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By Z. Sanuyem. California State University, Monterey. 2018.

Currently buy super p-force oral jelly 160 mg amex, the patient is sedated and is on a ventilator buy 160mg super p-force oral jelly otc. Physical examination is remarkable for right lower lateral consolida- tion buy 160 mg super p-force oral jelly with visa, ecchymoses of the lower extremities purchase super p-force oral jelly 160 mg visa, and the absence of hepatosplenomegaly buy generic super p-force oral jelly 160mg online. No myelocytes or metamyelocytes are noted, and there is no elevation of the basophil or eosinophil count. The leukocyte alkaline phosphatase (LAP) score is 140 µm/L. Which of the following cannot be the cause of this patient’s elevated neutrophil count? Cytokine release Key Concept/Objective: To understand the causes of the leukemoid reaction and distinguish them from malignant causes The term leukemoid reaction is used to describe a profound leukocytosis (generally defined as a leukocyte count exceeding 25,000 to 30,000/mm3) that is not leukemic in eti- 20 BOARD REVIEW ology. Leukemoid reactions are the response of normal bone marrow to cytokine release by lymphocytes, macrophages, and other cells in response to infection or trauma. In a leukemoid reaction, the circulating neutrophils are usually mature and are not clonally derived. The major differential diagnosis is with regard to CML. Leukemoid reactions should also be distinguished from leukoerythroblastic reactions: the presence of immature white cells and nucleated red cells in the peripheral blood irrespective of the total leuko- cyte count. Although less common than leukemoid reactions in adults, leukoerythroblas- tosis reflects serious marrow stimulation or dysfunction and should prompt bone marrow aspiration and biopsy, unless it occurs in association with severe hemolytic anemia, sepsis in a patient with hyposplenism, or massive trauma. In such patients, trauma, hemorrhage, and infection all will contribute to a potent cytokine release and marrow stimulation. The absence of splenomegaly, leukocyte precursors (myelocytes, metamyelocytes), basophilia, or eosinophilia all point away from CML, and the elevated LAP score confirms the diag- nosis of a leukemoid reaction. On routine examination, a 45-year-old man is found to have a neutrophil count of 1,100/mm3. He feels well, takes no medications, and has no history of infection. His medical records reveal a persistent, asymptomatic neutropenia of 1,000 to 1,800 neutrophils/mm3 over the past 10 years. Which of the following ethnicities would help explain this patient’s low leukocyte count? Inuit Key Concept/Objective: To be able to recognize constitutional causes of neutropenia in certain populations Neutropenia is present when the peripheral neutrophil count is less than 1,000 to 2,000 cells/mm3. The normal range in Africans, African Americans, and Yemenite Jews is lower. In these populations, neutrophil counts of 1,500/mm3 are common, and neutrophil counts as low as 100/mm3 are probably normal. Evaluation should focus on a history of unusual infections, medications, or toxic exposures. If these factors are absent and if previous asymptomatic neutropenia can be documented, no further evaluation or special precau- tions are needed. A 59-year-old woman with severe, progressive rheumatoid arthritis is found to have a neutrophil count of 1,200/mm3 on routine hematologic testing. She takes methotrexate and prednisone for her rheuma- toid arthritis. In addition to rheumatoid nodules and rheumatoid joint deformities, moderate spleno- megaly is noted on physical examination. Which of the following would not be contributing to this patient’s neutropenia? Large granular lymphocyte syndrome Key Concept/Objective: To understand the various causes of neutropenia in rheumatoid arthritis With the exception of prednisone, each of the listed factors can lead to neutropenia in patients with rheumatoid arthritis. Methotrexate (as well as gold, penicillamine, and other disease-modifying agents) can cause severe leukopenia and neutropenia and require CBC monitoring during therapy. Prednisone and other corticosteroids, however, do not lower the neutrophil count. Indeed, the neutrophil count rises acutely after corticosteroid 5 HEMATOLOGY 21 administration, owing to demargination. Felty syndrome is the triad of rheumatoid arthri- tis, splenomegaly, and neutropenia and frequently includes hepatomegaly, lym- phadenopathy, fever, weight loss, anemia, and thrombocytopenia. Leg ulcers and hyper- pigmentation may also be seen. This syndrome develops late in the course of chronic, seropositive rheumatoid arthritis, often after the inflammatory arthritis has resolved.

