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By N. Charles. Belmont Abbey College.

A skin biopsy specimen shows microabscesses at the tips of dermal papillae and granular deposits of IgA on the basement membrane zone order viagra plus 400 mg with visa. On the basis of this patient’s clinical presentation purchase 400 mg viagra plus with amex, what is the most likely diagnosis viagra plus 400mg without a prescription, and what treatment would you prescribe? Pemphigus foliaceus buy cheap viagra plus 400 mg; azathioprine Key Concept/Objective: To know the clinical presentation and management of dermatitis herpetiformis 2 DERMATOLOGY 23 Dermatitis herpetiformis is a vesiculobullous disease characterized by intensely pruritic discount viagra plus 400 mg with mastercard, small vesicles that are grouped in small clusters and typically appear on the extensor aspects of extremities and on the buttocks, scalp, and back. The condition is believed to be an immune-mediated disorder and is associated with abnormal granular deposits of IgA at the basement membrane zone and with asymptomatic, gluten-sensitive, spruelike enteropathy. The disease is chronic, with periods of exacerbation and remission. Lesions may clear if patients follow a strict gluten-free diet. Dermatitis herpetiformis responds rap- idly and dramatically to dapsone. Erythema multiforme is characterized by the presence of target lesions; it commonly affects mucosal surfaces. The histologic findings include subepidermal edema and a deep perivascular mononuclear infiltrate, sometimes with granular deposits of C3 or IgM. Pemphigus vulgaris and foliaceus show acantholysis; on immunofluorescence, intercellular autoantibodies, IgG, IgM, or IgA is seen. A 64-year-old retired Navy officer presents to clinic for a routine health maintenance visit. He has no complaints, but when asked about a pinkish papular lesion near the corner of his left eye, he states that it has been present “for years” and that it has become irritated on occasion with minor trauma or rub- bing. The lesion is 4 to 5 mm in diameter and appears pearly. You recommend that the patient undergo biopsy because you are concerned about the possibility of basal cell carcinoma (BCC). Which of the following epidemiologic and clinical statements is NOT true of BCC? The vast majority of BCCs occur on the head and neck C. Based on appearance, this patient’s lesion is likely a nodular BCC D. Metastatic disease and deaths associated with BCC have been reported E. BCC arises from cells in the dermis Key Concept/Objective: To understand fundamental aspects of basal cell carcinoma, a form of nonmelanoma skin cancer Malignant tumors can arise from cells of any layer of the skin, and epidermal skin cancers are the most common cancers in humans. Basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) arise from keratinocytes of the epidermis, whereas malignant melanoma arises from the melanocytes of the epidermis. Because BCC and SCC share many features, they are often lumped together under the term nonmelanoma skin cancer. BCC is the most common skin cancer and is more prevalent in people with lighter skin pigmentation. Over 90% of BCC lesions appear on the head and neck. The two most common forms are nodular BCC (which is likely the type that this patient demonstrates) and superficial BCC, which appears as a pink patch of skin. Although rare, metastases and death from BCC have been known to occur, and any suspi- cious lesions (especially long-standing ones in a sun-exposed area that easily bleed with minor trauma) should be excised and submitted for pathologic examination. A 50-year-old construction worker with hypertension presents for a return office visit. His blood pressure appears well controlled, and you are discussing other health maintenance issues as you examine him. You notice several rough-surfaced, irregularly shaped lesions on his face, scalp, and dorsa of the hands. On closer inspection, they appear hyperkeratotic and have a small rim of surrounding erythema. He says they are not painful, do not itch, and have been appearing over the course of years. Which of the following statements regarding this patient’s risk of skin cancer is true?

