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  • Which of the following statements concerning the treatment of gout is true?
    Which of the following statements concerning the treatment of gout is true?
    Intramuscular injections of ACTH are valuable if NSAIDS are contraindicated-indomethacin is the most normally utilized NSAID and should proceed for 24 hours after the side effects subside. colchicine hinders microtuble arrangement and obstructs the provocative reaction to precious stones in the joint. Colchicine is contraindicated in patients with hematologic, renal, and hepatic deficiency. Oral prednisone is valuable in safe cases and intra-articular infusion of steroids might be compelling for people with just 1 or 2 joints included once septic joint pain has been avoided. ACTH (40-80 iu im) is a valuable contrasting option to the above treatments. With just a solitary organization, hypothalamic-pituitary-adrenomedullary pivot concealment ought not occur. Long term treatment of gout is intended to diminish serum uric corrosive by either diminishing creation (allopurinol) or expanding discharge (probenecid). Unending prophylactic specialists ought not be halted or started amid an intense assault

  • What is the difference between Lupus and Rheumatoid Arthritis?
    What is the difference between Lupus and Rheumatoid Arthritis?
    Lupus is a disease that can be life-threatening and is affects a person’s immune system. The immune system is known for fighting off the germs and other viruses that could attack the rest of the body. Its symptoms include chest pain, fatigue, problems with your joints and other problems. Rheumatoid arthritis is also a disease that hurts your joints. However, the difference between Lupus and Rheumatoid Arthritis is that Lupus has more symptoms and Rheumatoid Arthritis is known for affecting your joints. Often times, the Rheumatoid Arthritis can cripple your hands. They both affect your immune system in some fashion. Both are very painful and can require a doctor’s care. Usually, a doctor will be able to determine whether someone has Rheumatoid Arthritis or Lupus.

  • Why would you do an arthrocentesis for the following case? A 46 year old male presents with an isolated swollen knee joint.  He has increased pain with both passive and active range of...
    Why would you do an arthrocentesis for the following case? A 46 year old male presents with an isolated swollen knee joint.  He has increased pain with both passive and active range of...
    1. arthrocentesis is contraindicated if infection of any kind covers the joint-one of the emergency indications for arthrocentesis is obtaining joint fluid for analysis. arthrocentesis is contraindicated if infection of any kind covers the area to be punctured. the synovial fluid should be sent for cell count, differential, grams stain, crystal analysis, and culture. a positive grams stain is diagnostic, but a negative result does not rule out septic arthritis, therefore cultures should always be obtained. the likelihood ratio for septic arthritis increases as the joint wbc rises, however low wbc counts do occur early in infectious arthritis and partially treated arthritis. most of the cells in both septic and severe inflammatory arthritis are pmns. cell counts should not be used to absolutely rule out a septic etiology; bacterial cultures should be obtained. the most serious complication of arthrocentesis is introducing infection into the joint space. other complications include bleeding, allergic reaction to anesthetic agents, dry taps. (chapter 114)

  • What are the symptoms of systemic lupus apart from triad of fever, joint pain, and rash in a woman of childbearing age?
    What are the symptoms of systemic lupus apart from triad of fever, joint pain, and rash in a woman of childbearing age?
    1. oral ulcerations commonly accompany disease flares-the vast majority of patients with sle will experience arthritis. arthritis in the hands, specifically the proximal interphalangeal and metacarpophalangeal joints is symmetrical and nonerosive. thirty percent of patients develop hitchhikers thumb, hyperextension of the ip joint of the thumb. up to 30% of patients have coexisting fibromyalgia. chronic nephritis is seen in approx. 50% of patients. renal biopsy can be useful in making treatment decisions in patients with renal disease. pericarditis is the most common cardiac manifestation of sle, reported in 30% of patients, with an associated effusion in 20% of patients. this rarely progresses to tamponade. the neurologic manifestations of sle are varied (including seizures, stroke, psychosis, migraines, peripheral neuropathies) and may appear early in disease, but are rarely the initial sign of sle. approx 50% of patients with sle will have cns involvement. gi complaints in sle are common and oral ulcerations usually accompany disease flares. other more rare gi complaints include esophageal dysmotility, intestinal pseudo-obstruction, pancreatitis, sbp, portal hypertension, and intestinal vasculitis (the most serious gi complication.) (chapter 116)

