By C. Lars. University of Arkansas at Monticello. 2017.

For this patient cheap 100 mg asendin otc, which of the following statements regarding renal vein thrombosis (RVT) is true? RVT is most frequently associated with idiopathic and secondary membranous nephropathy order asendin 50mg visa; of these patients, 30% may have RVT 10 NEPHROLOGY 17 B. In addition to acute lower back pain and hematuria, most patients present with some degree of renal insufficiency C. Doppler ultrasonography is the most common modality used in the diagnosis of RVT D. For patients with RVT, a 6-month course of warfarin is indicated Key Concept/Objective: To understand the prevalence, clinical presentation, diagnostic modal- ities, and treatment of RVT RVT has been most frequently associated with idiopathic and secondary membranous nephropathy; 30% of these patients may have RVT. Pulmonary embolism may develop in up to 30% of patients with RVT, although alarmingly, the vast majority of these patients are asymptomatic. The classic clinical presentation of RVT is acute lower back pain and gross hematuria. Patients typically do not have renal insufficiency or hyper- tension. RVT can be diagnosed by computed tomography, magnetic resonance imaging, and contrast venography. Doppler ultrasound imaging is notoriously operator depend- ent and therefore should not be used for the diagnosis of RVT. Anticoagulation with warfarin is indicated for patients with RVT. The appropriate duration of therapy is likely lifelong. A 48-year-old white man with no significant medical history presents to your office with fever, weight loss, malaise, and arthralgia. Over the past few weeks, he has developed a purplish rash over his lower extremities and several sores on his toes. He is afebrile, but his blood pressure is 187/92 mm Hg and his heart rate is 97 beats/min. Livedo reticularis and digital ischemia are noted on examination.

He denies having any respiratory or gastrointestinal symptoms but reports some frequency in urination buy discount asendin 50 mg. He states that he has poorly con- trolled diabetes and a history of prostate surgery buy asendin 100mg fast delivery. He takes a daily dose of trimethoprim-sulfamethoxa- zole for prophylaxis against urinary tract infections. He has tenderness in the suprapubic region and has bilateral cos- tovertebral tenderness. Which of the following statements regarding this patient is false? The type of infection seen in this patient is most common in persons with underlying genitourinary disease and in the elderly C. Recently, vancomycin-resistant enterococci have been recognized as noso- comial pathogens. Enterococci are morphologically and immunologically similar to group D streptococci, but unlike streptococci, they are uniformly penicillin-resistant. They have unique penicillin-binding proteins that permit cell wall synthesis to proceed even in the presence of β-lactam antibiotics. Enterococcal infections are most common in persons with underlying genitourinary or gastrointestinal disease, in the elderly, and in debilitated persons. The primary reason that enterococci have emerged as major pathogens is that these organisms are resistant to many antibiotics. Changing resistance patterns will necessitate changes in antibiotic therapy for patients with enterococcal infections. A 33-year-old woman who is a known intravenous drug abuser and who is HIV positive presents with fever and chills. She has been injecting in her right femoral vein and reports a red swollen mass in the area.

What is the most common cause of death in patients with RA? Non-Hodgkin lymphoma Key Concept/Objective: To understand that mortality is higher in patients with RA and to be able to identify the leading causes of death in patients with RA Patients with RA die at earlier ages than those without the disease 100mg asendin fast delivery. The leading cause of death in patients with RA is cardiovascular disease (40% to 45% of deaths) cheap 100mg asendin fast delivery; this increase in 15 RHEUMATOLOGY 7 cardiovascular mortality may be related to the chronic inflammation caused by the dis- ease and to the potential for vascular disease associated with treatments such as glucocor- ticoids. Malignancy accounts for 15% of deaths in these patients; infections account for 10%. There is an increased incidence of lymphoproliferative diseases such as non-Hodgkin lymphoma and Hodgkin disease in patients with RA. A 34-year-old woman with a 5-year history of rheumatoid arthritis presents for routine follow-up. She complains of 1 to 2 hours of morning stiffness and mild swelling of multiple PIP and MCP joints. Physical examination (in early after- noon) reveals mild synovitis of the MCPs and PIPs of both hands and difficulty making a full fist. X-rays demonstrate small erosions in the joints of the hands and feet that seem to have progressed since last year. What therapy would you recommend for this patient’s arthritis? This patient on sulfasalazine has developed further x-ray changes, and the next step for most rheumatologists would be to add methotrexate to the regimen to gain more control of the synovitis that is damaging her joints. The dose could be increased to as much as 25 mg/wk, if needed, to control her disease. More than 2 g/day of sulfasalazine is rarely more effective but is potentially more toxic. Low-dose prednisone may help her symptoms but would not affect the disease process. Finally, hydroxychloroquine, although safe, has less disease-modifying power than methotrexate.

