References

Management of gallstones and their complications. Am Fam Physician 2000 61 1673-1680. Grcenberger NJ. Paumgartner G. Diseases of the gallbladder and bile ducts. In Braunwald E, Fauci AS. Kasper KL. et al. eds. Harrison's principles of internal medicine, 15th ed. New York McGraw-Hill, 2001 1776-1788. Grcenberger NJ. Toskes PP. Acute and chronic pancreatitis. In Braunwald E. Fauci AS. Kasper KL. et al, eds. Harrison's principles of internal medicine. 15th ed. New...

Answers

The patient described best (its the picture of disseminated gonococcal infection. She has the rash, which typically is located on extensor surfaces of distal extremities. Pain on passive flexion of her wrist indicates likely tenosynovitis of that area. The fluid is inflammatory, but gonococci are typically not seen on Gram stain. Ceftriaxone is the usual treatment of choice for gonococcal infection. Nafcillin would be useful for staphylococcal arthritis and would be the more likely...

Answers To Case 22 Rheumatoid Arthritis

Summary This is a 32-year-old woman with a I-year history of symmetric polyarticular arthritis and morning stiffness. Joint examination reveals the presence of bilateral swelling, redness and tenderness of her PIP joints, MCP joints, wrists, and knees. She has a mild normocytic anemia with an otherwise normal complete blood count (CBC). Urinalysis, renal, and liver function tests are normal. The ESR is elevated, suggesting an inflammatory cause of her arthritis. Most likely diagnosis Rheumatoid...

Treatment

Disseminated intravascular coagulopathy (DIC) Secondary to some other process sepsis, trauma, metastatic malignancy, obstetric causes Can be relatively mild indolent course or severe life-threatening process ongoing coagulation and fibrinolysis can cause thrombosis or hemorrhage consumption of coagulation factors is seen as prolonged PT and PTT Treatment aimed at underlying cause. No proven specific treatment for the coagulation problem if bleeding, replace factors and fibrinogen with...

Joints Spared

Hands (often asymmetric) DIP (Heberden nodes) PIP (Bouchard nodes) Carpal metacarpophalangeal (CMP) of thumb Knee Hip Feet (usually first toe metatarsophalangeal joint) characteristics seen on x-rays include joint space narrowing, subchondral sclerosis, and subchondral cysts. It is critical to differentiate OA from other conditions that may present similarly. Periarticular pain that is not reproduced with passive motion suggests bursitis or tendonitis. Prolonged pain lasting more than 1 hour...

Etiology Of Transient Ischemic Attacks

Myocardial infarction (anterior wall sputum, akinetic segment) Cardiomyopathy (infectious, idiopathic) Arrhythmia (atrial fibrillation) Cardiac myxoma Valvular heart disease Rheumatic heart disease Bacterial endocarditis Nonbacterial endocarditis (carcinoma, Libman-Sacks disease) Mitral valve prolapse Prosthetic valve Primary central nervous system vasculitis Systemic necrotizing vasculitis (polyarteritis nodosa, allergic angiitis) Hypersensitivity vasculitis (serum sickness, drug-induced,...

Ulcerative Colitis

Erythema nodosum 15 Pyoderma gangrenosum rare Erythema nodosum 10 Pyoderma gangrenosum 1-12 Arthritis (polyarticular, assymmetric) common Ankylosing spondylitis 10 Arthritis less common Ankylosing spondylitis less common Uveitis common (photophobia. blurred vision, headache) Uveitis common (photophobia. blurred vision, headache) Cholelithiasis fatly liver common Primary sclerosing cholangitis rare Fatty liver common Primary sclerosing cholangitis rare Nephrolilhasis (10-20 ) after small bowel...

Clinical Approach

Osteoporosis is an important health issue because the resultant bone fractures cause a great deal of morbidity in chronic pain, loss of independence, and loss of function, as well as mortality. Risk factors for the development of osteoporosis include a low peak skeletal density reached in young adulthood, increasing age, loss of steroid hormone production (menopause or hypogonadism), smoking, nutritional deficiencies, and genetically low bone density. Approximately 14 of white women and 3-5 of...

Etiology of Thyrotoxicosis

Graves disease is the most common cause of hyperthyroidism (80 ) and usually is seen in women, especially between the ages of 30 and 50 years. It is an autoimmune disease caused by autoantibodies that activate the TSH receptor of the thyroid follicular cell, stimulating thyroid hormone synthesis and secretion as well as thyroid gland growth. These antibodies cross the placenta and can cause neonatal thyrotoxicosis. The disease might follow a relapsing and remitting course. Graves disease is...

