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By Z. Snorre. University of Minnesota-Duluth.

Physical exami- nation reveals ulnar deviation of the fingers order nizagara 100 mg visa, with 1+ synovitis of the MCPs and PIPs discount nizagara 25 mg with visa, hammer toe defor- mities discount 25mg nizagara fast delivery, and fibular deviation of the toes purchase nizagara 100mg free shipping, also with 1+ synovitis order nizagara 50 mg fast delivery. The right knee has a significant effusion, is erythematous, and is warm to the touch. X-rays of the knee show mild, diffuse joint-space narrowing, unchanged from films taken last year. Which of the following should be the next step in the care of this patient? Increase prednisone to 30 mg/day for 1 week, then taper B. Order an MRI to evaluate the knee for internal derangement D. The most com- mon joint affected by septic arthritis is the knee. Clues to an underlying septic arthritis in this patient include severe joint pain (rare in rheumatoid joints), erythema (also rare), and a joint that is much more symptomatic than the rest. Patients with rheumatoid arthritis may not have the usual systemic symptoms of fever and chills because of the anti-inflam- matory medications that are used to treat the chronic arthritis. In general, it is important to have a high degree of suspicion; when in doubt, rule out septic arthritis. The mortality is as high as 20% for septic monoarthritis in patients with underlying rheumatoid arthri- tis and up to 50% if more than one joint is infected. A 27-year-old man comes to your office asking that you evaluate him for the possibility of having anky- losing spondylitis. His older brother has recently been diagnosed with ankylosing spondylitis, and he has learned on the Internet that ankylosing spondylitis runs in families. He is completely asymptomatic, and his physical examination, including a careful examination of his back, sacroiliac joints, and heart, is unremarkable. You consider ordering a test to assess for the presence of the HLA-B27 allele. Any male patient under the age of 35 years who presents with chronic back pain (i. All first-degree relatives of patients with a confirmed diagnosis of ankylosing spondylitis should be screened for possible disease with HLA-B27 testing 10 BOARD REVIEW D. Only those patients whose clinical presentation and examination are consistent with ankylosing spondylitis but whose radiographic testing is negative should undergo HLA-B27 testing Key Concept/Objective: To understand the role of HLA-B27 in the diagnosis of ankylosing spondylitis The diagnosis of ankylosing spondylitis is based on the following modified New York cri- teria: (1) low back pain of at least 3 months’ duration that is alleviated with exercise and is not relieved by rest; (2) restricted lumbar spinal motion; and (3) decreased chest expan- sion relative to normal values for age and sex. In addition, the patient must have defini- tive radiographic evidence of sacroiliitis. The lack of specificity of HLA-B27 in asymptomatic patients precludes its use in this patient. Infrequently, a patient can present with clinical stigmata of disease without radiographic evidence of disease. After other primary disease processes have been ruled out, such as reac- tive arthritis, psoriasis, or inflammatory bowel disease, it is reasonable to test for HLA-B27. In this subgroup of patients, follow-up sacroiliac radiographic abnormalities will eventu- ally evolve; this may take as long as 10 years. A 28-year-old white man presents as a walk-in patient to your clinic. He reports a 5-day history of right- sided knee pain and bilateral ankle pain. He reports mild fever subjectively, no visual changes or eye pain, and very mild and intermittent dysuria. On physical examination, the patient is found to have mild effusion in his right knee, without overt inflammation, and bilateral tenderness of his Achilles tendons. Genital examination is significant for shallow ulcerations on the glans of the penis upon foreskin retraction. Which of the following statements regarding this patient is true? The diagnosis of reactive arthritis is highly unlikely given the absence of evidence of uveitis or urethritis in either the history or the physical examination B. Normal gut flora have a prominent role in the pathogenesis of this dis- ease process C.

