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Most patients with atheromatous renal vascular disease and hypertension have essential hypertension prednisolone 5mg free shipping allergy symptoms red face. A 55-year-old man presents to establish primary care quality prednisolone 40mg allergy medicine and adderall. His medical history is significant only for 40 pack- years of smoking. On physical examina- tion, the patient’s blood pressure is 158/98 mm Hg, and he is moderately obese (body mass index, 27); the rest of his examination is normal. His laboratory examination, including a chem 7, CBC, TSH, and urinalysis, is normal, as is his electrocardiogram. Repeated blood pressure measurements over the next month are similar to the values first obtained. With respect to this patient’s blood pressure, what therapeutic option should be offered to this patient now? Lifestyle modifications, including decreased alcohol consumption, weight loss, smoking cessation, and moderate exercise for 6 months ❏ D. Given his smoking history, he has greater than or equal to 1 risk factor for CV disease, which puts him in risk group 2. On the basis of the JNC VI (Joint National Committee on Prevention, Detection, and Treatment of High Blood Presssure) recommen- dations, it is appropriate to try lifestyle modifications (weight loss, dietary modification such as adherence to the DASH [Dietary Approaches to Stop Hypertension] diet, and mod- erate exercise) for 6 months before starting medications. The patient in Question 18 adhered to your recommendations, but his blood pressure remains elevated to the same degree. He is interested in controlling his blood pressure but is worried about the cost of medications. What should be the first-line pharmacologic therapy for this patient? Hydrochlorothiazide, 25 mg/day Key Concept/Objective: To know the recommended first-line medications for treatment of hyper- tension Thiazide diuretics for the treatment of high blood pressure have been shown most consis- tently to have the best outcomes with respect to stroke and CV disease, mortality, and patient compliance. Given that the benefits of treating high blood pressure accrue only over the long term, the last of these attributes is especially important. Also, hydrochloro- thiazide is by far the least expensive of all of the medications listed. Three months after starting therapy, the patient in Question 18 returns for follow-up. His blood pressure is 145/92 mm Hg, and blood pressure values that he has obtained outside the clinic are similar. He says that he has been taking hydrochlorothiazide as directed and has noted no unpleasant side effects. He is doing his best to adhere to the lifestyle modifications that you recommended. What is the best step to take next in the management of this patient? Double the dose of hydrochlorothiazide to 50 mg/day ❏ D. Add amlodipine, 5 mg/day Key Concept/Objective: To understand the goals of antihypertensive therapy and to be able to select an appropriate second medication to achieve those goals The goal for the treatment of hypertension is a blood pressure lower than 140/90 for most people (although this number is arbitrary, and some experts recommend still lower tar- gets). Given that your patient is compliant with his current therapy and has done as much as he can to achieve lifestyle modification, it is appropriate to add a second agent. Atenolol is the best choice because of its low cost and proven mortality benefit. Doses of hydrochlorothiazide higher than 25 mg/day will not improve blood pressure control, and higher doses of hydrochlorothiazide have been associated with increased mortality. Amlodipine is a reasonable choice, but it is expensive, and there are no data to suggest that the calcium channel blockers improve mortality. A 72-year-old woman comes to see you to establish care, after her previous physician retired. Her med- ical history is significant for diet-controlled diabetes and a myocardial infarction. What should be the target blood pressure in the long term for this patient?

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She asks you if you agree that this fall is the likely cause of her current pain syndrome purchase prednisolone 10 mg otc allergy symptoms eye twitch. Which of the following statements regarding fibromyalgia is true? Fibromyalgia most commonly occurs in middle-aged men B buy prednisolone 20 mg on line allergy medicine while breastfeeding. 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. Functional impairment is usually present, at least in patients with fibromyalgia who seek care. Patients report difficulty performing usual activities of daily living; in addition, they avoid exercise—indeed, patients with fibromyalgia are fearful of exercise. Regional pain syndromes, such as headache, temporomandibular joint syn- drome, or irritable bowel syndrome, are extremely common in fibromyalgia. It is essential that the physician not automatically attribute all such symptoms to fibromyalgia, howev- er, because fibromyalgia frequently coexists with other organically defined disorders. The pain radiates diffusely from the axial skeleton and is localized to muscles and muscle-tendon junctions of the neck, shoulders, hips, and extremities. A 35-year-old woman presents to your office with the complaints of severe joint pain, joint swelling, muscle aches, insomnia, and severe fatigue.