  • What is the suspected diagnosis you can deduce about the patient below? A 77-year-old woman complains of headache, low-grade fever, malaise, myalgias, intermittent blurred vision, jaw...
    What is the suspected diagnosis you can deduce about the patient below? A 77-year-old woman complains of headache, low-grade fever, malaise, myalgias, intermittent blurred vision, jaw...
    1. elevated esr level may be a helpful diagnostic clue-temporal or giant cell arteritis is most common in branches of the carotid artery but may involve any large or medium artery. the disease is most commonly seen in women in the sixth and seventh decades of life. the classic symptoms of ta are consistent with ischemia to the organs fed by branches of the internal and external carotid artery: visual loss in one eye, temporal artery tenderness, and jaw claudication. patients may complain of nonspecific, vague symptoms such as malaise, weight loss, and fever. headache may be the initial complaint. although the diagnosis is made clinically, helpful laboratory findings include elevated esr (usually > 100 mm/hr on a westergren blot), elevated crp, and anemia. the definitive diagnosis is made by temporal artery biopsy. most patients are extremely sensitive to glucocorticoids, and treatment should be started for any patient with a high clinical suspicion of ta. the steroids do not significantly change the results of the biopsy and may prevent progression to visual loss. (chapter 116)

  • What is the most appropriate initial treatment for the following patient? A healthy 27 year old male presents to the ED after being stung by something while apple picking.  He complains of...
    What is the most appropriate initial treatment for the following patient? A healthy 27 year old male presents to the ED after being stung by something while apple picking.  He complains of...
    1. epinephrine 0.1 mg of 1:10,000 solution iv over 5 minutes-since most of the morbidity and mortality associated with anaphylaxis originates from acute respiratory failure or cardiovascular collapse, the immediate goal in the ed is to stabilize any cardiorespiratory insufficiencies while confirming the diagnosis of anaphylaxis and anaphylactic shock along with other diagnostic alternatives. if the patient demonstrates severe upper airway obstruction, acute respiratory failure, or shock, intravenous epinephrine should be administered. use of the intravenous route with epinephrine increases the risk of supraventricular, accelerated idioventricular, and ventricular tachydysrhythmia; accelerated hypertension; and myocardial ischemia, including the stunned heart syndrome. because of these risks, dilution and slow administration are recommended and continuous cardiac monitoring should be done at all times. see rosens chapter 117, box 117-5 for treatment options for anaphylaxis. 2005 american heart association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care (circulation. 2005;112:iv-143 iv-145.)epinephrine: administer epinephrine by im injection early to all patients with signs of a systemic reaction, especially hypotension, airway swelling, or definite difficulty breathing. use an im dose of 0.3 to 0.5 mg (1:1000) repeated every 15 to 20 minutes if there is no clinical improvement.administer iv epinephrine if anaphylaxis appears to be severe with immediate life-threatening manifestations.12 use epinephrine (1:10 000) 0.1 mg iv slowly over 5 minutes. epinephrine may be diluted to a 1:10 000 solution before infusion. an iv infusion at rates of 1 to 4 g/min may prevent the need to repeat epinephrine injections frequently.(chapter 117)

  • What is the following patient's likely diagnosis? A young woman is concerned about some patches on her back and chest that did not tan over the summer.
    What is the following patient's likely diagnosis? A young woman is concerned about some patches on her back and chest that did not tan over the summer.
    1. tinea versicolor-tinea versicolor is a superficial yeast infection caused by pityrosporum ovale. superficial scaling patches occur primarily on the chest and trunk, but may involve the head and limbs. lesions can be a variety of colors and may be pruritic. these lesion do not tan. a koh preparation shows short hyphae mixed with spores (chopped spaghetti and meatballs.) tineas versicolor is treated with selenium sulfide shampoo, imidazole creams, or oral ketoconazole, but the recurrence rate is 15-50%.

  • What excessive dose has the following patient most likely taken? An 18-year-old male presents to the emergency room with persistent nausea and vomiting, malaise and diaphoresis. He has...
    What excessive dose has the following patient most likely taken? An 18-year-old male presents to the emergency room with persistent nausea and vomiting, malaise and diaphoresis. He has...
    1. acetaminophen-poisoning from acetaminophen is due to toxic metabolites (mainly n-acetyl parabenzoquinone)that accumulate when glutathione is not available for conjugation. in theabsence of glutathione these toxic metabolites react with cellular proteins, resulting inhepatotoxicity. this occurs after the ingestion of toxic doses or when alcohol is taken togetherwith acetaminophen, since in both cases glutathione is depleted faster than it can begenerated.the alcohol-acetaminophen syndrome occurs in a clinical setting in which acute, sometimesfulminant, hepatic necrosis develops after large doses of acetaminophen are taken during analcoholic binge or a period of chronic, excessive alcohol intake. peculiar to the alcoholacetaminophensyndrome are the extremely high serum transaminase levels. early treatmentconsists of the administration of n-acetylcysteine, although at 48 hours or more after theingestion its use remains controversial.a, b, d, e) overdose of all the other listed drugs does not cause a high increase in serumtransaminase levels.

