By V. Innostian. Husson College.
However buy extra super cialis 100mg with mastercard, epidermoid cysts can involve the oral mucosa buy extra super cialis 100mg without a prescription, breasts buy extra super cialis 100mg with visa, and perineum buy extra super cialis 100 mg with amex. However, the contents can be cultured and the lesion can be biopsied. MOLLUSCUM CONTAGIOSUM (PLATE 19) Molluscum contagiosum is a skin lesion caused by the DNA poxvirus. On occasion, patients present with the complaint of burning or pruritus at the site of lesion, although they are usually asymptomatic. The lesion has a smooth surface, with exception of a central indentation. Although the lesion is skin-colored or pink, the area immediately surrounding the lesion may be red. If the surface over the center of the lesion is broken, pressure may express keratotic material. The skin over trunk and extremities is most often the site, although it can affect oral mucosa and the inguinal area. Studies are not generally necessary because diagnosis is made based on findings. XANTHOMAS (PLATE 32) Xanthomas are reflective of lipid metabolism and are caused by accumulations of lipid-laden macrophages in the skin. There may be a family history of similar lesions and/or a history of hyperlipidemia or heart, thyroid, or liver disorders. The distribution includes the area surrounding the eyes, including the eyelids, and the extensor areas of the elbows, knees, and elbows. There are usually no symptoms associated with the lesions, although patients complain of mild pruritus on occasion. There is commonly a family history of atopic diseases, such as asthma and eczema. The lesions consist of areas of hypopigmentation, usually covered with a very fine scale. The hypopigmented area is poorly defined and often dry. Over time, the dryness and/or scaling resolves to leave a smooth area of hypopigmentation. The lesions sometimes arise from an initial area of mild erythema. TINEA VERSICOLOR (PLATE 27) Caused by Malassezia furfur (formerly named Pityrosporum orbiculare), a yeastlike organism that is not contagious. Tinea versicolor, also know as pityriasis versicolor, consists of scaly patches of hyper- or hypopigmented skin. The color can range from paler than the surrounding skin to dark brown. An individual’s multiple lesions are similar in color. It usually occurs in the warm months and in adolescents and young adults. Skin scrapings with potassium hydroxide solution reveal hyphae and spores. MILIA Milia occur in infants and are similar to epidermal inclusion cysts. Milia consist of 1–2-mm pearl-colored lesions scattered over a newborn infant’s face. They may involve the oral mucosa over the palate (Epstein’s pearls). VITILIGO (PLATE 31) Vitiligo is a progressive loss of pigmentation. The patient often describes a history of the progressive development of small, multiple areas of depigmentation that, over time, become larger and confluent. The hair in the affected area may also lose pigmentation. There is a higher inci- dence of vitiligo in patients with autoimmune disorders, particularly those affecting the endocrine system, including hypothyroidism, diabetes mellitus, and Addison’s disease.
To assist the patient in describing a complaint buy cheap extra super cialis 100mg on-line, a skillful inter- viewer knows how to ask salient questions to draw out necessary information without straying buy discount extra super cialis 100 mg. A shotgun approach buy extra super cialis 100mg overnight delivery, with lack of focus order 100mg extra super cialis free shipping, is not recommended and the provider should know, based on the chief complaint and any preceding information, what other ques- tions are essential to the history. It is important to determine the capacity of the symptom to bring the patient to the office, that is, the 2 Copyright © 2006 F. Assessment and Clinical Decision-Making: An Overview 3 significance of this symptom to the patient. This may uncover anxiety that the patient has about a certain symptom and why. It may also help to determine severity in a stoic patient who may underestimate or underreport symptoms. Throughout the history, interviewers recognize that patients may forget details, so prob- ing questions may become necessary. Moreover, patients sometimes have trouble finding the precise words to describe their complaint. However, good descriptors are necessary to isolate the cause, source, and location of symptoms. Often, the patient must be encouraged to use common language and terminology, to tie a symptom to something common. For instance, encourage the patient to describe the problem to you just as he or she would describe it to a relative or neighbor. The history should include specific components, to ensure that the problem is compre- hensively evaluated. These components are summarized in Table 1-1, and the specific ques- tions to include in each section are described in detail in subsequent chapters. PHYSICAL EXAMINATION The expert diagnostician must also be able to perform a physical assessment accurately. This requires extensive practice with all components of the physical examination and keen Table 1-1. Important to consider using the patient’s terminology. History of Present Illness To provide a thorough description of the chief complaint and current problem. P: precipitating and To identify factors that make symptom worse and/or better; any previ- palliative factors ous self-treatment or prescribed treatment, and response. Q: quality and quantity To identify patient’s rating of symptom (e. R: region and radiation To identify the exact location of the symptom and any area of radiation. S: severity and associated To identify the symptom’s severity (e. T: timing and temporal To identify when complaint was first noticed; how it has changed/pro- descriptions gressed since onset (e. Past Medical History To identify past diagnoses, surgeries, hospitalizations, injuries, allergies, immunizations, current medications. Habits To describe any use of tobacco, alcohol, drugs, and to identify patterns of sleep, exercise, etc. Sociocultural To identify occupational and recreational activities and experiences, liv- ing environment, financial status/support as related to health care needs, travel, lifestyle, etc. Family History To identify potential sources of hereditary diseases; a genogram is help- ful; the minimum includes 1st-degree relatives (parents, siblings, chil- dren), although 2–3 orders are helpful. Review of Systems To review a list of possible symptoms that the patient may have noted in each of the body systems. Extensive, repetitive practice is required to develop physical examination skills, with exposure to a range of normal variants and abnormal findings.