Air bags reduce the risk of death by an additional 9% in drivers using seat belts cheap 400mg viagra plus with visa. Because air bags reduce the risk of death by only 20% in unbelted drivers generic 400 mg viagra plus otc, physicians must tell their patients not to rely on air bags order 400mg viagra plus with amex. A 78-year-old woman with hypertension presents for a 3-month follow-up visit for her hypertension order viagra plus 400mg line. A year ago buy viagra plus 400mg visa, she moved to a retirement community, where she began to eat meals more regularly; during the past year, she has gained 15 lb. She is a lifelong smoker; she smokes one pack of cigarettes a day and has repeatedly refused to receive coun- seling regarding smoking cessation. She has occasional stiffness on waking in the morning. She reports taking the prescribed antihypertensive therapy almost every day. She is concerned about her weight gain because this is the most she has ever weighed. She has reported that she has stopped eating desserts at most meals and is aware that she needs to reduce the amount of fat she eats. She has never exercised regularly, but her daughter has told her to ask about an aerobic exer- cise program. She has asked for exercise recommendations, although she does not know whether it will make much difference. Which of the following would you recommend for this patient? Attendance at a structured aerobic exercise program at least three times a week ❏ B. Membership in the neighborhood YMCA for swimming ❏ C. Walking three times a week, preferably with a partner ❏ D. Contacting a personal trainer to develop an individualized exercise program ❏ E. No additional exercise because she has symptoms of osteoarthritis Key Concept/Objective: To recognize that even modest levels of physical activity such as walking and gardening are protective even if they are not started until midlife to late in life Changes attributed to aging closely resemble those that result from inactivity. In sedentary patients, cardiac output, red cell mass, glucose tolerance, and muscle mass decrease. Systolic blood pressure, serum cholesterol levels, and body fat increase. Regular exercise appears to retard these age-related changes. In elderly individuals, physical activity is also associated with increased functional status and decreased mortality. Although more stud- ies are needed to clarify the effects of exercise in the elderly, enough evidence exists to war- rant a recommendation of mild exercise for this patient, along with counseling concern- ing the benefits of exercise at her age. Walking programs increase aerobic capacity in indi- viduals in their 70s with few injuries. Although structured exercise is most often recom- mended by physicians, recent studies demonstrate that even modest levels of physical activity such as walking and gardening are beneficial. Such exercise is protective even if it is not started until midlife or late in life. Because this patient is used to a sedentary lifestyle 4 BOARD REVIEW and is not strongly motivated to begin exercising, compliance with exercise recommen- dations may be an issue. Lifestyle interventions appear to be as effective as formal exercise programs of similar intensity in improving cardiopulmonary fitness, blood pressure, and body composition. Exercise does not appear to cause or accelerate osteoarthritis. However, counseling concerning warm-ups, stretches, and a graded increase in exercise intensity can help prevent musculoskeletal problems as a side effect of exercise. A 50-year-old woman presents for a follow-up visit to discuss the laboratory results from her annual physical examination and a treatment plan. Her total serum cholesterol level is 260 mg/dl, which is up from 200 mg/dl the previous year. Her blood pressure is 140/100 mm Hg, which is up from 135/90 mm Hg; she weighs 165 lb, a gain of 12 lb from the previous year. Results from other tests and her physical examination are normal.

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The lesions may be discrete or multiple purchase 400mg viagra plus visa; they begin as painless macules or nodules and may become bullous purchase viagra plus 400 mg without a prescription. Lesions undergo central necrosis over a period of 12 to 24 hours cheap 400mg viagra plus with amex; surrounding the lesion is a rim of tender ery- thema best 400mg viagra plus. Pseudomonas and other pathogens commonly colonize the trachea in intubat- 7 INFECTIOUS DISEASE 33 ed patients without causing pneumonia buy generic viagra plus 400 mg on line. Whether bronchoscopy actually affects outcome is unclear. Typhlitis refers to localized gan- grenous necrosis of the cecum that causes pain in the right lower quadrant. It is associ- ated with neutropenia as well as Pseudomonas infection. The use of two agents increases the likelihood of effective initial therapy. Most reported cases have occurred in injection drug users; episodes have been known to complicate cardiac surgery. Hemodynamic decompensation in a bacteremic patient should always provoke consideration of infective endocarditis as the underlying cause. A 23-year-old man who is status post splenectomy after a motor vehicle accident 1 year ago presents to the emergency department with fever, shortness of breath, and severe pain on swallowing. He is accom- panied by his wife and their 6-month-old child. On physical examination, he has stridor and is sitting up with his neck extended and chin forward. Which of the following statements is correct regarding the care of this patient and his family? A lateral neck radiograph should be ordered, after which the patient should be reevaluated B. This local infection rarely results in positive blood cultures E. Ampicillin is the drug of choice if the patient is not allergic to penicillin Key Concept/Objective: To understand the treatment of epiglottitis caused by H. Patients with epiglottitis can experience airway obstruction of rapid onset because of