  • Which of the following statements are true regarding the following patients diagnosis? A healthy 27 year old female presents with atraumatic joint pain and swelling.  Over the past 4...
    Which of the following statements are true regarding the following patients diagnosis? A healthy 27 year old female presents with atraumatic joint pain and swelling.  Over the past 4...
    1. this type of arthritis is more commonly oligoarthritis than monoarthritis-although it has declined over the past decade, gonococcal arthritis remains the most common form of septic arthritis in the sexually active population, with a 4:1 female predominance. gonococcal arthritis is clinically and pathologically distinct from other bacterial infections and is less likely to create long-term joint pathology. this infection is more commonly oligoarthritis than monoarthritis, with the knee, ankle and wrist being the most commonly affected joints. diagnosis is difficult as both synovial and blood cultures are positive in only 10-50% of cases. however, synovial fluid often yields a positive grams stain. cervical, urethral, rectal and pharyngeal cultures are positive in up to 75% of cases and therefore should be cultured appropriately. treatment should be with a parenteral 3rd generation cephalosporin, with transition to oral antibiotics 24-48 hours after clinical improvement. (chapter 114)

  • How does Pseudogout differ from gout?
    How does Pseudogout differ from gout?
    1. the knee is the most commonly involved joint-pseudogout (calcium pyrophosphate dihydrate deposition disease) presents very similarly to gout, however these patients tend to be older and the knee is more commonly involved (the knee is the most common joint involved followed by the wrist, ankle and elbow). the average attack is not as severe as acute gout. synovial fluid examination shows rhomboidal, weakly positive birefringent crystals of calcium pyrophosphate dihydrate. treatment for an acute attack is identical for acute gout: nsaids, steroids, acth, or oral colchicine, although colchicine is not as effective as with gout. prophylaxis is generally less effective. (chapter 114)

  • Which tendon is most commonly involved in a rotator cuff injury?
    Which tendon is most commonly involved in a rotator cuff injury?
    1. supraspinatus-the muscles of the rotator cuff are the supraspinatus, infraspinatus, teres minor, and subscapularis. there are three progressive stages of impingement syndrome as a result of overuse. 1st young athletes who participate in sports that require repetitive overhead motions of the shoulder; no weakness or loss of motion is present. 2nd fibrosis and thickening of the tendon and subacromial bursa can occur, the pain becomes more constant and active motion may be limited by pain & any overhead movement exacerbates the symptoms. 3rd range of motion of the shoulder is usually decreased due to disuse or a partial rotator cuff tear and pathologically tendon degeneration and attrition may be present. the supraspinatus tendon is the most often involved in rotator cuff tendinopathy. the empty can test (or jobes sign) assesses the supraspinatus tendon against resistance. (chapter 115)

  • Which of the following pairings is NOT correct, in regards to provocative testing for tendinopathies?
    Which of the following pairings is NOT correct, in regards to provocative testing for tendinopathies?
    1. bicipital tendinopathy – empty can test-provocative testing for teninopathies:rotator cuff tendinopathy: - empty can test with the arms abducted at 90 degrees, the arms are internally rotated with the thumbs pointed downward, downward force is placed on the arms against resistance (weakness or pain = supraspinatus tendinopathy)- neer test the examiner forward-flexes the arms causing impingement of the greater tuberosity of the humerus with the anterior & inferior edge of the acromium (pain = mechanical impingement of rotator cuff)- hawkins test forcibly internally rotating the proximal humerus while the shoulder is forward-flexed to 90 degrees and the elbow is flexed to 90 degrees (pain = mechanical impingement of the rotator cuff)- drop arm test the arm is passively abducted to 90 degrees and the patient is asked to maintain abduction (arm drops = complete rotator cuff tear)- shrug sign when the arm is abducted to 90 degrees, the patient appears to be shrugging on that side (acute macrotrauma to the rotator cuff)bicipital teninopathy:- yergasons sign flex the elbow to 90 degrees with the arm against the body and resist supination of the forearm (pain in proximal biceps tendon = bicipital tendinopathy)- speed test with the elbow extended and the forearm supinated, the patient resists forward flexion of the adducted shoulder at 60 degrees (pain in bicipital groove = bicipital tendinopathy or labral pathology)lateral epicondylitis:- cozen test patient keeps fist clenched while extending the wrist while examiner grasps the forearm with one hand and pulls the patients hand toward flexion again the patients resistance (pain at lateral epicondyle = lateral epicondylitis)de quervains tenosynovitis:- finkelstein test patient holds the affected thumb in the palm by the fingers and the wrist is then ulnar-deviated (pain near radial styloid = de quervains)achilles tendon rupture:- thompson test (simmonds test) examiner squeezes the calf muscles with the patient prone and feet hanging over the edge of the bed (absence of plantar flexion = achilles tendon tear)(chapter 115)

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