A zone remains between the various arterial ter- called a transient ischemic attack (TIA) order 100mg asendin mastercard. Its cause could ritories — the arterial borderzone region (a watershed be blockage of a blood vessel that resolves spontaneously purchase 100 mg asendin fast delivery, area). This area is poorly perfused and prone to infarction, or perhaps an embolus that breaks up on its own. Regard- particularly if there is a sudden loss of blood pressure less, people are being educated to look at this event as a (e. The statistics indicate that many of CLINICAL ASPECT these people would go on to suffer a significant stroke. The most common clinical lesion involving these blood vessels is occlusion, often due to an embolus originating © 2006 by Taylor & Francis Group, LLC Neurological Neuroanatomy 165 Premotor Central (area 6) fissure Frontal Precentral Postcentral eye field Supplementary gyrus gyrus (area 8) motor (area 4) (areas 3, 1, 2) P Parieto- F occipital fissure O Visual association (areas 18 , 19) T Broca’s Lateral Anterior Middle Wernicke’s area fissure cerebral a. FIGURE 60: Blood Supply 4 — Cortical Dorsolateral Surface (photograph with overlay) © 2006 by Taylor & Francis Group, LLC 166 Atlas of Functional Neutoanatomy FIGURE 61 the control of micturition seems to be located on this medial area of the brain, perhaps in the supplementary BLOOD SUPPLY 5 motor area (see Figure 53), and symptoms related to vol- untary bladder control may also occur with lesions in this area. CORTICAL: MEDIAL (PHOTOGRAPHIC The clinical deficit found after occlusion of the pos- VIEW WITH OVERLAY) terior cerebral artery on one side is a loss of one-half of the visual field of both eyes — a contralateral homony- In this illustration, the blood supply to the medial aspect mous hemianopia. The blood supply to the calcarine cor- of the hemispheres has been superimposed onto this view tex, the visual cortex, area 17, is discussed with Figure of the brain (see Figure 17). The vascular territories of the various cerebral deficits that are found after a lesion in different parts of blood vessels are shown in color in this diagram. It runs in the blood supply is marginal, but which is still viable and may interhemispheric fissure, above the corpus callosum (see be rescued — the “penumbra,” as it is now called. In this Figure 16) and supplies the medial aspects of both the area surrounding the infarcted tissue, the blood supply is frontal lobe and the parietal lobe; this includes the cortical reduced below the level of nervous tissue functionality areas responsible for sensory-motor function of the lower and the area is therefore “silent,” but the neurons are still limb. The posterior cerebral artery (PCA) supplies the These studies have led to a rethinking of the therapy occipital lobe and the visual areas of the cortex, areas 17, of strokes: 18, and 19 (see Figure 41A and Figure 41B). The posterior cerebral arteries are the terminal branches of the basilar • In the acute stage, if the patient can be seen artery from the vertebral or posterior circulation (see Fig- quickly and investigated immediately, the site ure 58). The demarcation between these arterial territories of the lesion might be identified.

In addition to determining the characteristics of the pain generic 50mg asendin free shipping, identifying all associated symptoms is helpful in narrowing the differential diagnosis asendin 100 mg free shipping. It is important to identify any other recent illnesses, as well as recent exposures to others who are ill. Determine whether the patient is experiencing any dys- phagia or respiratory difficulty. Physical Examination The physical examination for sore throat should include comprehensive assessment of the upper and lower respiratory systems, including ears, nose, mouth, throat, and lungs. The neck assessment should include, at a minimum, assessment of the cervical lymph nodes. A more-thorough neck assessment is indicated if carotidynia or thyroiditis is suspected. Diagnostic Studies Strep screens, throat cultures, and mononucleosis screens are common diagnostic studies used to narrow the differential diagnosis of sore throat. Complete blood counts with dif- ferential counts are helpful in determining the cause of sore throat. INFECTIOUS PHARYNGITIS Most cases of pharyngitis are viral in origin, and any number of the respiratory viruses can cause inflammation of the throat. The majority of viral pharyngitis cases are self-limited. Group A beta-hemolytic streptococcal (GABHS) pharyngitis is a bacterial infection of the pharynx, commonly referred to as strep throat. Complications of GABHS pharyngitis, although rare, include rheumatic heart dis- ease and glomerulonephritis and the condition requires prompt diagnosis and definitive treatment. Most patients with GABHS pharyngitis are children and youths.