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Thrombolytics have been studied in the setting of acute coronary syndromes without ST segment elevation or bundle branch block and have been found to be deleterious cheap cialis extra dosage 50 mg online, so they are contraindicated in this setting quality 60 mg cialis extra dosage. A previously healthy 52-year-old man presents with complaints of intermittent substernal chest dis- comfort. The symptoms occur with exercise, and they are not relieved by rest. You determine that the patient has an intermediate pretest probability of having significant coronary artery disease, and you elect to have him undergo exercise ECG testing to further evaluate his symptoms. Which of the following findings would be most highly suggestive of significant ischemic heart disease (IHD) on exercise ECG testing? Exercise-induced falls in blood pressure or the development of an exercise-induced S3 heart sound are strongly suggestive of ischemic left ventricular dysfunction. Specific exercise-induced ECG changes include changes ≥ 1 mm horizontal or downward-sloping ST segment depression or elevation during or after exer- cise. Exercise-induced changes in lead V5 are most reliable for the diagnosis of IHD. A 56-year-old man with hypertension presents to your clinic for a routine health maintenance visit. He is asymptomatic and takes only hydrochlorothiazide. His total cho- lesterol level is 190 mg/dl, and his high-density liproprotein (HDL) cholesterol level is 36 mg/dl. He tells you he is concerned about IHD and that he has read about new methods to detect early disease, including CT imaging. He is interested in this screening test in hope of detecting any dis- ease he may have before it becomes a problem. How should you advise this patient with regard to electron-beam computed tomography (EBCT)? You should tell him that EBCT is a safe and effective method of detect- ing early coronary artery disease ❏ B. You should recommend this test because it will hopefully alleviate his concerns about IHD ❏ C. You should recommend against this form of testing because his risk of heart disease can be equally well determined by the information already known about him ❏ D. You should recommend against this test because even if the test is neg- ative, he would still have a high likelihood of having significant lesions Key Concept/Objective: To understand the limitations of new technology in the diagnosis of IHD Although the sensitivity of EBCT for the diagnosis of significant coronary artery stenosis is high, the specificity of EBCT for significant coronary artery stenosis ranges from only 41% to 76%, yielding many false positive results. To date, no prospective, population-based studies have been performed to investigate a potential association between the calcium score derived from EBCT and the risk of future coronary events, and no studies have shown that screening for IHD with EBCT reduces mortality. Asymptomatic patients for whom EBCT results indicate a potentially high risk of cardiac events may suffer anxiety and unnecessary procedures as a result of the study. The ACC/AHA do not currently rec- ommend EBCT and other imaging procedures, such as magnetic resonance imaging 26 BOARD REVIEW angiography, in asymptomatic patients. A 61-year-old woman was recently admitted to the hospital with acute coronary syndrome. She was found to have coronary artery disease that is not amenable to revascularization procedures. She smokes approximately 1 pack of cigarettes a day. Medical therapy and lifestyle changes are recommended for this patient. Which of the following statements is true regarding the management of this patient? Clopidogrel and ticlopidine are equally effective in reducing future cardiovascular events ❏ B. Smoking cessation is as effective as or more effective than any current medical therapy in reducing the risk of future cardiovascular events ❏ C. Patients with chronic stable angina should be placed on statin therapy only if their low-density lipoprotein (LDL) cholesterol level is greater than 100 mg/dl ❏ D. It is clear that patients who walk for at least 1 hour five to seven times a week derive more benefit than patients who walk only for 30 min- utes five to seven times a week Key Concept/Objective: To understand the management of patients with IHD and chronic stable angina A systematic review of prospective cohort studies of smokers with IHD found a striking 29% to 36% relative risk reduction in all-cause mortality for patients who were able to quit smoking.

