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By G. Carlos. Lee University. 2018.

Most patients with chronic bronchitis and emphysema who are given a sufficiently strong bronchodilating medication will exhibit at least a 10% increase in maximal expiratory airflow buy mentat 60caps without a prescription. Dyspneic patients should be given a trial of bronchodilators even if pulmonary function testing shows that they do not manifest significant bronchodilation cheap mentat 60caps with mastercard, because bronchodilator responsiveness may vary over time mentat 60 caps online. Given the underlying pathophysiology of emphysema purchase 60 caps mentat free shipping, corticosteroids would be expected to provide little benefit order 60 caps mentat mastercard, because tissue destruction is the basic disease mecha- nism. Only some patients derive significant benefit from corticosteroids. Clinical trials of daily antibiotic use in patients with mild chronic airflow obstruction demonstrated that neither the degree of disability nor the rate of progression of disease was signifi- cantly altered by this intervention. Intermittent antibiotic administration is indicated for acute episodes of clinical worsening marked by increased dyspnea, excessive sputum production, and sputum purulence. Physical-training programs, such as treadmill walk- 14 RESPIRATORY MEDICINE 13 ing, significantly increase the exercise capacity of patients with even far-advanced chronic bronchitis and emphysema. A 23-year-old male college student with no history of cigarette smoking presents with a complaint of productive cough that has not improved with three courses of antibiotics. He reports some intermittent wheezing and dyspnea, which have worsened over the past 2 days, but he has no fever. He states that he has had various recurrent respiratory infections ever since childhood. On examination, his chest x- ray shows diffuse increased markings with cystic spaces predominantly in the upper lobes and hyperin- flation. Further testing reveals an abnormal sweat chloride test. Which of the following is the most likely diagnosis for this patient? The chest radiograph may strongly suggest the diagnosis of cystic fibrosis. The generalized bronchiectasis manifests itself as a diffuse increase in interstitial markings, and discrete bronchiectatic cysts are often visible; typically, involvement of the upper lobes predominates. The diagnosis can be established by abnormal results on a sweat test. Bronchiolitis obliterans is a rare cause of chronic airflow obstruction in adults but can occur after inhalation of toxic gases (e. Emphysema develops in at least 80% of patients with homozygous PiZ α1-antitrypsin deficiency. The mean age at onset of dyspnea is 45 to 50 years in nonsmokers and approximately 10 years earlier in those who smoke. A 56-year-old male industrial worker presents with concern of possible exposures that can cause lung dis- ease. Which of the following diseases does NOT have an occupational exposure etiology? Bronchiectasis is a localized, irreversible bronchial dilatation caused by a destructive inflammatory process involving the bronchial walls. Necrotizing bacterial or mycobacterial infection is thought to be responsible for most cases of bronchiectasis. Adult-onset bronchiectasis may result from an untreated or inadequately treated bronchopneumonia that is caused by virulent organisms such as staphylococci or gram-negative bacilli. Prolonged exposure to res- pirable dusts in the work environment has long been recognized as a cause of so-called industrial or occupational bronchitis in nonsmoking workers engaged in occupations such as coal or gold mining, textile manufacturing, and cement and steel making. Bronchiolitis obliterans can occur with inhalation of toxic gases (e. A 31-year-old healthy man who has no significant medical history or current complaints presents to your office with concern about an abnormal chest x-ray that was taken at a local health fair. He has nei- ther constitutional nor pulmonary symptoms. He reports no toxic exposures or family history of lung diseases. On review of the chest x-ray, a 1 cm focal lesion with central calcification is seen in right middle lobe. There are no previous films available for comparison. Which of the following describes the most appropriate treatment plan for this patient? Although asymptomatic, this patient requires thoracic surgery con- sultation and open lung biopsy B.