worsening inflammation. Therefore, a physician prepared to secure an airway should accompany this patient to the radiology suite. Rifampin prophylaxis should be administered to all adults and children in households with at least one member (other than the index case) who is younger than 4 years and who has not been immunized or whose immunization is incomplete. Thus, both wife and child should receive prophylaxis. Epiglottitis should be considered an invasive infection; blood cultures are positive in many cases. The antibiotic of choice is a third-generation cephalo- sporin. Ampicillin is highly effective against sensitive strains, but 35% to 40% of North American isolates of H. In Arkansas, a previously healthy 14-year-old boy presents to a clinic with fever, chills, headache, and malaise. Approximately 10 days earlier, he spent a day hunting rabbits with a relative. Examination reveals an ulcerated lesion with a black base on the left forearm as well as left axillary lymphadenopa- 34 BOARD REVIEW thy. Laboratory tests are unremarkable except for a mildly elevated hepatic transaminase level. Which of the following statements regarding the diagnosis of tularemia is false? Serum agglutinins are usually detectable 2 to 3 weeks into the illness B. Pathology of infected lymph nodes is likely to reveal mononuclear cell infiltrate and granuloma formation C.

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He naps during the day for about 30 minutes when he can and almost always falls asleep while watching the news after work cheap 400 mg viagra plus mastercard. Serum electrolytes are remarkable for a potassium level of 3 buy viagra plus 400 mg mastercard. Which of the following is the most likely cause of this patient’s fatigue? Cerebrovascular disease Key Concept/Objective: To understand the presenting complaints of patients with excessive day- time somnolence Patients with excessive daytime somnolence (EDS) commonly awaken in the morning not feeling refreshed cheap 400mg viagra plus with visa. Insufficient sleep is among the most common causes of EDS discount 400mg viagra plus visa. Others include obstructive and central sleep apnea buy 400mg viagra plus with mastercard, narcolepsy, and periodic limb movements. These patients commonly have a decreased sleep-onset latency, fatigue upon awakening, and urges to sleep during the day. History-taking should be directed at sleep patterns, drug and alcohol use, and psychiatric illness. If an obvious cause of sleep disturbance is not found during the clinical exam, a sleep study can help identify such causes as obstructive sleep apnea, restless leg syndrome, and periodic limb movement in sleep. Complaints of pain are among the most common reasons for patients to visit a health care profession- al. New pain complaints account for close to 40 million physician visits annually in the United States. Which of the following statements regarding pain is false? Chronic pain, in contrast to acute pain, does not warn the patient of bodily injury and serves no useful function B. Neuropathic pain is caused by injury to the peripheral nervous system or CNS and can occur chronically without ongoing damage C. Between one third and one half of cancer patients report pain that cannot be controlled with analgesics D. Treatment of chronic pain should not be undertaken unless physical examination reveals demonstrable pathology, such as neurologic changes or signs of duress (e. Inquiries about psychosocial and financial factors related to pain are an important part of an initial pain evaluation Key Concept/Objective: To understand that chronic pain is common and to know the basic tenets of the management of chronic pain 11 NEUROLOGY 39 Pain is a subjective experience, and its expression is unique to each patient. Often there is little objective evidence with which to assess the source or intensity of pain. Thus, one of the most important aspects of the patient-physician relationship regarding the treatment of chronic pain is trust: the physician is obligated to rely on the patient’s self-reports of pain; to do otherwise may be unethical. Pain is a complex process that involves biologic and psychosocial factors. It can be classified as somatic (involving activation of nocicep- tors in cutaneous and deep musculoskeletal tissues), visceral (resulting from abnormal forces on thoracic, abdominal, and pelvic viscera), and neuropathic (resulting from injury to the peripheral nervous system or the CNS). Pain complaints are extremely common in patients with chronic disease, such as cancer and AIDS; over three fourths of such patients report pain symptoms. Unfortunately, a large percentage of patients with terminal cancer have pain that is inadequately controlled. A detailed financial and psychosocial history is of paramount importance because of the multifactorial nature of pain. A 50-year-old diabetic woman has diabetic nephropathy and neuropathy that involves her lower extremities. She complains of paresthesias and chronic lancinating pains in the feet. She has received treatment with several nonsteroidal anti-inflammatory drugs (NSAIDs), and for the past 6 months she has been taking a combination of acetaminophen and codeine. Her pain has limited her ability to perform her job, which requires spending long periods of time on her feet. Which of the following is the most appropriate option for treating this patient’s chronic pain? Substitution of oral meperidine for her current analgesic regimen B. Addition of an adjuvant analgesic such as gabapentin or a tricyclic antidepressant to her regimen C. Immediate discontinuance of opioid medication and referral to physi- cal therapy D. The addition of high-dose ibuprofen three times daily to her current regimen Key Concept/Objective: To understand the use of adjuvant medications for the treatment of neu- ropathic pain Neuropathic pain is common in patients with diabetic neuropathy and in those who have had shingles (postherpetic neuralgia).