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Systemic disease involving the liver order 200mg cialis extra dosage with mastercard, spleen buy generic cialis extra dosage 50 mg on line, and bone also occurs. Peliosis hepatis is a characteristic finding in the liver and appears as hypodense lesions on abdominal CT. Treatment with erythromy- cin or doxycycline usually results in rapid improvement; this treatment should be con- tinued for 2 months. Relapses are frequent after discontinuance of therapy, and some patients need lifelong treatment with tetracycline or a macrolide for disease control. A 15-year-old girl who works as a veterinary technician presents to clinic with complaints of painful swelling under her right arm that developed over the past 10 to 14 days. The swelling has been accom- panied by low-grade fever, fatigue, and headache. She was previously healthy and is receiving no med- 36 BOARD REVIEW ications other than acetaminophen. On examination, you note a 3 by 3 cm tender lymph node in the right axilla, with overlying erythema and slight fluctuance. There is a small healing pustule on the dor- sum of the right hand and several superficial linear abrasions over both forearms. Which of the following statements regarding this infection is true? Encephalitis, seizures, and coma are well-recognized sequelae of the illness B. Tissue aspirated from an affected lymph node is likely to reveal acid-fast bacilli C. Symptoms are unlikely to improve in the absence of sustained antimicrobial therapy D. Skin testing for a reaction to the causative organism is the diagnos- tic procedure of choice E. Person-to-person spread of the illness is a common mode of transmission Key Concept/Objective: To recognize cat-scratch disease (CSD) and its manifestations CSD is one of several diseases caused by Bartonella species, which are small, fastidious gram-negative rods. After the scratch or bite of a cat (typically a kitten), a primary cutaneous papule or pustule typi- cally develops at the site of inoculation. Although in immunocompetent hosts the disease usually self-resolves within weeks to months, well-described neurologic complications occur in a minority of patients; these complications include encephalitis, seizures, and even coma. Another atypical presen- tation of the disease is Parinaud oculoglandular syndrome, which consists of granulo- matous conjunctivitis and preauricular lymphadenitis. The differential diagnosis for CSD includes tularemia, mycobacterial infections, plague, brucellosis, sporotrichosis, and lymphogranuloma venereum. Diagnosis is often clinical but can be confirmed by demonstration of antibodies directed against B. Serologic studies have largely supplanted the use of CSD skin testing. Symptoms generally resolve without antimi- crobial therapy. Only azithromycin has been demonstrated in a clinical trial to hasten resolution of lymphadenopathy in typical cases of CSD. A 24-year-old man from sub-Saharan Africa comes to your office to establish primary care. He has been blind since 20 years of age because of a recurrent eye infection. The infection is caused by Chlamydia trachomatis, which is an intracellular pathogen B. The organism causing blindness in this patient is identical to that causing sexually transmitted diseases such as urethritis and lym- phogranuloma venereum (LGV) C. Chlamydia pneumoniae has been associated with an increased risk of cardiovascular disease D. Chlamydia organisms are widespread in nature and can cause infec- tions in mammals and other animal species 7 INFECTIOUS DISEASE 37 Key Concept/Objective: To understand the clinical presentations of infections caused by differ- ent species of Chlamydia The chlamydiae are widespread obligate intracellular pathogens.

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This is detailed in subsequent chapters but some examples are given purchase 50 mg cialis extra dosage visa. Trauma can be prevented in many circumstances such as road traffic accidents purchase 50 mg cialis extra dosage with mastercard, land mines and in the workplace if the effective policies are implemented. The management of trauma can now result in far less long term disability if appropriate services are available in a timely and appropriate fashion. It is possible 6 CARE FOR MUSCULOSKELETAL CONDITIONS to identify those at risk of osteoporosis and target treatment to prevent fracture. Treatment can also prevent the progression of osteoporosis even after the first fracture, with drugs which maintain or even increase bone strength. Structural changes can be prevented in rheumatoid arthritis by effective second line therapy with recognition of the need for early diagnosis and intervention. Osteoarthritis cannot yet be prevented but large joint arthroplasty has dramatically altered the impact that it has on ageing individuals who would have lost their independence. There have been major developments in preventing back pain becoming chronic. There have been major advances in the management of pain. Pain control can now be much more effectively achieved with new ranges of effective and well tolerated drugs, and there have been advances in techniques related to a greater understanding of the mechanisms of pain and its chronification. There remain many outstanding problems concerning the management of musculoskeletal conditions. There are many interventions in use for which there is little evidence to prove effectiveness. Many of these are complex interventions dependent on the therapist, such as physiotherapy, or provision of social support and these are complex to evaluate. Evidence is, however, essential to ensure such interventions, if truly effective, are adequately resourced in the future. Many, however, are not benefiting from the proven advances and achieving the potentially improved outcomes. This is largely because of lack of awareness, resources and priority. These resources are not just money to pay for new expensive drugs but also the human resources of clinicians and therapists with the necessary competencies to effectively manage those with musculoskeletal conditions. The public and many health professionals are not fully aware of what can now be achieved and therefore perpetuate a negative attitude. If they think little can be done, they do not seek expert help. Lack of awareness and knowledge of medical advances means that these are not delivered to the main benefactor – the patient. There are many suffering pain which could be much more effectively managed. Lack of knowledge of what can be achieved alongside a lack of awareness of the enormous burden on the individual and society leads to lack of priority and resources. There are few health policies that highlight the importance of musculoskeletal conditions despite their enormous costs to society and to the individual. As a consequence, for example, the waiting 7 BONE AND JOINT FUTURES times for joint replacement surgery for osteoarthritis, a highly cost effective intervention, are amongst the longest in the UK. The challenge is to ensure as many people as possible can benefit from the current effective means of prevention, treatment and rehabilitation. What is the future Demand The demand for care for musculoskeletal conditions is going to increase. The global disease burden of non-communicable diseases was 36% in 1990 but it is predicted to be 57% in 2020. First, because of the change in population demographics. By 2030, 25% of the population in the UK will be over the age of 65 years and the prevalence of musculoskeletal conditions increases dramatically with age.

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