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Many patients discount 60 caps mentat free shipping, however purchase mentat 60caps fast delivery, experience mild to moderate side effects purchase mentat 60caps with amex, including localized discomfort buy mentat 60 caps otc, headache order mentat 60caps without prescription, or tiredness. Brain stem or cerebellar infarction, vertebral fracture, tracheal rupture, internal carotid artery dissection, and diaphragmatic paralysis are rare but have all been reported with cervical manipulation. Given the lack of efficacy data and the risk (although small) of catastrophic adverse events, it is difficult to advocate routine use of this technique for treatment of neck or headache disorders. Physicians should also recognize potential contraindications to chiropractic ther- apy. Patients with coagulopathy, osteoporosis, rheumatoid arthritis, spinal neoplasms, or spinal infections should be advised against such treatments. A 63-year-old man presents to your clinic for an initial evaluation. He has a history of coronary artery disease, congestive heart failure, atrial fibrillation, benign prostatic hyperplasia, and erectile dysfunction. His current medical regimen includes hydrochlorothiazide, metoprolol, enalapril, digoxin, coumarin, and terazosin. During the visit, the patient pulls out a bag of vitamins and herbal supplements that he recently began taking. He hands you several Internet printouts regarding the supplements and asks your advice. Which of the following statements about dietary supplements is true? Under the Dietary Supplement Health and Education Act (DSHEA), all supplements are now required to undergo premarket testing for safety and efficacy ❏ B. Because they are natural products, dietary supplements are uniformly safe, with no significant drug-drug interactions ❏ C. The dietary-supplement industry has little incentive for research because natural substances cannot be patented ❏ D. The Food and Drug Administration regulates dietary supplements under the same guidelines as pharmaceuticals Key Concept/Objective: To understand the potential for toxicity and drug-drug interactions asso- ciated with dietary supplements The supplement industry has become a billion-dollar business, largely as a result of loos- ening of federal regulations. In 1994, DSHEA expanded the definition of dietary supple- ments to include vitamins, amino acids, herbs, and other botanicals. Furthermore, under DSHEA, supplements no longer require premarket testing for safety and efficacy. Dietary supplements, such as herbs, may have a significant profit potential, but the incentive for research is weakened by the fact that herbs, like other natural substances, cannot be patented. In addition, foods and natural products are regulated under rules different from those for pharmaceuticals, which must meet stringent standards of efficacy and safety. Although most dietary supplements are well tolerated and are associated with few adverse effects, the potential for harm from the lack of regulation can be seen from examples of misidentification of plant species, contamination with heavy metals, and addition of pharmaceutical agents. Overall, there is only limited evidence supporting the use of most dietary supplements. Most clinical trials have been small, nonrandomized, or unblinded. The potential for significant toxicity and drug interactions does exist. A 56-year-old man with a history of coronary artery disease and a documented ejection fraction of 40% by echocardiography presents for further management. At this visit, the patient denies having shortness of breath, dyspnea on exertion, orthopnea, or lower extremity edema. He has never been admitted to the hospital for congestive heart failure (CHF). According to the new American College of Cardiology/American Heart Association (ACC/AHA) guidelines for the evaluation and management of heart failure, in what stage of heart failure does this patient belong? Stage D Key Concept/Objective: To understand the new classification of heart failure proposed by the ACC/AHA The ACC/AHA classification is a departure from the traditional New York Heart Association (NYHA) classification, which characterizes patients by symptom severity. The aim of the new ACC/AHA guidelines is to identify patients at risk for developing heart failure. Early recognition of contributing risk factors, as well as the identification and treatment of asymptomatic patients with ventricular dysfunction, can prevent pathologic progression to symptomatic heart failure. Stage A identifies patients who are at high risk for developing heart failure but who have no apparent structural abnormality of the heart.

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He denies having fever cheap mentat 60caps line, chills 60caps mentat free shipping, cough order mentat 60caps on-line, dysuria order mentat 60 caps otc, blood loss buy discount mentat 60 caps online, or weight loss. Routine laboratory studies reveal a hemoglobin concentration of 8. The patient denies eating nonfood substances but does admit to craving and eating large amounts of ice daily. The patient’s stool is positive for occult blood by guaiac testing. For this patient, which of the following statements regarding iron deficiency anemia is true? In men and postmenopausal women, pica and a poor supply of dietary iron are the most common causes of iron deficiency anemia B. Pagophagia, or pica with ice, is a symptom that is believed to be spe- cific for iron deficiency C. Measurement of the serum iron concentration is the most useful test in the detection of iron deficiency D. The preferred method of iron replacement for this patient is parenteral therapy Key Concept/Objective: To understand the historical components, laboratory diagnosis, and treatment of iron deficiency anemia Blood loss is the most common cause of increased iron requirements that lead to iron defi- ciency. In men and postmenopausal women, iron deficiency is almost always the result of gastrointestinal blood loss. In older children, men, and postmenopausal women, a poor supply of dietary iron is almost never the only factor responsible for iron deficiency; there- fore, other etiologic factors must be sought, especially blood loss. Pagophagia, or pica with ice, is thought to be a highly specific symptom of iron deficiency and disappears shortly after iron therapy is begun. Measurement of the serum ferritin concentration is the most useful test for the detection of iron deficiency, because serum ferritin concentrations decrease as body iron stores decline. A serum ferritin concentration below 12 mg/L is vir- tually diagnostic of absent iron stores. In contrast, a normal serum ferritin concentration does not confirm the presence of storage iron, because serum ferritin may be increased independently of body iron by infection, inflammation, liver disease, malignancy, and other conditions. Oral and parenteral replacement therapy yield similar results, but for almost all patients, oral iron therapy is the treatment of choice. Oral iron therapy is effec- tive, safe, and inexpensive. A 55-year-old white man with type 2 diabetes mellitus and dyslipidemia presents to your clinic for follow- up. His diabetes has been well controlled for the past year. On review of systems, the patient states that his skin has become tan over the past several months. Routine laboratory studies show that the patient’s alanine aminotransferase level is elevated today; there are no other liver function abnormalities. Physical examination confirms that the patient’s skin is hyperpig- mented with a bronze hue. You strongly suspect that this patient may have hereditary hemochromatosis. For this patient, which of the following statements regarding HFE-associated hereditary hemochro- matosis is true? The classic tetrad of clinical signs associated with hemochromatosis is liver disease, diabetes mellitus, skin pigmentation, and gonadal failure 5 HEMATOLOGY 5 B. Measurement of the serum iron level is usually recommended as initial phenotypic screening, followed by genotypic testing C. The treatment of choice for hemochromatosis is chelation therapy or intermittent phlebotomy for 2 or 3 months D. In patients with hemochromatosis and cirrhosis, the rates of develop- ment of hepatocellular carcinoma equal that of the standard population Key Concept/Objective: To know the clinical features of and appropriate therapy for HFE-associ- ated hemochromatosis In homozygotes who present with hereditary hemochromatosis in middle age or later, the classic tetrad of clinical signs is liver disease, diabetes mellitus, skin pigmentation, and gonadal failure. Measurement of serum transferrin saturation is usually recommended as the initial phenotypic screening determination. Although individual laboratories may have their own reference ranges, a persistent value of 45% or higher is often recommend- ed as a threshold value for further investigation. The serum ferritin level is then used as a biochemical indicator of iron overload; in the absence of complicating factors, elevated concentrations suggest increased iron stores. Genetic testing should be considered in patients with abnormal elevations in transferrin saturation, serum ferritin, or both.