Osgood–Schlatter’s disease a childhood condition of the site of attachment of the patellar (kneecap) tendon into the tibial tubercle cheap 100mg nizagara with visa, a bony prominence an inch or so below the kneecap discount nizagara 50 mg otc. Results in localized pain and tenderness that can sometimes be confused with enthe- sitis at this site seen in some children with juvenile AS and related diseases osteitis condensans ilii increased bone density (sclero- sis) at the sacral side of the sacroiliac joint that is of unknown cause and is usually without symptoms purchase nizagara 50 mg otc. Its X-ray appearance can be confused with sacroiliitis osteoarthritis (osteoarthrosis) degenerative disorder of joints buy nizagara 50mg with mastercard, most often from disease in the spine and in the weight bearing joints (knees and hips) cheap nizagara 100 mg with visa. Normally seen with aging, but can occur prematurely due to various reasons, for instance after an injury to a joint. Also 164 thefacts AS-App 2(151-172) 5/29/02 5:56 PM Page 165 Appendix 2: Glossary known as degenerative joint disease, it can cause joint pain, loss of function, reduced joint motion, and deformity osteomalacia bone-thinning disorder resulting from deficiency of vitamin D. Can be mistaken for osteo- porosis, and can also be confused with spondylitis. The childhood form of osteomalacia is called rickets osteophyte bony outgrowth (seen on X-ray) at joint margin of an osteoarthritic joint, or in degenerative disc disease osteoporosis a disease characterized by reduction in mineral content usually seen with aging, but also in connection with certain conditions such as paralysis, or due to prolonged use of certain drugs, such as corti- costeroids Paget’s disease a disease characterized by accelerated bone turnover, resulting in the involved bone becom- ing enlarged but weak and fragile. The bone also feels warmer to touch due to increased blood supply. Also called osteitis deformans pathogenesis process of development of a disease pauciarthritis same as oligoarthritis pelvis the bony structures in the lowest part of the trunk. The term pelvic is used for anything that belongs or refers to the pelvis peptic ulcer a sore in the lining of the stomach (gastric ulcer) or duodenum (duodenal ulcer). The word peptic refers to the stomach and the duodenum, where pepsin is present, an enzyme that breaks down proteins. An ulcer can sometimes occur in the lower part of the esophagus in association with heartburn. Proteins are made of multiple peptides linked together placebo originally a Latin word meaning ‘I will please’. Now used for inactive substance (sham) given to par- ticipants of a research study in order to test the efficacy of another substance or treatment. In short- thefacts 165 AS-App 2(151-172) 5/29/02 5:56 PM Page 166 Ankylosing spondylitis: the facts term clinical trials, many of the most valued drugs in clinical use are only about 25% more effective than placebo. Scientists often have to compare the effects of active and inactive substances to learn more about how the active substance affects participants; in such studies both doctor and patient are unaware of who is receiving the active or inactive substance. Such studies are known as double blind placebo controlled studies polyarthralgia pains in many joints; conventionally refers to more than four joints, without signs of inflammation in the symptomatic joints polyarthritis inflammation in many joints; convention- ally in more than four joints preclinical diagnosis diagnosis of a genetic disease before there are any symptoms or signs prevalence the observed number of people in a given population affected with a particular disease or con- dition at a given time, usually stated as the number of cases observed per 100 000 individuals, or listed as a percentage. In contrast with incidence, prevalence can be thought of as a snapshot of all existing cases at a specified time prognosis the probable end result or outcome of a disease protein a large molecule composed of amino acids. Essential components of the body tissue (see also peptide) proton pump inhibitors a group of drugs used to treat heartburn and peptic ulcer disease. These include omprezole (Prilosec), esomeprazole (Nexium) and pansoprazole (Prevacid) prospective, randomized, double blind study clinical trial or study in which the method of data analysis is specified in a protocol before the study is begun (prospective). Patients are randomly assigned to receive either the study drug or an alternative treat- 166 thefacts AS-App 2(151-172) 5/29/02 5:56 PM Page 167 Appendix 2: Glossary ment, and neither the patient nor the doctor conduct- ing the study knows which treatment is being given to which patient (see also placebo) proximal the part of a limb that is closest to the trunk. For example, the shoulder joint forms the proximal end of the upper extremity (opposite of distal) psoriasis a common chronic skin disease, more common in whites (2% of the population) than in other racial groups, in