks are most com- mon in the summer and fall months. On occasion, the condition is associated with menin- gitis. Skin and oral lesions are often preceded by a period of malaise and fever. The patient often presents once the oral lesions appear on the lips and/or oral mucosa. The lesions erupt as vesicles, which later ulcerate.

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