By W. Peratur. University of Arkansas, Fayetteville.

A new class of com- pounds generic sildigra 25mg free shipping, the neuraminidase inhibitors sildigra 50 mg generic, is active against influenza A and B viruses 25 mg sildigra for sale. The neuraminidase inhibitors are also effective for prophylaxis of influenza A and B infec- tions 50mg sildigra otc. A 22-year-old female college student presents to your office as a new walk-in patient. She has no med- ical history and takes no medications. She states that she had unprotected sex with a new partner about 1 week ago. Four days ago, she developed fever and chills, severe fatigue, painful groin swellings, and "blisters" on her labia. She states that she has had a total of five sexual partners. On physical examination, the patient is afebrile, has tender superficial inguinal lymphadenopathy measuring 2 cm bilaterally, and has several clustered vesicular lesions on her labia majora. Which of the following statements regarding herpes simplex virus (HSV) infections is false? Direct contact with infected secretions is the principal mode of transmission of HSV B. Herpes simplex virus type 2 (HSV-2) is transmitted more efficiently from males to females than from females to males C. HSV-2 is a local infection that is confined to the genitourinary system D. Among the general public, herpetic whitlow is typically caused by HSV-2 Key Concept/Objective: To understand the important clinical features of HSV-2 infection Direct contact with infected secretions is the principal mode of HSV transmission. HSV- 1 is usually transmitted by an oral route and HSV-2 by a genital route. Transmission of HSV occurs frequently, even in the absence of lesions. HSV-2 is transmitted more effi- ciently from males to females than from females to males. Autoinoculation to other skin sites also occurs, more often with HSV-2 than with HSV-1. Extragenital lesions 7 INFECTIOUS DISEASE 85 develop during the course of primary infection in 10% to 18% of patients. Aseptic meningitis is not uncommon with primary genital herpes, particularly in women; in rare instances, herpetic sacral radiculomyelitis occurs. Primary finger infections, or whitlows, usually involve one digit and are characterized by intense itching or pain fol- lowed by the formation of deep vesicles that may coalesce. Among the general public, whitlows are most often caused by HSV-2, whereas among medical and dental person- nel, HSV-1 is the principal culprit. A 70-year-old male patient who has diabetes and hypertension presents with a complaint of severe flank pain. He was in his usual state of health until 5 days ago, when he developed intermittent, severe, lan- cinating pain that radiated from his midchest to his right flank and then to his right middle back. He denies having undergone any trauma or having hematuria, dysuria, fever, chills, weight loss, or a histo- ry of renal stones. He also states that his shirt has been "sticking to his back" during this period. On phys- ical examination, the patient is afebrile and has a diffuse vesicular eruption in a T4 distribution with severe pain to palpation. Which of the following statements regarding varicella-zoster virus (VZV) infection is true? Primary varicella infection is communicable and can result in her- pes zoster infection in a contact B. Hospitalized patients with varicella or herpes zoster infection should be isolated to prevent spread of the virus to other susceptible persons C. There is no available medical therapy for herpes zoster eruptions D.

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One week ago buy 25 mg sildigra amex, he had a generalized tonic-clonic seizure that resulted in a fall order sildigra 120 mg with mastercard, at which time he injured his right clavicle sildigra 120 mg amex. His clavicle injury is being treated conservatively with a sling discount 25 mg sildigra fast delivery. His care- takers have brought him to clinic with reports that he has become more withdrawn and is eating and sleeping poorly. Although communication with the patient regarding his specific symptoms is difficult, there is concern that he may be in significant pain. Using a face pain-rating scale, you are able to elicit a complaint of pain from the patient that rates 6 on a scale of 10. Which of the following is the most appropriate pharmacologic intervention for treatment of this patient’s pain? Combination acetaminophen 300 mg/codeine 30 mg, 1 to 2 tablets every 4 to 6 hours as needed, plus a stool softener D. Prednisone at an initial dosage of 60 mg a day, tapering to discontinu- ance over the next 2 weeks Key Concept/Objective: To understand which analgesic medications can lower seizure threshold The assessment and treatment of pain in patients with cognitive impairment can be chal- lenging. Treatment of any patient must take into account any comorbid conditions, and pharmacologic therapy must be initiated carefully, with attention given to possible adverse effects. In this patient with a known seizure disorder, a combination of acetamin- ophen and codeine is a safe choice for short-term treatment of pain. Tramadol, a nonnar- cotic analgesic that binds to mu opiate receptors in the CNS and causes inhibition of ascending pain pathways, is contraindicated in this patient because it tends to make seizures worse. Similarly, tricyclic antidepressants and the opioid analgesic meperidine can induce seizures and thus would not be the best initial choice for this patient. Although cor- ticosteroids are potent anti-inflammatories that are useful adjuncts in certain conditions, their use here would be unlikely to give symptomatic relief. A 67-year-old woman comes to your office accompanied by her family. She has a history of multiple falls, which have been increasing over the past 6 months. She says that she feels unsteady almost all the time, is frequently light-headed, and has difficulty walking. On examination, she has bradykinesia, mild cog- wheeling of both upper extremities, a blood pressure drop of 25 mm Hg on standing with no change in pulse, and an ataxic gait. Which of the following is the most likely diagnosis for this patient? Progressive supranuclear palsy Key Concept/Objective: To be able to recognize the symptoms of different parkinsonian disorders Bradykinesia could occur in patients with Parkinson disease, multiple systems atrophy, or progressive supranuclear palsy. Parkinson disease is sometimes accompanied by autonom- ic insufficiency in its later stages, but this patient presents with only mild motor symp- toms. The combination of parkinsonism, autonomic insufficiency, and ataxia is strongly suggestive of multiple systems atrophy. A 35-year-old man is referred to your clinic for evaluation of early-onset Parkinson disease. His symp- toms began approximately 2 years ago with tremor and difficulty speaking. These symptoms have pro- gressed to the degree that he has become severely depressed and unable to work. His family history is remarkable for mental illness and alcoholism, and his maternal grandfather had cirrhosis of the liver. There is no history of Parkinson disease in his family. On examination, the patient has a mild resting tremor and uneven gait but no bradykinesia. As you speak with him, he is quite dysarthric and occa- sionally manifests writhing facial and neck movements. When asked if these are voluntary, he becomes angry, then tearful, and then says that God is punishing him with these movements. Which of the following is the most appropriate step to take next in the management of this patient? Measurement of 24-hour urinary copper excretion E.

