By H. Mojok. Brewton-Parker College.
Today order 250 mg ponstel with amex, she states that her generalized pain is slightly improved generic ponstel 250 mg overnight delivery. She is sleeping better order ponstel 250mg without a prescription, and her energy level has improved order ponstel 250mg with mastercard. She remembers that just before her pain syndrome started 3 years ago, she fell down her neighbor’s doorsteps. She asks you if you agree that this fall is the likely cause of her current pain syndrome. Which of the following statements regarding fibromyalgia is true? Fibromyalgia most commonly occurs in middle-aged men B. Fibromyalgia is considered to be a purely somatic disease; social or psy- chological factors have little bearing on the disease C. The type of pain associated with fibromyalgia is typically nociceptive or neuropathic D. Fibromyalgia patients often have fixed beliefs that minor traumatic events or exposure to pathogens, chemicals, or other physical agents caused their illness Key Concept/Objective: To know the general features of fibromyalgia Fibromyalgia is a chronic syndrome that occurs predominantly in women. It is marked by generalized pain, multiple defined tender points, fatigue, disturbed or nonrestorative sleep, and numerous other somatic complaints. Fibromyalgia becomes more common after 60 years of age but also occurs in children. Despite extensive research, no definitive organic pathology has been identified. Psychological factors associated with chronic distress appear to be very important. In fibromyalgia, negative psychological elements constituting stress and distress are major contributors to the development of increased pain sensitivity and myriad other symptoms. There are four principal categories of pain: nociceptive, neuropathic, psychogenic, and chronic pain of complex etiology. Chronic pain of complex etiology is the type of pain 34 BOARD REVIEW characteristic of fibromyalgia. Fibromyalgia patients often have fixed beliefs that minor traumatic events, pathogens, chemicals, or other physical agents caused their illness. A 27-year-old woman visits your clinic as a new patient. She was in very good health until 1 year ago, when she developed severe neck, shoulder, and hip pain. Her primary physician has completed an exten- sive workup for rheumatologic disorders; the patient has brought the data from that workup with her today. The patient is in constant pain and has difficulty sleeping; she also has a “nervous stomach” and chronic diarrhea, and she feels that her “memory is slipping. Her social history reveals that she was divorced 1 year ago and is a single parent of three children. Which of the following statements regarding the historical diagnosis of fibromyalgia is true? Cognitive complaints, such as difficulty with concentration and mem- ory, are notably absent in patients with fibromyalgia B. Fibromyalgia does not lead to functional impairment C. Regional pain syndromes, such as headache, temporomandibular joint syndrome, or irritable bowel syndrome, are uncommon in fibromyalgia D. Pain is the hallmark of fibromyalgia Key Concept/Objective: To understand important historical elements in patients with fibromyalgia Cognitive complaints, such as difficulties with concentration and memory, may be promi- nent in fibromyalgia.
A non- 7 INFECTIOUS DISEASE 51 tender stage 3 ulceration of the plantar surface is noted on the patient’s left first metatarsal purchase 250mg ponstel visa, with sur- rounding erythema and mild discharge ponstel 500mg lowest price. Which of the following statements regarding osteomyelitis in this patient is true? The most likely reason for osteomyelitis in this patient is hematoge- nous seeding B buy generic ponstel 250 mg on line. Prolonged antibiotic therapy alone cures the majority of these patients C buy 250 mg ponstel with mastercard. Vascular insufficiency impairs wound healing and allows bacterial proliferation Key Concept/Objective: To know the clinical features of osteomyelitis in diabetic patients Osteomyelitis secondary to vascular insufficiency occurs most frequently in older patients with diabetes mellitus or severe vascular impairment. In these patients, osteomyelitis usually develops by contiguous spread of infection from soft tissue to underlying bone; it often occurs in the small bones of the feet. Complex foot lesions in diabetic patients result from a combination of neuropathy, atherosclerotic peripheral vascular disease, and repetitive trauma to the area. Bone infections develop in about 25% of diabetic patients with superficial mild to moderate foot infections; however, of those patients with serious foot infections, over 50% will have osteomyelitis. Extensive debridement is necessary, and about two thirds of cases require bone resection or par- tial amputation. Limb ischemia, combined with poor collateral circulation, impairs wound healing in foot ulcers and allows for the contiguous spread of infection to bone. In addition, this anoxic environment contributes to the development of gangrenous changes and anaerobic infections. Furthermore, peripheral vascular