By N. Elber. Sonoma State University.
He denies having any cough trusted 2mg coumadin, dysuria buy coumadin 5 mg on line, urinary hesitancy, or rash, and he has not had any contact with sick persons. He generally feels very healthy, and he plays golf three times each week at his local golf course in Tennessee. He does state that the ticks have been especially bad this year at his golf course, and he notes that he has removed at least five ticks from his body this month alone. His complete blood count reveals leukopenia and thrombocytopenia. Which of the following statements regarding ehrlichiosis is true? Skin rash does not occur in patients with ehrlichiosis B. For this patient, human granulocytic ehrlichiosis (HGE) is more like- ly than human monocytic ehrlichiosis (HME) C. The common laboratory abnormalities associated with HME are leukopenia, thrombocytopenia, abnormal liver function tests, and elevation of lactate dehydrogenase (LDH) and alkaline phosphatase D. The principal animal reservoir for Ehrlichia chaffeensis is rabbits Key Concept/Objective: To know the important clinical characteristics of Ehrlichia infection Skin rash is uncommon in patients with HME, but when present, it may be macular, maculopapular, or petechial. Although skin rash was reported in 36% of cases in one case series of 211 patients with HME, skin rash has been less common in the experience of many clinicians working in HME-endemic regions. HME has been recognized as endemic throughout the southeastern and south central United States. First described in patients from the north central United States, HGE is now known to occur in Wisconsin, Minnesota, Connecticut, New York, Massachusetts, California, Florida, and western Europe. The most common laboratory abnormalities seen in patients with HME is leukopenia (often accompanied by a left shift), thrombocytopenia, and elevat- ed plasma levels of aminotransferases (transaminases), lactate dehydrogenase, and alka- 54 BOARD REVIEW line phosphatase. Anemia and an elevated plasma creatinine concentration also may be seen. Later in the course of illness or during recovery, a striking atypical lymphocytosis may occur.
The use of physical restraints has been associated with the precipita- tion of delirium in elderly hospitalized patients Key Concept/Objective: To understand the significant risks of delirium in elderly hospitalized patients Elderly patients are at increased risk for developing delirium during hospitalization 1mg coumadin sale. Delirium is an important condition to recognize discount 5 mg coumadin, as the majority of cases are reversible with treatment of the underlying illness. Dementia or cognitive impairment is the sin- gle most important risk factor for the development of delirium. Other factors include acute infections, hypoxemia, and medications with psychoactive or anticholinergic effects. Cardiac medications such as digoxin and other antiarrhythmics can also cause delirium; elderly patients may be susceptible even when taking the drug at therapeutic doses. In a multicenter cohort study, delirium in the hospital setting was associated with higher rates of mortality and future nursing home admissions. She has hypertension that is well controlled on hydrochlorothiazide. She states that intermit- tently, she experiences a sudden overwhelming need to void, which often results in loss of urine before she is able to reach the toilet. She is otherwise active and highly functional but has lately been limiting her social activities because of embarrassment. She has no loss of urine with coughing or ambulation. Her physical examination is unremarkable, and the results of urinalysis are within normal limits. Postvoid residual urine volume obtained in the office is 45 ml. Stress incontinence; prescribe an intravaginal estrogen preparation and consider surgical referral B. Overflow incontinence; discontinue the diuretic and teach the patient intermittent self-catheterization C. Urge incontinence; recommend behavioral therapies, including scheduled voiding and bladder retraining D.
Younger siblings liked sessions to be focused on their age range of interests and fundamental to this was being given a choice rather than having imposed sessions order coumadin 1mg on line, otherwise discount 5 mg coumadin mastercard, ‘I could be at school – following a course for GCSE. Siblings enjoyed the sense of free choice in pursuing activities within group sessions organised on their behalf by the siblings’ group facilitator. The younger ones liked the spacious environment of the clubroom; all age groups enjoyed art-related activities which enabling creative energies to be expressed. Other activities, such as weekend outdoor pursuits were seen as the sort of exciting challenge, which would not necessarily be possible within their families. Outdoor experiences mentioned were caving, abseiling, horse riding, sleeping in a tent and orienteering. It is clearly important that when opportunities are provided for siblings the purpose is to enable them to express themselves through the new experiences. Having a say in what is available, perhaps through providing a menu of 100 / BROTHERS AND SISTERS OF CHILDREN WITH DISABILITIES activities to encourage the flexibility of group choice enables preferences to be established. However, facilitators should not have a restrictive menu and need be open to new ideas and suggestions expressed by the group. Inevitably, some restrictions might apply, like when a sibling suggested a group trip to Australia, which lay beyond the means of the group to arrange, even though many warmed to the idea. The scale and scope of suggestions need to be realistic and possible, otherwise disappointments can only result. It is clear that the siblings group is seen as a valuable resource, but it needs to be available on a regular basis. The group under evaluation only met on a weekly sessional basis over an eight-week period. Different groups met at different times of the year.
Patients whose cultural background and language differ from those of the physician present special challenges and rewards and need to be approached in a culturally sensitive manner order 2mg coumadin free shipping. People from other cultures may be less willing to discuss resuscitation status discount coumadin 2 mg line, less likely to forgo life-sustaining treatment, and more reluctant to complete advance direc- tives. For example, because of their history of receiving inappropriate undertreatment, African-American patients and their families may continue to request aggressive care, even in terminal illness. Further interventions in this patient may not be indicated, and the physician may decide that doing more procedures on the patient would be unethical; how- ever, it would be more appropriate to have a discussion with the family and to educate them about the condition and prognosis. Not uncommonly, the family will understand, and a consensus decision to avoid further interventions can be obtained. If the medical condition is irreversible and the family insists on continuing with aggressive therapies, the physician may decide that further treatments would be inhumane; in such a circumstance, the physician is not obligated to proceed with those interventions. An ethical consult may also be helpful under these circumstances. A 66-year-old man with Parkinson disease comes to your clinic for a follow-up visit. He was diagnosed with Parkinson disease 3 years ago. His wife tells you that he is very independent and is able to perform his activities of daily living. While reviewing his chart, you find that there are no advance directives. Which of the following would be the most appropriate step to take with regard to a discussion about advance directives for this patient? Postpone the discussion until his disease progresses to the point where the patient is unable to perform his activities of daily living, making the discussion more relevant ❏ B. Ask the patient to come alone on the next visit so that you can discuss these difficult issues without making the patient feel uncomfortable in the presence of his wife ❏ C. Wait until the patient has a life-threatening illness so that the discussion would be more appropriate ❏ D. Start the discussion on this visit Key Concept/Objective: To know the appropriate timing for discussing advance directives Public opinion polls in the United States have revealed that close to 90% of adults would not want to be maintained on life-support systems without prospect of recovery.