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Ophthalmologists can perform additional tests generic super p-force oral jelly 160mg overnight delivery, including gonioscopy cheap 160 mg super p-force oral jelly with mastercard, which assesses the drainage angle buy super p-force oral jelly 160 mg fast delivery, to determine whether it is open or closed discount super p-force oral jelly 160mg otc. ACUTE CLOSED-ANGLE GLAUCOMA This less-common form of glaucoma results in acute visual disturbance order super p-force oral jelly 160mg fast delivery. The increased intraocular pressure may be transient, triggered by conditions that cause pupillary dilata- Copyright © 2006 F. As the intraocular pressure acutely increases, the patient typ- ically experiences considerable symptoms, although they may resolve before the patient arrives for evaluation. It is very important that the examiner not dilate the eyes when a patient presents with a history of unilateral eye pain and visual disturbance because the dilation may further exacerbate the intraocular pressure increase. During an episode of acute closed-angle glaucoma, the patient usually experiences severe, unilateral eye pain. Accompanying symptoms may include photophobia, headache, and nausea. The vision blurs, and the patient may perceive halos around lights. The eye reddens, with a ciliary flush, and the pupil may become fixed and mid-dilated. The cornea may become edematous, causing it to appear “hazy” and may develop a “dew drop” appearance. Whenever acute angle-closure glaucoma is suspected, the patient must be immediately referred to an ophthalmologist, who can complete tonometry and further diagnosis, in order to provide definitive treatment and to preserve the vision. AMAUROSIS FUGAX Amaurosis fugax is a monocular, transient loss of vision. It stems from transient ischemia of the retina and presents an important warning sign for impending stroke. Depending on the circumstances reported, the patient should be immediately referred to either a cardiovascular or neurological specialist. Four broad causes of amaurosis fugax include emboli, retinal vascular insufficiency, arterial spasms, and idiopathy. An episode of the vision loss that accompanies amaurosis fugax may last from only sec- onds to minutes. The patient often describes the episode as vision loss that is as if a shade were being pulled over one eye in a descending fashion and then, a short time later, the shade is raised. Unlike acute glaucoma, there is no associated pain during the episode. Depending on the duration of the episode, the funduscopic examination may reveal the retina as whitened, with a bright red fovea. If the occlusion is of the carotid, the patient may report or exhibit transient sensorimotor deficits. The funduscopic exam may reveal emboli, altered vessels, microaneurysms, and blot hemorrhages. Depending on the setting, a primary care provider can obtain carotid studies before the patient is actually seen by the physician. If valvular embolus has caused the disorder, the embolus may be visible. RETINAL DETACHMENT Retinal detachments are caused by trauma or by the traction caused by diabetic retinal disease. Regardless of the cause, patients suspected of having a retinal detachment should be immediately referred to an ophthalmologist. The patient usually provides a history of some trauma, followed by a sudden visual dis- turbance, such as flashing light, floaters, or scotoma. The visual defect may advance or progress, as the retinal detachment enlarges. Depending on the size of the defect, the patient may exhibit an afferent pupil defect. However, unilateral loss of vision in patients over 65 years of age may be caused by temporal arteritis; in this case, the patient is at risk for losing vision in the alter- nate eye. The visual loss is unilateral and may be limited to either the upper or lower visual field. However, patients with temporal arteritis will have previously experienced pain of the head, temple, or face, as well as more generalized symp- toms of polymyalgia rheumatica, including joint pain, malaise, weakness, fatigue, and even weight loss. With temporal arteritis, the sedimentation rate will often be elevated. A temporal artery biopsy is diagnostic, although treatment must not be withheld pending the biopsy.

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The diagnosis can be made with electrocardiogram if it is obtained while the patient is having pain discount super p-force oral jelly 160mg with visa, or with a graded exercise test order super p-force oral jelly 160mg otc. DENTAL PAIN The most common causes of dental-related jaw pain are the eruption of wisdom teeth and tooth decay or abscess buy generic super p-force oral jelly 160 mg, particularly in the molars buy cheap super p-force oral jelly 160 mg online. Wisdom teeth generally erupt in the late teens or early twenties buy cheap super p-force oral jelly 160mg online, so they should be part of the differential diagnosis in patients of that age. In patients with obviously poor dental hygiene, decay should be included in the differential diagnosis at any age. There are several other periodontal diseases that can cause jaw pain, and these are more prevalent with aging and poor dental hygiene. Jaw pain that is constant and throbbing in nature is typical when dental decay or abscess is the cause. The pain can be quite severe and requires analgesics and, if infection is pres- ent, antibiotics, until dental referral can be made. With the eruption of wisdom teeth, the pain is milder and generally not constant. Decay and abscess are quite obvious with a simple oral exam, whereas other forms of dental disease require in-depth dental evaluation. BRUXISM The term is used to define the clenching or grinding of teeth during sleep. The most common causes are malocclusion or tension and stress. Over the long term, bruxism can cause the teeth to wear down, erode, and loosen. Patients are usually not aware of the problem because it occurs during sleep, but they may experience TMJ pain. The diagnosis is usually made via the report of family members or through a routine dental exam. Occlusal guards for the teeth are helpful to prevent dental injury. PAROTITIS There are two types of parotid infection, suppurative (usually caused by Staphylococcus aureus) and epidemic, more commonly called mumps (caused by a paramyxovirus). In developed countries, mumps is rarely seen because children are immunized against it within the first 2 years of life. Patients with Sjögren’s syndrome are also predisposed to inflammation of the salivary glands (Figure 3-2)—parotid or submandibular—termed sialadenitis. In bacterial parotitis, the symptoms include fever, chills, rapid onset of pain, and swelling, usually in the preauricular area of the jaw. The gland is firm on palpation, with tenderness and erythema overlying the gland. Symptoms are similar to those of mumps, with both glands usually being affected. Clinical signs and symptoms most often make the diagnosis of infectious parotitis. The examiner should attempt to express pus from Stensen’s duct, which helps to make the diag- nosis of infection. Treatment includes antibiotic therapy and massage of the gland to promote drainage. Surgery is rarely neces- sary in infectious parotitis. Parotid duct Sublingual gland and ducts Submandibular Parotid gland gland and duct Submandibular gland Sublingual gland Figure 3-2. Head, Face, and Neck 39 SALIVARY GLAND TUMORS The majority of these tumors occur in the parotid gland, and over 80% are benign. Those occurring in the submandibular gland are more likely to be malignant (about 50%). Salivary gland tumors are often painless and may go unnoticed for months. If malig- nancy is present, the facial nerve is often affected. Magnetic resonance imaging or a CT scan is recommended once a mass is found. Fine needle aspiration is necessary for diagnosis and treatment.

