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Diffuse rash after administration of ampicillin Items 37–41 Match the following diseases with their appropriate signs or associations dutas 0.5 mg with mastercard hair loss questions and answers. A previously healthy 25-year-old music teacher develops fever and a rash over her face and chest dutas 0.5mg lowest price hair loss zoloft. The rash is itchy and on exam involves mul- tiple papules and vesicles in varying stages of development purchase 0.5mg dutas overnight delivery hair loss in men 1 symptoms. One week later she complains of cough and is found to have an infiltrate on x-ray. Which of the following statements about the treatment of the above patient is correct? Trimethoprim-sulfamethoxazole is the treatment of choice in the nonallergic patient c. A 25-year-old male from East Tennessee had been ill for 5 days with fever, chills, and headache when he noted a rash that developed on his palms and soles. A 19-year-old male has a history of athlete’s foot but is otherwise healthy when he develops the sudden onset of fever and pain in the right foot and leg. On physical exam, the foot and leg are fiery red with a well- defined indurated margin that appears to be rapidly advancing. He is treated with ceftriaxone, but the discharge has not resolved and the cul- ture has returned as no growth. Herpes simplex Infectious Disease 15 Items 62–68 Match the clinical description with the most likely etiologic agent. A Filipino patient develops a pulmonary nodule after travel through the American Southwest. Overwhelming pneumonia with adult respiratory distress syndrome occurs on an Indian reservation in the Southwest following exposure to deer mice. Because of the possibility of impending airway obstruction, the patient should be admitted to an intensive care unit for close monitoring. The diagnosis can be confirmed by indirect laryngoscopy or soft tissue x-rays of the neck, which may show an enlarged epiglottis. Many of these organisms are β-lactamase-producing and would be resistant to ampicillin. The clini- cal findings are not consistent with the presentation of streptococcal pharyngitis. The swelling and inflammation of the external auditory meatus strongly suggest this diagnosis. This infection usually occurs in older diabetics and is almost always caused by P. The hypertrophic, wartlike lesions around the anal area, called condylomata lata, are specific for secondary syphilis. In this patient, who has condylomata and no systemic symptoms, Rocky Mountain spotted fever would be unlikely. Blood cultures might be drawn to rule out bacterial infection such as chronic meningococcemia; however, the clinical picture is not consistent with a sys- temic bacterial infection. Interferon α has been used in the treatment of condyloma acumi- nata, a lesion that can be mistaken for syphilitic condyloma. The combination of sore throat, bullous myringitis, and infiltrates on chest x-ray is consistent with infection due to M. The low hematocrit and elevated reticulocyte count reflect a hemolytic anemia that can occur from mycoplasma infection. These IgM- class antibodies are directed to the I antigen on the erythrocyte membrane. In a young patient with fever, pharyngitis, lymphadenopa- thy, and lymphocytosis, the peripheral blood smear should be evaluated for atypical lymphocytes. The symptoms described in association with atypical lymphocytes and a positive heterophile test are virtually always due to Epstein-Barr virus. Workup for toxo- plasmosis or cytomegalovirus infection or hepatitis B and C would be considered in heterophile-negative patients, Hepatitis does not occur in the setting of rheumatic fever, and an antistreptolysin O titer is not indicated. Corticosteroids are indicated in the treatment of infectious mononucleosis when severe hemolytic anemia is demonstrated or when airway obstruc- tion occurs. Neither fatigue nor the complication of hepatitis is an indica- tion for corticosteroid therapy. The 80-year-old-male with a Foley catheter in place has developed a nosocomial infection likely secondary to urosepsis. Providencia species frequently cause urinary tract infection in the hospitalized patient.