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If there is no history of head trauma and the patient’s general neurological status is intact generic 20mg prednisolone mastercard allergy treatment singapore, proceed to the examination of the ears cheap prednisolone 20 mg mastercard allergy shots nyc. Observe both external ears, comparing for symmetry of appearance. Identify areas of inflammation, swelling, deformity, or distortion of landmarks, signs of trauma. Identify the color, odor, and consistency of any discharge that is visible. Palpate the structures of the external ear, noting any tenderness or palpable abnormalities. Observe the distal portion of the canal for swelling, erythema, and discharge, as well as any obvious foreign body. Complete the otoscopic examination, noticing the condition of the canal walls, TM, and visible portion of the middle ear structures. Diagnostic Studies Diagnosis is usually made based on history and physical examination. Some specific diag- noses are discussed in preceding subsections along with other conditions that can be asso- ciated with discharge. Aom With Perforation Particularly in children, spontaneous rupture of the TM may occur owing to the pressure in the middle ear, resulting in a white or purulent discharge from the ear. In addition to the typical findings of AOM, there may be a visible perforation (Figure 5-6). Cerebrospinal Fluid Leakage Cerebrospinal fluid (CSF) leaks are associated with head trauma or surgery. If the history and/or physical examination suggest the potential for leakage of CSF, the drainage can be tested for glucose. Providing the patient is stable, a referral is warranted for definitive diag- nosis, as CSF leakage indicates a heightened potential for the development of meningitis, in addition to the condition responsible for the leakage. Further diagnostic studies, includ- ing imaging, will be completed following referral. Nursing health assessment: A critical thinking, case studies approach. Reprinted with permission) CHOLESTEATOMA A cholesteatoma is an abnormal growth of epithelial tissue in the middle ear. The tissue can grow to invade surrounding bone and/or extend into the inner ear. Surgical excision is usually indicated, so the patient should be referred when this is suspected. The patient often presents with a history of drainage from the ear. There may be asso- ciated sense of aural fullness and/or decreased hearing in the affected ear. The examination will reveal drainage and/or granulatory tissue in the canal. If there is an associated infection, inflammatory changes may be evident, as seen with AOM. Because of the risk of permanent hearing loss and invasiveness, the patient should be referred for definitive diagnosis and surgical intervention. Nursing health assessment: A critical thinking, case studies approach. In children, hearing deficits are often associated with middle ear effusions. Other reasons for decreased hearing include repetitive exposure to loud noise, which may occur with recreational activities such as concert attendance, firearms use, all terrain vehi- cle riding, and the operation of woodworking equipment, as well as other outside equip- ment and occupational exposure. Mechanical obstruction of the ear canal by cerumen or a foreign body may also cause hearing impairment.

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Eye Discharge Eye discharge is most commonly associated with infectious disorders but can also be asso- ciated with other inflammatory conditions or systemic diseases affecting the eye order 40 mg prednisolone otc allergy killeen tx. By far the most common causes of eye discharge are the various forms of conjunctivitis 20mg prednisolone visa allergy medicine companies. It is important to know whether the discharge is per- sistent or, instead, occurs in certain settings. Determine whether there are any associated eye symptoms, such as pain, altered vision, photophobia, or swelling. Ask about extraocu- lar symptoms, such as sneezing, itching, fever, malaise. Determine past history of atopic disorders and exposure to infectious diseases. Physical Examination Test visual acuity, and then perform a general inspection, observing for the quality and location of any discharge and noting the consistency and color. Although not generally nec- essary, a culture of the discharge may be warranted. To obtain a culture, retract the lower lid and place a conjunctival swab in the palpebral space. DACRYOCYSTITIS Dacryocystitis is an infection of the lacrimal sac and is most common in infants, sec- ondary to congenital stenosis of the lacrimal duct. In adults, it can be caused by hyper- trophic rhinitis, polyps, or trauma. Older adults lose the elasticity of the drainage system, so that the duct is not flushed by tears, and dacryocystitis may result. If the duct is occluded, constant tearing may occur. The surrounding area can also become inflamed, tender, and swollen. Associated conjunctivitis or blepharitis may be present. ERYTHEMA MULTIFORME—STEVENS-JOHNSON SYNDROME Erythema multiforme involves inflammation of the mucous membranes and skin. It is often related to an infection or can be due to almost any medication. The most severe form is called Stevens-Johnson syndrome. Because the condition can be fatal, it is important to immediately recognize and treat. In Stevens-Johnson syndrome, conjunctivitis with copious amounts of purulent dis- charge may occur. Conjunctival bullae and ulcerations may Copyright © 2006 F. Patients develop erythematous lesions and bullae over the skin and hemorrhagic lesions of the mucous membranes. The patient appears acutely ill and has systemic symp- toms, including malaise, fever, and arthralgias. The diagnosis is often made by identifying the classic skin lesions, which consist of red- centered bullae, surrounded by white areas. In addition to the eye tissue, the palms, soles, anus, vagina, nose, and mouth are commonly affected. Ptosis Ptosis, or drooping of an eyelid, can be related to simple aging, with natural loss of elas- ticity and lid drooping or it can result from a variety of other causes. The causes of ptosis that are neither congenital nor acquired include trauma, conditions that add mass to the eyelid, and conditions that affect the nerves or muscles controlling the lid’s position. In 75% of the cases, in fact, the first manifestation of myasthenia gravis is ptosis. History It is important to determine how and when the ptosis developed. Identify any associated altered vision and whether the patient believes the vision has been altered by the drooping eyelid. Ask about all other medical dis- orders and medications. Determine whether the patient has a history of hypertension, peripheral vascular disease, or any other risk factors for stroke, or a history of myasthenia gravis.

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