disease may com- promise the efficacy of antibiotic therapy by preventing the accumulation of adequate drug levels in the infected tissues. A 72-year-old woman returns to your clinic for hospital follow-up 8 days after undergoing replacement of the right hip. Her postoperative course was unremarkable until 2 days ago, when she experienced increasing right hip pain, fever, and purulent discharge from the surgical site. The patient is admitted to the hospital and is diagnosed with osteomyelitis of the right hip. For this patient, which of the following statements regarding osteomyelitis is true? The infection was likely introduced after discharge from the hospital C. Late-onset postoperative osteomyelitis is likely to be secondary to hematogenous seeding D. Osteomyelitis can be seen in the immediate postoperative period or as late as 2 years after joint replacement Key Concept/Objective: To know the clinical features of osteomyelitis that occurs after joint replacement surgery Osteomyelitis may occur soon after surgery or later after replacement of the hip joint. Often evident within the first few days or weeks after surgery, acute contiguous infec- tions result directly from infection of the skin, subcutaneous tissue, or muscle. Fever, pain, erythema, edema, and purulent drainage often occur when early infections are caused by pyogenic organisms such as S. When early infections are caused by less pathogenic organisms, such as S. Chronic contiguous 52 BOARD REVIEW infections are usually diagnosed 6 to 24 months after surgery. Most infections are prob- ably introduced during surgery but remain quiescent for a long time. A 13-year-old girl is brought to your office by her mother for evaluation of left leg pain. Two weeks ago, the patient began to experience anterior left leg pain, which caused a slight limp. Over the past 2 weeks, the pain has become more severe, and the patient has experienced temperatures of up to 101° F (38. The patient reports that approximately 4 weeks ago, she sustained an injury to her left leg during a soccer game. At that time, x-rays were negative for a fracture, and the swelling and bruising resolved with rest and the use of ice packs.
The dosage of the steroid triamcinolone depends on the size of the joint order 250mg ponstel mastercard; dosages range from 5 to 10 mg for small joints of the hands or feet to 40 to 60 mg for larger joints discount 500mg ponstel visa, such as the knee ponstel 500mg overnight delivery. Systemic corticosteroids may also be useful in patients for whom colchicine or NSAIDs are inadvisable and for patients with polyarticular attacks buy ponstel 500mg overnight delivery. A 55-year-old man presents with a painful swollen right great toe. The pain is severe, even with minimal pressure from his sock or bed sheet. The medical his- tory includes reflux esophagitis, GI bleeding, and COPD. Laboratory results include the following: uric acid, 8. Key Concept/Objective: To appreciate comorbid conditions when selecting treatment for acute gout This patient’s acutely painful great toe is suggestive of gout. His uric acid level is high, which is consistent with this diagnosis. Appropriate treatment would be either oral pred- nisone or steroids injected into the joint. He should not receive NSAIDs because he has renal insufficiency. Rofecoxib, a COX-2 inhibitor, can also be detrimental to renal function and should not be used in this setting. Allopurinol is not indicated for the acute treatment of gout. He had his first attack 6 months ago; gout was con- firmed by joint aspiration that revealed uric acid crystals. Three months later, he had a second attack, which involved his knee and left great toe. The medical history includes hypertension, reflux esophagi- tis, and psoriasis. The patient reports drinking one glass of wine once a week. Medications include omeprazole, lisinopril, hydrochlorothiazide, and triamcinolone ointment. What would you recommend for this patient to prevent future episodes of gout? Begin colchicine Key Concept/Objective: To understand that hydrochlorothiazide is a common trigger for elevated uric acid and gout 26 BOARD REVIEW This patient has had several attacks of gout over a 6-month period. Hydrochlorothiazide can decrease uric acid excretion and raise uric acid levels, triggering attacks of gout. Before considering use of prophylactic medications in this patient, it would be appropriate to withhold the hydrochlorothiazide and see whether the gout attacks stop. Alcohol con- sumption can also precipitate attacks, but this patient’s infrequent alcohol use is unlikely to be the cause of his gout attacks. He brings with him old records that include results of lab testing done a year ago. Laboratory tests are repeated, and the results are nor- mal, with the exception of a uric acid measurement of 10. Aspirin Key Concept/Objective: To understand that asymptomatic hyperuricemia does not need therapy This patient has asymptomatic hyperuricemia. There is no need to treat asymptomatic patients with hypouricemic agents. They should be followed closely for the development of gout or renal stones.