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History discount super p-force oral jelly 160 mg on-line, physical examination discount super p-force oral jelly 160mg amex, complete blood count super p-force oral jelly 160mg low cost, and urinalysis ❏ B cheap 160mg super p-force oral jelly mastercard. History 160mg super p-force oral jelly fast delivery, physical examination, chest x-ray, and electrocardiogram ❏ C. History, physical examination, and echocardiography ❏ D. History, physical examination, exercise, and electrocardiography Key Concept/Objective: To understand the evaluation of patients starting an exercise program Physicians can provide important incentives for their patients by educating them about the risks and benefits of habitual exercise. A careful history and physical examination are central to the medical evaluation of all potential exercisers. Particular attention should be given to a family history of coronary artery disease, hypertension, stroke, or sudden death and to symptoms suggestive of cardiovascular disease. Cigarette smoking, sedentary living, hypertension, diabetes, and obesity all increase the risks of exercise and may indicate the need for further testing. Physical findings suggestive of pulmonary, cardiac, or peripheral vascular disease are obvious causes of concern. The choice of screening tests for apparently healthy individuals in controversial. A complete blood count and urinalysis are reasonable for all patients. Young adults who are free of risk factors, symptoms, and abnormal physical findings do not require further eval- uation. Although electrocardiography and echocardiography might reveal asymptomatic hypertrophic cardiomyopathy in some patients, the infrequency of this problem makes routine screening impractical. The AHA no longer recommends routine exercise electro- cardiography for asymptomatic individuals. A healthy 50-year-old mother of three moves to your town from an inner-city area where she received no regular health care. She has never had any immunizations, will be working as a librarian, and plans no international travel. History and physical examination do not suggest any underlying chronic illnesses. Which of the following immunizations would you recommend for this patient? All of the above Key Concept/Objective: To know the recommendations for routine adult immunization Only 65 cases of tetanus occur in the United States each year, and most occur in individu- als who have never received the primary immunization series, whose immunity has waned, or who have received improper wound prophylaxis. The case-fatality rate is 42% in individuals older than 50 years. This patient should therefore receive the primary series of three immunizations with tetanus-diphtheria toxoids. Because she was born before 1957, she is likely to be immune to measles, mumps, and rubella. She does not appear to fall into one of the high-risk groups for whom hepatitis A, hepatitis B, and pneumococcal vaccinations are recommended. A 43-year-old man with asymptomatic HIV infection (stage A1; CD4+ T cell count, 610; viral load, < 50 copies/ml) seeks your advice regarding immunizations for a planned adventure bicycle tour in Africa. He is otherwise healthy, takes no medications, and has no known allergies. He is known to be immune to hepatitis B but is seronegative for hepatitis A. His trip will last approximately 3 weeks and will include travel to rural areas and to areas beyond usual tourist routes. You counsel him about safe food practices, safe sex, and mosquito-avoidance measures. Amoxicillin Key Concept/Objective: To know the specific indications and options for malaria prophylaxis for the international traveler Appropriate malaria chemoprophylaxis is the most important preventive measure for trav- elers to malarial areas. In addition to advice about the avoidance of mosquitos and the use of repellants, most visitors to areas endemic for malaria should receive chemoprophylax- 8 BOARD REVIEW is, regardless of the duration of exposure. In most parts of the world where malaria is found, including Africa, chloroquine resistance is common, so chloroquine would not be recommended as prophylaxis for this patient. Pyrimethamine-sulfadoxine is no longer rec- ommended for prophylaxis because of the associated risk of serious mucocutaneous reac- tions. Amoxicillin does not have known efficacy against Plasmodium. Mefloquine is the preferred agent for malaria chemoprophylaxis in areas of the world where chloroquine- resistant malaria is present.

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