His laboratory values are as follows: Hct cheap extra super cialis 100mg overnight delivery, 60% discount extra super cialis 100mg mastercard; WBC effective 100 mg extra super cialis, 15 purchase 100mg extra super cialis with visa,000/mm3; platelets, 400,000/mm3; serum erythropoietin, 0. What is the most appropriate treatment for this patient? Anagrelide Key Concept/Objective: To understand that patients with polycythemia vera who are older than 70 years should be treated with a myelosuppressive agent such as hydroxyurea in combination with phlebotomy The elevated hematocrit level, reduced serum erythropoietin level, headache, fever, mem- ory difficulties, and weight loss seen in this patient are characteristic of polycythemia vera. Although there is not an overall consensus on treatment of polycythemia vera, phleboto- my is frequently used as an initial treatment. Because this patient is older than 70 years and has previously had a thrombotic event, a myelosuppressive agent such as hydroxyurea should be used in addition to phlebotomy. This combination of hydroxyurea and phle- botomy has been demonstrated to be an effective therapeutic regimen in controlling the hematocrit in most patients with polycythemia vera and in lowering the risk of thrombo- sis that occurs with use of phlebotomy alone. When hydroxyurea is used, complete blood 5 HEMATOLOGY 17 counts should be frequently monitored to avoid excessive myelosuppression. Two reports have shown an increased risk of acute myeloid leukemia in patients taking hydroxyurea, although it remains controversial whether the use of hydroxyurea increases the risk of acute myeloid leukemia. A 45-year-old man presents with weakness and shortness of breath. He complains of a headache, fatigue, light-headedness, and ringing in his ears. He smokes three packs of cigarettes a day and has smoked for 30 years. He has been treated for hypertension for the past 10 years with a therapeutic regimen consisting of an antihypertensive agent and a diuretic. Laboratory reports reveal the following: Hct, 57%; red cell mass, 34 ml/kg; low-normal plasma volume; oxygen saturation, 97%. Which of the following is the most likely diagnosis for this patient? Chronic myeloid leukemia Key Concept/Objective: To recognize that middle-aged, obese, hypertensive men who are heavy smokers and who are being treated with diuretics may have Gaisböck syndrome even if their hematocrit levels are lower than 60% The red cell mass of less than 36 ml/kg, reduced oxygen levels, and low-normal plasma volume seen in this patient suggest a diagnosis of Gaisböck syndrome. Gaisböck syndrome, or relative polycythemia, is often seen at an earlier age (45 to 55 years) than polycythemia vera. In the male population in the United States, 5% to 7% have Gaisböck syndrome. Those affected are usually middle-aged, obese, hypertensive men who may also be heavy smokers. Smoking-induced elevations in the level of carboxyhemoglobin or hypoxemia may play a role in the development of Gaisböck syndrome. Long-term exposure to carbon monoxide results in chronically high levels of carboxyhemoglobin. Carbon monoxide binds to hemoglobin with an affinity many times greater than oxygen, decreasing the quantity of hemoglobin available for oxygen transport. Thus, long-term carbon monoxide exposure in cigarette and cigar smokers may cause polycythemia. In this patient, diuretic use for treatment of hypertension may also have exacerbated the deficit in plasma volume. Before treatment with phlebotomy, patients may be taken off diuretics and encouraged to lose weight and stop smoking. A 21-year-old man presents to the emergency department for evaluation of pain and fever. One week ago, the patient was involved in a head-on motor vehicle accident; he was not wearing a seat belt. At that time, the patient underwent an emergent resection of his spleen. The patient states that for the past 2 days, he has been experiencing swelling and redness of his incision site, as well as fever. On physical examination, the patient’s temperature is 102° F (38. Diffuse swelling and induration is noted at his incision site, and diffuse erythema surrounds the incision.