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Significant cardiovascular or neurologic disease C generic sildigra 120mg with amex. Extensive portal and splanchnic venous thrombosis Key Concept/Objective: To know the contraindications for liver transplantation Contraindications for liver transplanatation can be categorized into issues of abuse 120mg sildigra overnight delivery, under- lying significant medical problems buy 120mg sildigra fast delivery, malignancy purchase sildigra 50 mg mastercard, and technical limitations. Ongoing abuse of drugs or alcohol is one of the most frequent contraindications to transplantation. Patients with significant cardiovascular or neurologic disease cannot withstand the stress of transplantation. Although transplantation is often performed for hepatocellular carci- noma, extrahepatic malignancy is a contraindication. Extensive portal and splanchnic venous thrombosis prevents viable blood flow to the transplanted liver. Although patients with hepatitis B or C may require antiviral therapy before and after transplantation, hav- ing hepatitis B or C is not a contraindication. A 40-year-old man with cirrhosis secondary to hepatitis B is being evaluated for orthotopic liver trans- plantation. He asks you what he should expect after his operation. Which of the following statements is true regarding this patient? There is a 1% to 2% chance of failure of his transplanted organ in the immediate postoperative period B. Although he may develop progressive jaundice over time, suggesting ductopenic rejection, this has little consequence C. His hepatitis B will most likely be cured after transplantation, so he will not need his antiviral medications anymore D. Infections are among the most serious complications after liver trans- plantation E. Thirty percent of patients taking cyclosporine or tacrolimus develop kidney failure within 10 years after transplantation Key Concept/Objective: To know the most common and serious complications after liver trans- plantation From 5% to 10% of liver transplant patients experience immediate graft failure. Although ductopenic rejection is a more indolent process, it usually creates a need for retransplan- tation. Hepatitis B is not cured by transplantation and can even cause rapidly progressive liver disease after transplantation; however, aggressive antiviral therapy before and after transplantation has been associated with prolonged graft longevity. Approximately 10% of patients treated with the calcineurin inhibitors cyclosporine or tacrolimus develop renal failure after transplantation. Because of the strong immunosuppressive agents required, infections remain among the most serious complications, both short-term and long-term, after transplantation. A 37-year-old woman with a history of cryptogenic cirrhosis who underwent orthotopic liver transpla- nation 1 year ago asks you to assume her posttransplantation care. Which of the following is true regarding this patient? She can expect to return to work, but it is unlikely that she will be able to tolerate vigorous activity B. The phenytoin she takes for her seizure disorder may result in an ele- 4 GASTROENTEROLOGY 27 vation in serum cyclosporine level, leading to a need for lower doses of cyclosporine C. Infection is the leading cause of death in the posttransplantation pop- ulation D. Most transplant centers report 75% to 80% 5-year survival rates E. If she develops hyperlipidemia as a result of taking cyclosporine, she is unlikely to benefit from a change in immunosuppressive medications Key Concept/Objective: To understand the long-term prognosis of liver transplant recipients, in terms of both mortality and functional status Many posttransplantation patients not only return to work but are able to participate in such vigorous activities as marathon running. Phenytoin induces the cytochrome P-450 system, leading to decreased serum levels of cyclosporine. Age-related cardiovascular dis- ease is the leading cause of death in posttransplantation patients.

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