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Because this patient was admitted with pneumonia 68 BOARD REVIEW and because initial cultures were drawn on admission evista 60 mg low price, mechanical ventilation cannot be a causal factor. Sex and age are not known risk factors for pneumonia caused by gram-negative rods. A 34-year-old air-conditioning repairman is admitted to the hospital because of respiratory distress. He reports fever, chills, a mildly productive cough, myalgias, headache, and nausea. Physical examination shows a toxic-appearing man in moderate respiratory distress. Crackles at both lung bases with diffuse wheezes are noted. Laboratory data show pro- found leukocytosis with a left shift and a serum sodium level of 126 mEq/L. He is admitted to hospital for treatment of community-acquired pneumonia. Which of the following is the best antibiotic regimen for this patient? Azithromycin or levofloxacin Key Concept/Objective: To understand the treatment of suspected Legionella pneumonia Since it was first recognized in 1976, Legionnaires disease has become recognized as a common cause of both community-acquired and hospital-acquired pneumonia. Contaminated water systems have been responsible for both community-acquired and hospital-acquired outbreaks. Legionnaires disease is characterized by a 1-day prodrome of myalgias, malaise, and slight headache after an incubation period of 2 to 10 days. Acute onset of high fever, shaking chills, nonproductive cough, tachypnea, and, often, pleuritic pain ensues. The cough may subsequently become slightly productive, but the sputum is not purulent. Hyponatremia, although common in many pathologic lung conditions, is suggestive of Legionella infection. Current evidence indicates that azithromycin or levofloxacin is the treatment of choice.

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Similarly cheap evista 60mg visa, sex- ually acquired infections with Chlamydia trachomatis and perhaps Ureaplasma urealyticum may cause reactive arthritis (endemic or postvenereal form). HLA-B27 is found in 63% to 75% of patients with both forms of reactive arthritis and confers a relative risk of approxi- mately 37. Because the symptoms associated with Chlamydia genital infections can be sub- tle, a careful sexual history should be obtained; testing for Chlamydia should be pursued if a history of venereal exposure or genitourinary symptoms is obtained. Early treatment of genitourinary infections with appropriate antibiotics (tetracycline or erythromycin) has been shown to reduce the likelihood of subsequent reactive arthritis; however, even early 15 RHEUMATOLOGY 11 antibiotic use in patients with gastroenteritis does not appear to prevent reactive arthritis. A blinded, placebo-controlled trial of the use of tetracycline for the treatment of reactive arthritis demonstrated that the duration of disease was shortened only in patients who had Chlamydia-induced disease. A 49-year-old white male patient of yours comes to you with hand pain of new onset. His medical his- tory is significant only for hypertension, which is well controlled. He has experienced hand pain and swelling intermittently for the past 6 months, but this has hardly interfered with his daily activities. He indicates that the second and third distal interphalangeal joints on his right hand and the fourth distal interphalangeal joint on his left hand give him the most trouble. Physical examination reveals fingers that are markedly swollen and inflamed but are remark- ably nontender on palpation. Skin examination reveals no rash; however, the scalp has several small areas of silver scaling. Regarding this patient, which of the following statements is true?

This thick sheath of dura keeps the two will be divided in the process evista 60mg discount. The fibers of the corpus halves of the hemispheres in place within the cranial cav- callosum can be followed from the midline to the cortex ity. A whitish structure is seen in the depths of the fissure (see Figure 19A). It is difficult on this view to appreciate the depth of One of the other major features of the cerebral cortex the corpus callosum within the interhemispheric fissure. These interneu- on the medial surface of the hemispheres, as represented rons are essential for the processing and elaboration of by the frontal, parietal, and occipital lobes (see the next information, whether generated in the external world or illustration). These interconnecting sels are the pericallosal arteries, a continuation of the axons are located within the depths of the hemispheres. It should and these regions are called the white matter (see Figure also be noted that the cerebral ventricles are located 27 and Figure 29). The anterior commissure is an older and smaller • Association bundles — interconnecting the commissure connecting the anterior portions of the tem- cortical areas on the same side poral lobe and limbic structures (see Figure 70A). On this medial view, the thalamic portion of the diencephalon is separated from the hypothalamic part by CEREBRAL HEMISPHERES 7 a groove, the hypothalamic sulcus. This sulcus starts at the foramen of Monro (the interventricular foramen, dis- cussed with the ventricles, see Figure 20A and Figure CEREBRAL HEMISPHERES: MEDIAL 20B) and ends at the aqueduct of the midbrain. The optic (PHOTOGRAPHIC) VIEW chiasm is found at the anterior aspect of the hypothalamus, and behind it is the mammillary body (see Figure 15B). This view of the brain sectioned in the midline (mid- The three parts of the brainstem can be distinguished sagittal plane) is probably the most important view for on this view — the midbrain, the pons with its bulge understanding the gross anatomy of the hemispheres, the anteriorly, and the medulla (refer to the ventral views diencephalon, the brainstem, and the ventricles.

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Symptoms of malignancies are more likely to be fatigue discount evista 60 mg on line, weakness, anorexia, weight loss, fever, night sweats, bleeding, and easy bruisability. A history of tobacco and/or EtOH abuse may be present in neoplasms of the head and neck. Physical Examination The physical exam includes palpation of the thyroid for enlargement, asymmetry, or nod- ules. Look for periorbital edema, which may be present in hypothyroidism. Check the vital signs for hyper- or hypotension, tachy- or bradycardia, and fever or subnormal temperature. Abnormalities in any of these areas would indicate the need for further thyroid studies, including thyroid-stimulating hormone (TSH), T3, T4, and possi- bly a thyroid scan. A complete examination of the mouth, throat, nose, ears, and eyes should be performed as you look for infection. Palpate for lymphadenopathy in other areas of the body, which might be present in malignancies. Laboratory studies for a CBC might be warranted to check for leukocytosis or leukopenia. A “mono spot” would definitively diagnose mononu- cleosis. A chest x-ray may be necessary to look for mediastinal lymphadenopathy, indicating Hodgkin’s or other malignancy. Depending on sexual practices, a Neisseria gonorrhoeae (GC) or Chlamydia trachomatis cul- ture of the throat may be necessary, or blood studies for rapid plasma reagin (RPR) or human immunodeficiency virus (HIV).