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Postural blood pressure for monitoring fluid loss and to prevent excessive diuresis safe 0.5mg dutas hair loss from chemotherapy. Common complications of acute renal failure include: » fluid overload and pulmonary oedema purchase 0.5 mg dutas with visa hair loss cure replicel, » hyperkalaemia 0.5 mg dutas visa hair loss news, » bleeding, » acidosis, and » encephalopathy. Both haemodialysis and peritoneal dialysis are acceptable modalities of therapy in the acute setting. For long-term or chronic, non-urgent need for potassium removal: • Sodium polystyrene sulfonate, oral, 15 g with 15 mL lactulose, 6 hourly. Hyperphosphataemia To decrease absorption of phosphate in acute renal failure: • Aluminium hydroxide 300 mg/5 mL, oral, 10 mL 8 hourly. Do not administer aluminium hydroxide and sodium polystyrene sulfonate simultaneously as this may potentiate aluminium toxicity. Alkalinising agents are not advised as many antibiotics require a lower urinary pH. For pregnant women: • Amoxicillin/clavulanic acid, oral, 875/125 mg 12 hourly for 7 days. If there is a poor response, perform an ultrasound on all hospitalised patients urgently as in-patients or electively as out-patients. Duration of antibiotic therapy: » fluoroquinolones 7 days » other antibiotics 14 days. Longer courses of therapy, 2–3 weeks, should be given for complicated pyelonephritis. Switch to oral therapy as soon as the patient is able to take oral fluids: • Ciprofloxacin, oral, 500 mg 12 hourly for 7 days. Switch to oral therapy as soon as the patient is able to take oral fluids: • Ciprofloxacin, oral, 500 mg 12 hourly for 7 days. Two types occur: » Relapse or recurrence of bacteriuria with the same organism within 3 weeks of completing treatment. Send urine for microscopy, culture and sensitivity as treatment is determined by the results. Patients with impaired bladder emptying require careful urological examination to establish whether surgical treatment is required. In this setting, treatment with a short, intensive course of antibiotic is appropriate. Clinical features include: » pyrexia, » acute pain in the pelvis and perineum, » urinary retention or difficulty, and » acutely tender prostate on rectal examination. Note: The presence of blood on urine test strips does not indicate infection and should be investigated as above. The cause is unknown and believed to be due to changes in hormone levels associated with ageing. For patients presenting with urinary retention, insert a urethral catheter as a temporary measure while the patient is transferred for referral. Organic causes include neurogenic, vasculogenic or endocrinological causes as well as many systemic diseases and certain drugs. Investigations 08h00 serum cortisol level (or at time of presentation in acute crisis): > 550 nmol/L: virtually excludes the diagnosis < 100 nmol/L: highly suggestive of hypoadrenalism 8. To maintain adequate intravascular volume guided by blood pressure: • Sodium chloride 0. For patients who remain symptomatically hypotensive: • Fludrocortisone, oral, 50–100 mcg daily. With minor stress maintenance therapy should be doubled for the duration of illness and gradually tapered to usual dose. Low dose betamethasone (equivalent to dexamethasone) suppression test: • Betamethasone, oral, 1 mg. In patients with type 2 diabetes mellitus, appropriate weight loss if weight exceeds ideal weight. Measure HbA1c: » annually in patients who meet treatment goals, and » 3–6 monthly in patients whose therapy has changed until stable. In patients with severe target organ damage, therapy should be tailored on an individual patient basis and should focus on avoiding hypoglycaemia. Combination therapy with metformin plus a sulphonylurea is indicated if therapy with metformin alone (together with dietary modifications and physical activity/exercise) has not achieved the HbA1c target. For persisting HbA1c above acceptable levels and despite adequate adherence to oral hypoglycaemic agents, add insulin and withdraw sulphonylurea. Note: Secondary failure of oral agents occurs in about 5–10% of patients annually.

