By U. Tizgar. Lutheran Theological Seminary at Gettysburg.

Of the following purchase ibuprofen 400 mg mastercard, which is the best step to take next in the treatment of this patient? Increase prednisone to 60 mg/day and reevaluate in 2 weeks B order ibuprofen 600mg online. Refer to surgery for biopsy of one of the quadriceps muscles C. Decrease prednisone to 20 mg/day and reevaluate in 2 weeks D. Refer to physical therapy to initiate strengthening exercises Key Concept/Objective: To be able to recognize steroid myopathy This patient with polymyositis has evidence of steroid myopathy. There is an increasing sense of proximal weakness without any increase in the CK. The best way to determine whether steroid myopathy is contributing to the weakness is to try a steroid taper and see 15 RHEUMATOLOGY 19 if the weakness improves. If so, a second-line agent such as methotrexate would be useful, although even methotrexate may take several weeks to months to be effective. Biopsy of the muscle may show type 2 fiber atrophy typical of steroid myopathy, but in the setting of polymyositis, the diagnosis may be difficult to interpret. A 34-year-old woman complains of weakness, fatigue, hair loss, and numbness of the fingers. Her symp- toms began 4 months ago, soon after the delivery of her second child. While visiting her mother, she saw her mother’ s physician for the above complaints and was found to have a CK of 600 mg/dl.

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Concomitant chemoradiotherapy is now consid- ered standard care for a majority of patients with locoregional disease cheap ibuprofen 600mg on line. Early-stage disease is treated initially with either surgery or radiation therapy purchase ibuprofen 400mg amex, depending on tumor location; this therapy results in a 60% to 90% cure rate. However, the risk of developing a second head and neck cancer is 3% to 5% per year. In recurrent or metastatic disease, chemother- apy is the standard approach for preserving quality of life while providing palliation. Induction chemotherapy leads to tumor shrinkage, laryngeal preservation, and decreased disease in areas other than the head and neck, presumably by eradicating micrometastases. A 56-year-old man is admitted to the coronary care unit and is diagnosed as having a non–Q wave myocardial infarction. The patient is aggressively managed and is clinically stable. During his admission, he describes to his treating physician that he has struggled with depression in the past but has been reluc- tant to share this with his local doctor. His recent symptoms include insomnia, unintentional weight loss, and depressed mood. He also has not been performing well at work and blames his poor performance on "being tired" and being incapable of concentrating. He has stopped playing golf with his friends on Saturday morning because it is not fun anymore. Which of the following statements regarding depression is true? The patient is not at increased risk for committing suicide B. The mortality 6 months after a myocardial infarction is five times higher for depressed patients than for nondepressed patients Key Concept/Objective: To be able to recognize and treat depression in patients with medical problems A broad array of antidepressants are available for the treatment of depression.

He also wonders which intervention is most likely to alter the natural history of his COPD safe ibuprofen 400 mg. For this patient generic 400mg ibuprofen visa, which of the following statements is true? Long-term administration of oxygen will favorably alter the natural history of this patient’s disease B. Probably the single most important intervention is to help this patient quit smoking C. Physical training programs have been shown to significantly increase the exercise capacity of patients with even far-advanced chronic bronchitis and emphysema; such programs lead to objective improvements in lung function, as measured by FEV1 D. Nebulized bronchodilators are generally of greater benefit than MDIs Key Concept/Objective: To understand the importance and the benefits of smoking cessation in patients with COPD Of the therapeutic measures available for patients with chronic bronchitis and emphy- sema, only smoking cessation and long-term administration of supplemental oxygen to the chronically hypoxemic patient have been definitively shown to alter the natural history of the disease favorably; in this patient with normal O2 saturation, administra- tion of oxygen would be of no clinical benefit. Helping a patient to quit smoking is probably the single most important intervention; effective methods include counseling by physicians and nurses, use of nicotine replacement therapy, behavioral intervention (e. A variety of other therapies offer potential relief of symp- toms in patients with COPD. These include the use of bronchodilators; anti-inflamma- tory therapy; administration of antibiotics during acute purulent exacerbations; pul- monary rehabilitation programs, including physical exercise and respiratory muscle 14 RESPIRATORY MEDICINE 7 training; and, for patients with cor pulmonale, the use of diuretics. There is no evidence that nebulized bronchodilators are of greater benefit than properly administered dry- powder inhalers or MDIs used with a spacer. Physical-training programs, such as tread- mill walking, significantly increase the exercise capacity of patients with even far- advanced chronic bronchitis and emphysema. These results have been achieved despite the fact that lung function, as reflected in such measurements as vital capacity and FEV1, is not affected and that maximal heart rate is generally not reached during the training sessions. A 62-year-old man with a history of COPD (FEV1, 38%) presents with worsening dyspnea, which now occurs at rest; purulent sputum; and wheezing of 6 days’ duration.

