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Julian is computer-literate discount atarax 10 mg fast delivery, so he was also given the Internet addresses of reputable self-help groups and organizations for AS patients. When he was seen at a follow-up visit 2 weeks later, Adam’s symptoms were already much better. Assessment of pain, physical function, spinal mobility (including chest expansion), duration of morning stiffness, presence of any inflamed peri- pheral joints, and enthesitis are critical elements that will be followed over time by the medical personnel caring for him. Laboratory tests, such as C-reactive protein (CRP) and erythrocyte sedi- mentation rate (ESR), and occasionally muscu- loskeletal imaging (changes on X-ray pelvis and spine) will also help his doctors to assess and monitor the activity and severity of his disease. Adam asked a lot of questions about AS and possible treatments, and he had already accessed many websites and other information sources. Avoiding falls • Always wear a good pair of skid-resistant shoes. Posture • It is important to sleep on a firm bed to maintain a good resting posture at night. You should preferably make a habit of sleeping on your back, to prevent the hip joints and the back from becoming bent (Figure 14a). Avoid a pillow thefacts 75 AS-11(75-86) 5/29/02 5:50 PM Page 76 Ankylosing spondylitis: the facts Figure 14 Recommended sleeping positions: (a) A flat sleeping position opposes the tendency of curvature. If your head would fall into over-extension because your thoracic spine is already curved, a small pillow of just the right thick- ness under the back of your head may make the position easier. A suitable board (made of plywood or chipboard) can be put between the mattress and the bed frame to make the bed more firm. Or you can lie on your back across your bed with your legs over the side and knees bent. Dynamic posture • Be aware of how you are standing, and try to maintain an erect tall posture, with the spine kept as straight as possible.

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On physical examination purchase 25 mg atarax fast delivery, the patient’s temperature is 100. A non- 7 INFECTIOUS DISEASE 51 tender stage 3 ulceration of the plantar surface is noted on the patient’s left first metatarsal, with sur- rounding erythema and mild discharge. Which of the following statements regarding osteomyelitis in this patient is true? The most likely reason for osteomyelitis in this patient is hematoge- nous seeding B. Prolonged antibiotic therapy alone cures the majority of these patients C. Vascular insufficiency impairs wound healing and allows bacterial proliferation Key Concept/Objective: To know the clinical features of osteomyelitis in diabetic patients Osteomyelitis secondary to vascular insufficiency occurs most frequently in older patients with diabetes mellitus or severe vascular impairment. In these patients, osteomyelitis usually develops by contiguous spread of infection from soft tissue to underlying bone; it often occurs in the small bones of the feet. Complex foot lesions in diabetic patients result from a combination of neuropathy, atherosclerotic peripheral vascular disease, and repetitive trauma to the area. Bone infections develop in about 25% of diabetic patients with superficial mild to moderate foot infections; however, of those patients with serious foot infections, over 50% will have osteomyelitis. Extensive debridement is necessary, and about two thirds of cases require bone resection or par- tial amputation. Limb ischemia, combined with poor collateral circulation, impairs wound healing in foot ulcers and allows for the contiguous spread of infection to bone. In addition, this anoxic environment contributes to the development of gangrenous changes and anaerobic infections. Furthermore, peripheral vascular disease may com- promise the efficacy of antibiotic therapy by preventing the accumulation of adequate drug levels in the infected tissues. A 72-year-old woman returns to your clinic for hospital follow-up 8 days after undergoing replacement of the right hip. Her postoperative course was unremarkable until 2 days ago, when she experienced increasing right hip pain, fever, and purulent discharge from the surgical site.

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Red Flags: Warnings for the Nose and Sinuses • Epistaxis—persistent discount atarax 25mg mastercard, recurrent, or profuse. However, depending on the patient’s complaints, it may be part of the limited ear, nose, and throat (ENT) exam. Special Maneuvers Transillumination of the sinuses is accomplished in a slightly dark- ened room. A bright, focused light—an otoscope can be used—is placed directly on the cheek over the maxillary sinuses. The patient’s mouth is opened and the examiner looks for a light glow on the roof of the mouth. Unequal light may indicate unilateral sinus fullness. Examination of the Mouth and Throat The examination of the mouth and throat should begin with an inspection of all the struc- tures that can be observed without touching, followed by an examination that requires touching and moving of the structures in order to facilitate the examination. The exami- nation should end with palpation of the structures, paying particular attention to observed abnormalities. Ask the patient to remove any dental appliances, and proceed to systematically examine the mouth and the pharynx. The use of a tongue depressor facilitates complete examination of the inner cheeks/buccal mucosa, the floor and roof of the mouth, the gums, posterior mouth, and tongue. The examination should include an inspection of the size, shape, and symmetry of the lips. Obvious lesions should be noted and their characteristics recorded.

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