Clinical Pearls

Rheumatoid arthritis is a chronic systemic inflammatory disorder characterized by the insidious onset of symmetric polyarthritis and extraarticular symptoms. Rheumatoid factor is found in the serum of 85 of patients with rheumatoid arthritis. In nearly all patients with rheumatoid arthritis, the wrist, metacarpophalangeal joints, and proximal interphalangeal joints are affected, whereas the distal interphalangeal joints are spared. Distal interphalangeal joints and large weight-bearing joints...

Suggested Treatment Of Anaphylaxis

Address ABCs (airway, breathing, circulation) intubate if needed Epinephrine either as intravenous solution (1 1000 0.1-0.3 mL in 10 mL of normal saline over several minutes) or intramuscularly (1 1000 0.3-0.5 every 5 minutes as needed) Place the patient in a recumbent position, elevate the legs Normal saline volume replacement and or pressors as required Diphenhydramine 50 mg orally or intravenously every 4 hours as needed Ranitidine or other H, blockers Albuterol or levalbuterol for...

Info

Approach to the patient with pain in one or a few joints. In Kelly's textbook of internal medicine. New York Williams and Wilkins, 2000 1322. Source Koch AE. Approach to the patient with pain in one or a few joints. In Kelly's textbook of internal medicine. New York Williams and Wilkins, 2000 1322. intravenous ceftriaxone is the usual initial therapy, usually with rapid improvement in symptoms. Nongonococcal septic arthritis usually is caused by Gram-positive organisms, most...

Approach To Osteoarthritis

Bouchard nodes Bony enlargement of proximal interphalangeal (PIP) joints, often asymptomatic. Crepitus A creaking or hook and loop (Velcro)-like sound made by a joint in motion. Typically not painful. Heberden nodes Bony enlargement of DIP joints, often asymptomatic. Synovitis Inflammation of the joint space characterized by redness, swelling, and tenderness to touch. OA is the most common joint disease in adults. The disease affects women more often than men. The incidence increases sharply in...

Classification Of Anemia By

Microcytic (low MCV) Iron deficiency Thalassemia Sideroblastic anemia Lead poisoning Normocytic (normal MCV) Acute blood loss Hemolysis Anemia of chronic disease Anemia of renal failure Myelodysplastic syndromes Macrocytic anemia (high MCV) Folate deficiency Vitamin Br deficiency Drug toxicity, e.g., zidovudine Alcoholism chronic liver disease after which the RBC circulates for approximately 120 days. The blood normally contains about one reticulocyte per 100 RBCs. The reticulocyte count,...

Complications

Larger intra- and extrahepatic ducts Autoimmune diseases such as rheumatoid arthritis Match the following diagnoses A-F with the most likely clinical situation described in Questions 41.1 to 41.4 . F. Primary sclerosing cholangitis 41.1 A 38-year-old man with a 12 pack of beer per day alcohol history presents with jaundice, ascites, and dark urine. His laboratory results are AST 350 U mL. ALT 150 U mL. alkaline phosphatase 120 U mL, total bilirubin 25 mg dL, direct bilirubin 12 mg dL, and...

Approach To Polyarticular Arthritis

Articular Manifestations

The first and most important step in evaluating a patient with polyarticular joint pain is determining whether or not synovitis arthritis is present, producing soft tissue swelling, joint effusion, tenderness, warmth of the joint, and limitation of both active and passive range of motion. If the only finding is pain without inflammatory changes, then the diagnostic considerations include noninflammatory diseases such as osteoarthritis OA , fibromyalgia, hypothyroidism. neuropathic pain, and...

Approach To Nephrotic Syndrome

Normally, the kidneys do not excrete appreciable amounts of protein lt 150 mg d because serum proteins are excluded from the urine by the glomerular filter both by their large size and their net negative charge. Thus, the appearance of significant proteinuria heralds glomerular disease, with disruption of its normal barrier function. Proteinuria in excess of 3-3.5 g of protein per 1.73 m2 body surface area normal adult male body surface area per day is considered to be in the nephrotic range....

Approach To Monoarticular Arthritis

Almost any joint disorder may begin as monoarthritis, or inflammation of a single joint however, the primary concern is always infectious arthritis, because it may lead to joint destruction and resultant severe morbidity. For that reason, acute monoarthritis should be considered a medical emergency and investigated and treated aggressively. Monoarthritis may be a result of infection e.g., bacterial, fungal, Lyme disease, tuberculosis or crystal-induced arthritis e.g., pseudogout and gout less...

Comprehension Questions

22.11 A 72-year-old man develops severe pain and swelling in both knees, shortly after undergoing an abdominal hernia repair surgery. Physical examination shows warmth and swelling of both knees with large effusions. Arthrocentesis of the right knee reveals the presence of intracellular and extracellular weakly positive birefringent crystals in the synovial fluid. Gram stain is negative. Which is the most likely diagnosis C. Calcium oxalate deposition disease 22.2 A 65-year-old man with a...