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Regarding resisting the generation of high joint reaction forces 30 Etiopathogenic Bases and Therapeutic Implications may be partially responsible for the arthrosis with uninjured generic ibuprofen 600 mg without prescription, injured discount ibuprofen 400 mg otc, or anterior cruciate ligament- that can occur after realignment surgery. Crosby and Insall have not found late Glydendal: Scandinavian University Books, 1957. Vastus medialis oblique/vastus lateralis mus- out movement of the tibial tubercle. Recurrent dislocation of the at medium-term follow-up after IPR. We have patella: Relation of treatment to osteoarthritis. J Bone found retropatellar arthrosis in only 3 knees Joint Surg 1976; 58-A: 9–13. The mosaic parable with degenerative changes presented at of pathophysiology causing patellofemoral pain: Therapeutic implications. Conclusions Lateral force-displacement behaviour of the human This study is not intended to advocate for a patella and its variation with knee flexion: A biome- chanical study in vitro. Syndrome d`hyper- vide insight into improving our understand- pression externe de la rotule (S. Rev Chir Orthop ing of the pathophysiology of anterior knee 1975; 61: 39. Anatomy of tify a relationship, or lack of one, between the patellar dislocation. Indications in knee pain and/or patellar instability; to ana- the treatment of patellar instability. J Knee Surg 2004; lyze the long-term response of VMO muscle 17: 47–56. The etiology of patellofemoral pain in young active patients: A prospective study. Clin Orthop determine the incidence of patellofemoral 1983; 179: 129–133.

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Half-way around they give off branches to supply the lateral chest 600mg ibuprofen with amex. They end by piercing the intercostal muscles near the sternum to form the medial anterior cutaneous nerve of the thorax discount 600mg ibuprofen amex. The T2 ventral ramus is unique in size and distribution, and called the intercostobrachial nerve. It supplies the skin of the medial wall and the abdom- inal floor of the axilla, then crosses to the upper arm and runs together with the posterior and medial nerves of the arm (branches of the radial medial cord). The second and third intercostobrachial nerves arise from the lateral cutane- ous branches of the third and fourth intercostal nerves. T7–T11 rami form the thoracoabdominal nerves, and continue beyond the intercostal spaces into the muscles of abdominal wall. They give off lateral cutaneous branches and medial anterior cutaneous branches. The eleventh and twelfth thoracic nerves, below the 12th rib, are called the subcostal nerve. The roots have a downward slant that increases through the thoracic region, such that there is a two-segment discrepancy with vertebral body and segmen- tal innervation. Pain and sensory symptoms at various locations (dorsal, ventral nerve). Muscle weakness only seen if bulging of abdominal muscles can be palpated. Signs Skin lesions may be residual symptoms from Herpes zoster. Surgical intervention may be necessary for symptomatic spinal compression. Differential diagnosis: postoperative thoracic pain Drainage in the intercostal space Injection into the nerve Postmastectomy pain (spectrum from tingling to causalgia) Rib retraction Neoplastic: Malignant invasion from apical lung tumors Pleural invasion Vertebral metastasis: Pain either locally, or in uni- or bilateral radicular distribu- tion. Inflammatory: Herpes: preherpetic, herpetic and postherpetic neuralgia.

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