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The glu- Renin is secreted from the juxtaglomerular apparatus in cocorticoids control glucose metabolism discount dutas 0.5 mg line hair loss cure male, for example the kidney in response to reduced renal blood flow order 0.5 mg dutas otc hair loss in men will trichomoniasis, for gluconeogenesis generic dutas 0.5 mg without a prescription hair loss joint pain fatigue, and mobilisation of fat stores (lipol- example due to hypotension. Inhibition of fibroblasts, causing reduced amounts of collagen Thinned skin, striae 6. Immunologic effects, mainly ↓ inflammation and ↑ migration of ↑ Susceptibility to inflammatory cells to areas of injury infections 8. In females 50% of the peripheral Cortisol opposes insulin, with a catabolic effect. Clinical features Common features include centripetal obesity (moon Cushing’s syndrome face, buffalo hump), plethora, osteoporosis, proximal Definition myopathy, easy bruising, striae, acne, hirsutism, poor Cushing’s syndrome is the clinical syndrome resulting wound healing and glucose intolerance. As there is a diurnal rhythm and vari- Pituitary adenoma able cortisol secretion a 24-hour urine collection or (Cushing’s disease) low-dose dexamethasone suppression test is used (see Pituitary carcinoma Fig. Radiotherapy is used in treatment of the adrenals of unresectable pituitary adenomas. Screening Tests Single dose dexamethasone given at night, plasma cortisol level taken at 9am the following day. It is familial, and associated with Pathophysiology/clinical features other organ specific autoimmune diseases, especially As for Cushing’s syndrome. Macroscopy Bilateral adrenocortical hyperplasia twice the size of Pathophysiology normal, with thickening of zona reticularis and the r The mineralocorticoids (90% activity by aldosterone, zona fasciculata. The zona glomerulosa appears normal, some by cortisol) act on the kidneys to conserve because mineralocorticoid production is controlled pri- + + sodium by increasing Na /K exchange in the dis- marily by the renin–angiotensin system. In Addison’s dis- ease, gradual loss of these hormones causes increased Microscopy sodium and water loss with a consequent decrease in The pituitary tumour is normally a microadenoma. Irradiationisusedpost-surgery,forpatientswhere cytomegalovirus complete resection was not possible. Drugs which in- Autoimmune hibit adrenal cortisol synthesis are often used as adjunc- Vascular – haemorrhage (associated with meningococcal tivetherapy,e. Their disadvantage is that they increase thrombosis Neoplastic – secondary carcinoma (e. Failure to exchange Na+ samples over a 24-hour period is used to distinguish for H+ ions can lead to a mild acidosis. Reduced cortisol may lead to symptomatic hy- Chronic adrenal insufficiency is treated with glucocor- poglycaemia. Par- pituitary, other hormones are also secreted such as enteral steroids are needed if vomiting occurs. There are often gastrointestinal com- Aetiology plaints such as anorexia, nausea, vomiting, abdominal Patients may already be diagnosed with Addison’s Dis- pain, constipation or diarrhoea. It Examination reveals weight loss, hyperpigmentation may also be caused acutely by bilateral adrenal haemor- especially in mouth, skin creases and pressure areas. Addisonian crisis may also occur on cessation of gluco- corticoid treatment including inhaled glucocorticoids in Complications children. Pathophysiology In adrenal failure, there is no glucocorticoid response to Investigations stress. If exogenous high-dose steroids are not provided r Hyponatremia, hyperkalemia and a hyperchloraemic the condition is fatal. Clinical features r Screening can be performed by measurement of early The patient is ill with anorexia, vomiting and abdominal morning cortisol and 24 hour urinary cortisol. A long Synac- r U&Es (hyponatraemia, hyperkalaemia and hyper- then test using a depot injection and repeated cortisol chloraemia). The r Definitive investigations should not delay treatment, muscle weakness may present with paralysis. Polydipsia steroids will not interfere with test results in the short- and polyuria may be a feature. Macroscopy/microscopy Management Adrenal cortical adenomas are well-circumscribed, yel- Immediate fluid resuscitation with 0. Intravenous hy- Adrenal cortical carcinomas are larger, with local inva- drocortisone and broad-spectrum antibiotics are given. In hyperplasia, the glands Any underlying causes need to be identified and appro- are enlarged, with increased number, size and secretory priately managed. Hypokalaemia may lead to a mild metabolic alkalosis (H+/K+ ex- Conn’s syndrome change in the kidney). However, the use of diuretics Definition to treat hypertension may mimic or mask these fea- Conn’s syndrome is a condition of primary hyperaldos- + tures. If negative, selective In the remainder, there is diffuse hyperplasia of the zona blood sampling may be required to find the source of glomerulosa. Raised aldosterone is much more commonly a physiological response to reduced renal perfusion as in Management renal artery stenosis or congestive cardiac failure. Bilateral adrenal hyperplasia is usually treated with spironalactone (inhibits the Na+/K+ pump, i. Ade- Aldosterone is the most important mineralocorticoid nomas and carcinomas should be removed surgically.