By P. Yespas. Endicott College.

Patients with SBP are at high risk for renal failure purchase 20mg nolvadex fast delivery women's health clinic in richmond hill. The use of albumin infusion at the time of diagnosis and on day 3 was shown to reduce substantially the incidence of renal failure in a recent clinical trial order nolvadex 20 mg with mastercard womens health workouts. Patients who have a history of SBP are at high risk for recurrence (69% within 1 year). Prophylactic therapy with norfloxacin or trimethoprim-sul- famethoxazole has been shown to decrease the incidence of SBP, but no significant dif- ference in survival has been noted. A 76-year-old woman presents with a 1-week history of spiking fevers with rigors, nausea, vomiting, and left lower quadrant pain. She has a history of steroid-dependent rheumatoid arthritis and diverticulosis. On physical examination, the patient is febrile, with a temperature of 103. Abdominal examination reveals moderate tenderness on deep palpation in the left lower quad- rant, without rebound or guarding. Peripheral WBC is 22,000; hematocrit, 39%; and platelets, 390,000. Urine analysis of a catheterized specimen reveals 3+ WBCs and abundant gram-negative rods of different morphologies and gram-positive cocci. Which of the following would be most useful to evaluate the possibility of intra-abdominal abscess in this patient? Gallium-67 scanning Key Concept/Objective: To understand the tests used in the diagnosis of intra-abdominal abscess Intra-abdominal abscesses typically present with fever, abdominal pain, and leukocy- tosis. Patients who are elderly or on corticosteroids can present atypically. The presence of multiple bacterial species in the urine of this patient raises the possibility of vesi- coenteric fistula and intra-abdominal abscess. The evaluation of suspected intra- abdominal abscess often begins with plain radiographs, which, given their speed and availability, are useful for revealing intra-abdominal free air, indicative of a perforated viscus. Ultrasound can be a very helpful imaging modality for the examination of the left and right upper quadrants and the true pelvis. It is limited by the inability to image through bowel gas. Spiral CT scanning is the most accurate study for the evaluation of intra-abdominal abscess, with specificity and sensitivity rates exceeding 90%. MRI and nuclear medicine studies are generally not useful in the diagnosis of intra-abdominal infections. In patients without ascites, the omentum is very much liable to contain intra-abdominal abscesses. For this reason, paracentesis is usually not helpful in mak- ing a diagnosis. Four-quadrant paracentesis is used in the setting of peritonitis second- ary to diffuse bowel disease, trauma, or surgery. The patient described in Question 119 is found to have a 5 cm × 5 cm × 8 cm abscess adjacent to the superior portion of the bladder. Which of the following treatments would not be useful in the management of this patient? Percutaneous drainage using ultrasound guidance B. Peritoneal lavage with antibiotics Key Concept/Objective: To understand the treatment of intra-abdominal abscess Intra-abdominal abscesses must be treated with drainage of the fluid collections. Ultrasound guidance can be used for superficial or large collections. CT-guided tech- niques can provide access to and drainage of smaller and deeper fluid collections. Intravenous antibiotics are essential in both preventing and treating bacteremia, but they will not eradicate infection and must be used in conjunction with drainage. Antibiotics should be chosen empirically to cover enteric flora (an example of such an antibiotic is imipenem).

Before considering use of prophylactic medications in this patient buy generic nolvadex 20mg online pregnancy xray, it would be appropriate to withhold the hydrochlorothiazide and see whether the gout attacks stop generic nolvadex 10mg mastercard women's health clinic yorkton. 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. If either condition develops, it would be appropriate to consider treatment. A 61-year-old man presents with a swollen, warm, tender left knee. He has had three episodes of gout this year, which were treated successfully with indomethacin. Key Concept/Objective: To understand how and when to start prophylactic medications for gout This patient presents with an acute attack of gout. It would be appropriate to treat him with indomethacin for the acute attack and to begin medication to decrease the risk of another attack in the near future. It should be started in conjunction with acute treatment (NSAIDs or steroids) and continued for 1 to 2 months. Colchicine should also be used when urate-lowering drug therapy is initiated. This patient should not receive allopurinol or probenecid during the acute attack because both of these agents can worsen the acute attack. There is no need to add prednisone to the indomethacin being used for acute treatment. A 51-year-old white woman presents to your primary care clinic for evaluation of knee pain. She states that the pain has been progressing gradually for at least a year. The patient denies having had any trau- 15 RHEUMATOLOGY 27 ma. She also states that she has not experienced any erythema, point tenderness, fevers, or chills, nor has she lost the ability to ambulate. However, she occasionally notes some swelling of the joint. Physical examination is notable for the absence of joint instability, fever, redness, edema, or warmth. Which of the following statements regarding osteoarthritis is false? In patients older than 50 years, men are more commonly affected than women B. In most patients with primary osteoarthritis, involvement is limited to one or a small number of joints or joint areas C. Intra-articular fractures and meniscal tears can lead to osteoarthritis years after the injury D. Most patients with radiographic changes consistent with osteoarthritis have few symptoms or functional limitations Key Concept/Objective: To understand the epidemiology and etiology of osteoarthritis Osteoarthritis is a common form of arthritis characterized by degeneration of articular car- tilage and reactive changes in surrounding bone and periarticular tissue. The disease process results in pain and dysfunction of affected joints and is a major cause of disability in the general population. Patients without a specific inflammatory or metabolic condi- tion known to be associated with arthritis who have a history of specific injury or trauma are considered to have primary osteoarthritis.

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