By L. Lester. Crichton College.

This description fits the patient presented in this case buy modafinil 200 mg with visa. The second group includes patients with anti-SRP antibodies cheap 100 mg modafinil overnight delivery; these patients tend to have an abrupt onset of weakness, and they may have cardiac disease. The third group is identified by the presence of antibodies against Mi-2; these patients have a dermatomyositis with the so-called shawl sign. A 58-year-old man is seen in your clinic for the first time. He says he has decided to see a doctor because over the past 2 years he has noticed some weakness of his arms and legs. He says these symptoms were not bothering him ini- tially but that, over the past few months, he has noticed more weakness in his left arm. On physical examination, there is no rash; his strength is 5/5 on the right side of his body, 5/5 in his left leg, and 3/5 in his left arm. His distal strength and proximal strength are quite sim- ilar. Neurologic examination results are otherwise normal. His creatine kinase (CK) level is moderately elevated. Which of the following is the most likely diagnosis for this patient? Inclusion body myositis (IBM) Key Concept/Objective: To understand the presentation of inclusion body myositis This patient is a middle-aged man with slow-onset muscle weakness. Dermatomyositis is defined by the presence of an inflammatory myopathy and a characteristic rash. Polymyositis is characterized by weakness that is symmetrical and predominantly proxi- mal, and the clinical course is more aggressive than the one described here. Sarcoidosis can cause a myopathy but usually is accompanied by other manifestations that are absent here. This patient’s symptoms are more consistent with IBM. The pattern of severity of muscle weakness in IBM differs from that seen in other idiopathic inflammatory myopathies. In addition to the presence of proximal weakness, distal muscles may be involved, and in some cases, muscle abnormalities are asymmetrical. Unlike most of the other inflammatory muscle disorders, IBM affects more men than women. Electron microscopy may be required to demonstrate the inclusion bodies that define IBM. A 40-year-old woman with polymyositis comes to your office for an initial visit. She was diagnosed 3 months ago and was placed on prednisone, 1 mg/kg/day. She says her strength has recovered signifi- cantly since she started therapy. She comes to visit you because she recently moved to your town. She has no other significant medical history; she has no allergies, and she is taking no medications other than prednisone. Her physical examination shows minimal proxi- mal weakness. Which of the following would be the best therapeutic intervention at this time? Continue steroids at the same dose for 3 more months and then pro- ceed with a slow taper B. Start tapering the steroids and start methotrexate or azathioprine C. Discontinue the steroids and start cyclophosphamide D. Order a muscle biopsy to see if the patient is in remission Key Concept/Objective: To understand the treatment of idiopathic inflammatory myopathies Corticosteroids are the mainstay of initial therapy for the inflammatory myopathies.

If patients respond poorly to treatment and are seronegative or belong to population groups at high risk for tuberculosis modafinil 200mg fast delivery, biopsy should be strongly considered purchase 200mg modafinil overnight delivery. Patients with AIDS who have been treated for toxoplasmosis require prolonged suppressive therapy. If the CD4+ T cell count rises above 200 cells/µl for 3 months, secondary prophylaxis for toxoplasmosis can be stopped. A 37-year-old woman presents with complaints of foul-smelling, greasy diarrhea; nausea; and excessive flatulence. She states that she returned from a camping trip about 2 weeks ago. Immunologic assay detects giardial antigen in the stool. Which of the following statements about treatment and prevention of giardiasis is true? The most effective treatment is metronidazole, 250 mg three times a day for 5 days B. When drinking water comes from a potentially contaminated source, it is essential that it be heated or, preferably, boiled for at least 10 minutes C. On a camping trip, iodine-based water treatments can provide rapid decontamination in a few minutes D. Metronidazole is generally considered to be safe in pregnant patients Key Concept/Objective: To understand prophylaxis against and treatment of giardiasis Boiling water or heating water to at least 158° F for 10 minutes renders water nonin- fectious. For hikers and campers, iodine-based water treatments are more effective than chlorine-based treatments; iodine disinfection must be carried out for at least 8 hours to be 99. Metronidazole is the principal drug used to treat giardiasis; how- ever, the usual dosage of 250 mg orally three times a day for 5 days may lead to recur- rences in up to 40% of patients. Between 500 and 750 mg given orally three times a day for 10 days is 60% to 95% effective. Administration of 2 g of metronidazole once daily for 3 consecutive days is associated with the highest cure rates, yielding 93% to 100% efficacy. Treatment of giardiasis in pregnancy can be difficult. Metronidazole is often avoided, although studies have not documented teratogenic risks of metronidazole dur- ing pregnancy. A 39-year-old man with AIDS (CD4+ T cell count, 100 cells/µl) presents with a complaint of profuse, watery diarrhea. Conservative treatment measures have been unsuccessful. Evaluation of the stool reveals oocysts consistent with infection with Cryptosporidium. Which of the following statements about cryptosporidiosis is true? Cryptosporidiosis is usually self-limited in AIDS patients unless CD4+ T cell counts are below 100 cells/µl 7 INFECTIOUS DISEASE 105 B. AIDS patients infected with Cryptosporidium are at risk for bacterial invasion of the biliary tract, which can cause complications that include cholecystitis and cholangitis C. Paromomycin has been proved to be highly effective in treating cryptosporidiosis in patients with HIV D. Antiretroviral therapy should be withheld during acute infection with Cryptosporidium Key Concept/Objective: To understand the characteristics of cryptosporidiosis in immunocom- promised patients In immunocompromised patients, cryptosporidiosis can be persistent and severe. In HIV-infected patients with CD4+ T cell levels greater than 180 cells/µl, cryptosporidio- sis can be self-limited. With more profound immunocompromise, however, the secre- tory diarrhea, which is chronic and profuse, is usually unremitting. In these persons, Cryptosporidium organisms may cause hepatobiliary disease, including cholecystitis, cholangitis, and papillary stenosis. Chemotherapy would be valuable in immunocom- promised patients, but an effective regimen for cryptosporidiosis has not been estab- lished.