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Characteristic findings include lowered CSF glucose (hypoglycorrhachia) buy mentat 60caps otc, elevated CSF protein generic 60caps mentat free shipping, and a lymphocytic pleocytosis order mentat 60 caps fast delivery. A high index of suspicion is needed to make the diagnosis cheap mentat 60caps with amex, because mycobacterial CSF cultures are positive in no more than 75% of cases best mentat 60 caps, and acid-fast smears are positive in only 25% of cases. A number of biochemical, immunologic, and molecular biologic tests are currently available, but none has yet emerged as the gold standard. At times, a clinical diagnosis depends on response to anti- tuberculous therapy. A 32-year-old resident of the state penitentiary is found to test positive on a purified protein derivative skin test (PPD), with 10 mm of induration. He is asymptomatic, and his chest x-ray is negative. Which of the following would you recommend at this time? Induced sputum cultures; treat only if positive C. HIV-seropositive patients with a PPD of 5 mm or greater should receive 9 to 12 months of INH chemoprophylaxis. Patients younger than 35 years with a recent PPD conversion of 10 mm or greater and patients older than 35 years with a 15 mm PPD conversion are candidates for chemoprophy- laxis. Several other factors lower the threshold for chemoprophylaxis, including recent exposure, an abnormal chest x-ray consistent with old TB, and membership in high- incidence population groups (e. INH chemoprophylaxis is no longer administered for 1 year; therapy for 6 to 9 months achieves the best balance between reducing the risk of active TB and minimiz- ing the risk of hepatitis. Rifampin and pyrazinamide for 2 months can be substituted for INH chemoprophylaxis in patients who are unable to take INH or in whom INH resistance is suspected. A 48-year-old physician from New York City develops fever, night sweats, cough, weight loss, and malaise. Chest x-ray reveals an infiltrate in the posterior-apical segment of the right upper lobe. Which of the following treatment options would you institute for this patient at this time? Await cultures and sensitivity testing before instituting therapy B. INH, rifampin, ethambutol, pyrazinamide, and streptomycin Key Concept/Objective: To understand the treatment of active tuberculosis 7 INFECTIOUS DISEASE 13 This patient has a clinical syndrome very suggestive of tuberculosis. He is smear-posi- tive, and treatment should be initiated immediately, pending the results of mycobacte- rial culture and antimicrobial sensitivity. He should be hospitalized and placed in a neg- ative-pressure isolation room for induction of chemotherapy until his symptoms improve and he becomes smear-negative. The United States Public Health Service rec- ommends initiation of therapy with INH, rifampin, ethambutol, and pyrazinamide unless the INH-resistance rate in the community is low (< 4%), in which case ethamb- utol can be withheld. In drug-sensitive cases, treatment is then changed to INH and rifampin for an additional 4 months (until spu- tum cultures have been negative for at least 3 months). A 27-year-old HIV-seropositive Haitian man develops cough, fever, and weight loss. Chest x-ray reveals a cavitary lesion in the left upper lobe. Sputum culture is found to be smear-positive and, subsequently, culture-positive for Mycobacterium tuberculosis. Medications include zidovudine, lamivudine, and indinavir, as well as trimethoprim-sulfamethoxazole. Which of the following drugs is contraindicated in this patient? Pyrazinamide Key Concept/Objective: To know the major drug interactions between antiretroviral and anti- tuberculosis drugs Rifampin is contraindicated in patients receiving protease inhibitors (PIs). It is also con- traindicated in patients taking nonnucleoside reverse transcriptase inhibitors (NNRTIs) such as nevirapine, delavirdine, and efavirenz.

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