which red flaky lesions occur— often on the elbows and knees, or in the scalp. May cause nail abnormalities psoriatic arthritis arthritis associated with psoriasis; occurs in more than 10% of people with psoriasis. May occur in several forms Qi Chinese term for vital energy or life force. Pronounced chee (see acupuncture) radiography/radiograph/radiogram/radiologic radiogra- phy (or roentgenography) is the method of taking a picture with the help of X-rays, and the terms radi- ograph or simply X-ray are sometimes used for the resulting picture. Radiogram is the correct name for an image taken by radiography randomized, double-blind, placebo-controlled, multi- center trial a clinical trial in which patients have been randomly assigned to receive either the study drug or the alternative treatment under study. Neither the patient nor the doctor conducting the study knows which treatment is being given; the alternative to the study drug is a placebo; and the study is conducted at several centers range of motion the extent to which a joint is able to go through all of its normal movements. Range-of- motion exercises help increase or maintain flexibility and movement in muscles, tendons, ligaments, and joints reactive arthritis arthritis resulting from infection else- where in the body; i. The commonest type is HLA B27-related and may follow certain types of bowel or genitourinary infection Reiter’s syndrome a form of HLA B27-related reactive arthritis with a classical triad of arthritis, conjunctivi- tis, and urethritis, with or without other features of spondyloarthropathies.

This energy pathway begins at the bottom of the trunk at the point midway between the anus and the testes buy cheap nizagara 25 mg on line, called 25mg nizagara amex, the "Hui-Yin" 50 mg nizagara with visa. From there - 159 - Summary of the Seven Stages it flows up the front of the body through the KuanYuan and the Chi- hai and then through the Chi-chung (the navel) discount nizagara 100mg with amex. Then it passes through the Chung-wan (solar plexus) and proceeds to the Shan- chung (the heart center) cheap 100 mg nizagara overnight delivery. Thereafter, it passes through the Hsuan- chi (throat) center and up to the tongue terminus. When connected with the Governor Channel the energy path reverses direction and flows down from the tongue, navel, to the Hui-Yin. The Governor (or control) Channel also starts at the Hui-Yin. From this point it moves up the posterior of the body. In doing so it passes through the Chang-chiang (the base of the spine) and goes up to the Ming-men (L2 and L3) or Door of Life where it continues up to the Chi-chung (Tl1) between the adrenal glands and then proceeds upwards to the Yu-chen or the Emerald Pillow of the medulla. Here it passes to the San Ken (the tip of the nose) and finally travels down to the palate, which is the terminus of the Governor Channel. Tongue is a Switch of the Circuit The circuit may be closed when the tongue end of the Functional Channel is raised to contact the palate terminus of the Governor. Thus, during practice, we must keep the tongue in contact with the palate. Placing the tongue against the palate has a calming effect for those who practice the Warm Current Method. It also generates saliva, which is regarded as the water of life in Taoist practice. Saliva is said to be the chief lubricant of all bodily functioning. In the Taoist view the soft palate is regarded as a direct link to the pituitary gland. As a man grows older he suffers increasingly from an imbalance of Yin (female) and Yang (male) energies in the body. As these disharmonies multiply, the bodily organs begin to suffer from the receipt of too much or too little energy. This represents an astounding accomplishment in the assimilation of energy by the material body. These are the lungs, spleen, heart, kidneys, circulation-sex, and liver. The Functional Channel controls the Yin organs, which are the colon, stomach, small intestine, bladder, triple warmer, and gall bladder. The tissues are Yang in tendency and the blood is Yin. Seven Formulas of the Seven Books of the Tao First Formula: Fusion of the Five Elements This formula literally combines the separate energies of the five principal elements into one harmonious whole. The meditation has a particularly powerful filtering and purifying effect upon the human nervous system. This reunites the other four elements of Chinese cosmogeny with the mothering Earth. Thus, metal, wood, water and fire are drawn back into the earth and are simmered gently at this point. Each element is purified but is not so hotly fused that it loses its integrity and dissolves into ashes. This formula is regarded as a highly secret method of Taoist meditation. In Chinese Philosophy each element corresponds to a particular organ. The Earth corresponds to the spleen, metal to the lungs, water to the kidneys, wood to the liver, and fire to the heart. The five elements interact with each other in three distinct ways: producing, overcoming, and threatening.