He has been getting some information on the Internet about the use of omega-3 polyunsaturated fatty acids as part of a cardioprotective diet buy modafinil 100mg otc. CLINICAL ESSENTIALS 5 Which of the following statements is most accurate concerning the use of omega-3 fatty acids? Consumption of omega-3 polyunsaturated fatty acids has been shown to decrease the incidence of recurrent myocardial infarctions ❏ B order modafinil 100 mg mastercard. Omega-3 polyunsaturated fatty acids have been shown to decrease low- density lipoprotein (LDL) cholesterol levels ❏ C. Consumption of omega-3 polyunsaturated fatty acids is inversely related to the incidence of atherosclerosis and the risk of sudden death and stroke ❏ D. Omega-3 polyunsaturated fatty acids have been shown to elevate triglyc- eride levels Key Concept/Objective: To understand the benefits of omega-3 polyunsaturated fatty acids Omega-3 polyunsaturated fatty acids have been shown to have a cardioprotective effect. Consumption of omega-3 fatty acids is inversely related to the incidence of atherosclero- sis and the risk of sudden death and stroke. In high doses, omega-3 fatty acids may reduce blood triglyceride levels, but in dietary amounts, they have little effect on blood lipids. Even in modest amounts, however, omega-3 fatty acids reduce platelet aggregation, there- by impairing thrombogenesis. They may also have antiarrhythmic and plaque-stabilizing properties. A 52-year-old woman is diagnosed with diabetes on a blood sugar screening test. She is started on a diet and undergoes education about diabetes. After a month, she comes back for a follow-up visit and asks you why she should eat complex carbohydrates instead of simple carbohydrates if they are all the same. Which of the following statements about simple and complex carbohydrates is true? Simple and complex carbohydrates are indeed of the same caloric value, and there is no advantage in using one over the other ❏ B. Simple carbohydrates have a higher glycemic index than complex carbo- hydrates, and they may decrease high-density lipoprotein (HDL) choles- terol levels ❏ C. Simple carbohydrates have a higher glycemic index than complex carbo- hydrates, and they may increase HDL cholesterol levels ❏ D. Simple carbohydrates have a lower glycemic index than complex carbo- hydrates, and they may decrease HDL cholesterol levels Key Concept/Objective: To understand the difference between simple and complex carbohydrates Plants are the principal sources of carbohydrates. Simple carbohydrates include monosac- charides such as glucose, fructose, and galactose and disaccharides such as sucrose, malt- ose, and lactose. Sugars, starches, and glycogen provide 4 cal/g; because fiber is indi- gestible, it has no caloric value. Complex carbohydrates include polysaccharides and fiber. Carbohydrates contribute about 50% of the calories in the average American diet; half of those calories come from sugar and half from complex carbohydrates. Because sugars are more rapidly absorbed, they have a higher glycemic index than starches. In addition to provoking higher insulin levels, carbohydrates with a high glycemic index appear to reduce HDL cholesterol levels and may increase the risk of coronary artery disease. Food rich in complex carbohydrates also provides vitamins, trace minerals, and other valuable nutrients. A 52-year-old woman comes to your clinic to establish primary care. She has no significant medical history, nor has she ever used tobacco or ethanol. You ask about her dietary habits and find that the amount of fat that she is eating is in accordance with the AHA recommendations for healthy adults. Results of routine laboratory test- ing are within normal limits.

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