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Frequently cheap 400mg viagra plus with mastercard, the usual signs and symptoms of infection are attenuated or absent in these patients because of the absence of the inflam- matory responses to infection purchase 400mg viagra plus amex. In the neutropenic patient cheap viagra plus 400mg mastercard, minor infections that might oth- erwise have been well localized can become serious disseminated infections very quickly proven viagra plus 400mg. Management includes careful evaluation of the oropharynx buy generic viagra plus 400mg, skin, lungs, GI tract, and gen- itourinary tract for subtle signs of infection. Cultures and a chest x-ray are obtained, and empirical antibiotics are started. Clinicians can select traditional combinations of a β-lac- tam antibiotic active against Pseudomonas (e. Although colony-stimulating factors may be considered for adjunctive use in selected high-risk, severely ill neutropenic patients, they are not indicat- ed in most febrile neutropenic patients. A 23-year-old woman underwent allogeneic bone marrow transplantation for acute myelogenous leukemia. On day 11, she began to complain of right upper quadrant pain, and her weight began to climb. On examination, peripheral edema and tender hepatomegaly were appreciated. Over the next several days, she developed increasing abdominal girth, and her bilirubin level increased to 12 mg/dl. Veno-occlusive disease of the liver Key Concept/Objective: To recognize veno-occlusive disease as a potential complication of hematopoietic stem cell transplantation This patient presents with typical findings of veno-occlusive disease, including ascites, hepatomegaly, jaundice, and fluid retention. Veno-occlusive disease typically occurs in the first few weeks after transplantation. Pathologically, there is cytotoxic injury to the hepat- ic venulae and sinusoidal endothelium, resulting in vascular blockage (the clinical picture is similar to that of Budd-Chiari syndrome). There is a high mortality, and research contin- ues in the fields of treatment and prevention. Other possible causes include GVHD, viral hepatitis, drug reaction, sepsis, heart failure, and tumor invasion. However, acute ascites and fluid retention are more typical of veno-occlusive disease. A 42-year-old man presents with fatigue and progressive left upper quadrant pain. CBC reveals a hematocrit of 32% and a WBC count of 97,000/mm3. Bone marrow biopsy reveals hyperplasia of the granulocytic series, and the cytogenetic analysis confirms the presence of the Philadelphia chromosome. A diagnosis of chronic myeloid leukemia (CML) is made. What is the most appropriate step to take next for this patient? Leukapheresis Key Concept/Objective: To understand the role of allogeneic transplantation in chronic myeloge- nous leukemia If an appropriate HLA-matched sibling can be found, most experts would recommend allo- geneic transplantation as initial therapy for a person younger than 50 years who is diag- nosed with CML. In older patients, therapy with interferon alfa or hydroxyurea may be more appropriate. Therefore, the search for potential donors is the critical first step. Leukapheresis is only infrequently used (primarily in chronic lymphocyte leukemia) when white cell counts are extremely elevated and there are acute CNS symptoms. What is the chance that the sister of the patient in Question 48 will be an HLA match? Therefore, there is a one-in-four chance of inheriting the identical haplotype of a sibling. An 18-year-old woman underwent allogeneic bone marrow transplantation for Hodgkin disease that had failed to respond to first-line chemotherapy. Roughly 6 weeks after transplantation, she is diagnosed with acute GVHD.

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