Contact dermatitis Key Concept/Objective: To know the distinguishing characteristics of diseases that cause pruritic skin lesions This patient has pediculosis pubis purchase nizagara 100mg free shipping, caused by Phthirus pubis order nizagara 50mg mastercard. Its characteristic blue-gray macules (maculae ceruleae) are caused by the pubic lice sucking blood from the dermis nizagara 25mg visa. The tan swellings are nits: lice eggs cemented to the hair shaft cheap nizagara 25mg visa. None of the other diseases 20 BOARD REVIEW listed have these findings cheap nizagara 25 mg otc. Scabies is caused by a burrowing mite that can at times be seen as a line in the stratum corneum. The mite’s eggs are deposited in the burrows rather than as nits. Dermatitis herpetiformis is an autoimmune vesicular dermatitis characterized by grouped vesicles symmetrically distributed over the extensor skin surfaces. Genital herpes can be pruritic but is more often painful. Contact dermatitis can cause pruritic lesions but is not caused by a parasitic infestation. A 32-year-old man returns from a vacation to the Caribbean. He spent time swimming and sunbathing at the local beaches. He now has intensely pruritic skin lesions on the abdomen. Examination reveals several serpiginous thin lines in the skin. Which of the following organisms is most likely responsible for this disease? Avian schistosome free-swimming larvae (cercariae) C. Sandfleas Key Concept/Objective: To understand the causes and presentations of skin lesions that can occur during travel to tropical regions Tungiasis (sandflea cutaneous infestation), seabather’s eruption (infestation with larvae of the thimble jellyfish), swimmer’s itch (infestation with cercarial larvae of an avian schis- tosome), and cutaneous larva migrans (infestation with hookworm larvae) can all cause intensely pruritic skin lesions. It is the migration of larval hookworms that causes the ser- piginous or linear tracks in the skin. Tungiasis causes erythematous edematous papules in clusters. Seabather’s eruption presents as a pruritic dermatitis in areas covered by swimwear. Swimmer’s itch is a papulovesicular eruption on exposed skin sites. The larvae of the botfly cause myiasis, a nonpruritic nodular skin lesion mimicking an infected cyst or abscess. Two months after returning from an expedition to the Amazon, a 42-year-old archeologist notices a red- brown papule on her nose. She also has a verrucous nodule with early ulceration where she first noted the papule on the nose. Perform biopsy of the nodule for histopathology B. Treat with oral sodium stibogluconate (a pentavalent antimony com- pound) C. Inject the nodule intralesionally with antimonials E. Treat with oral ivermectin Key Concept/Objective: To understand the presentation of cutaneous leishmaniasis and its management This patient’s clinical examination and course fit the diagnosis of New World cutaneous leishmaniasis. The differential diagnosis includes various inflammatory and neoplastic disorders, including squamous cell carcinoma. The safest course in this case would be to perform biopsy of the lesion to confirm the diagnosis. Once the diagnosis is confirmed, the patient could be treated with oral sodium stibogluconate. Old World leishmaniasis is usu- ally limited to the skin and can be treated with cryosurgery, heat therapy, or intralesional injection of antimonials.

10 of 10 - Review by Z. Snorre
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Total customer reviews: 113

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