By X. Vak. Northwest College of Art.
Common causes of urinary obstruction include nephrolithiasis safe 5 mg dulcolax, prostate enlargement in men purchase dulcolax 5 mg without prescription, neurogenic bladder in diabetic patients, and an enlarg- ing cervical cancer in women. The urinalysis result is typically unremarkable in obstructive uropathy. The diagnosis is most often made by demonstrating ureteral dilatation on renal sonography. A 75-year-old woman with diabetes and hypertension is admitted to the hospital with nausea, vomiting, and abdominal pain. At admission, laboratory values include a blood urea nitrogen (BUN) measurement of 18 and a plasma creatinine measurement of 0. As part of her workup, she undergoes a con- trast-enhanced CT scan of the abdomen. During the first 48 hours of the hospital stay, repeat laborato- ry studies reveal a plasma creatinine level of 1. A low baseline plasma creatinine value may lead to an overestima- tion of GFR because of decreased muscle mass in this elderly patient B. The use of drugs such as cimetidine and trimethoprim increase plas- ma creatinine levels without affecting true GFR because of inhibi- tion of tubular secretion of creatinine D. Creatinine is produced at a relatively constant rate by hepatic conversion of skeletal muscle creatine, and the clearance of creatinine is used as an estimate of filtration. In females, the results are multiplied by a correction factor of 0. Because the production of creatinine is dependent on mus- cle mass, plasma levels are typically lower in elderly patients and in patients with con- ditions that result in profound muscle wasting. Additionally, because creatinine clearance correlates inversely with plasma creatinine levels, a doubling of the plasma creatinine value (as seen in this patient) reflects a reduction in creatinine clearance by about half. It is important to note that creatinine clearance is not a perfect reflection of GFR because creatinine, in addition to being filtered, is also secreted in the tubules. Certain drugs, such as cimeti- dine, trimethoprim, and probenecid, inhibit this tubular secretion; this results in a decrease in creatinine clearance, but this decrease has no bearing on GFR.
Laboratory results reveal the following: Hb dulcolax 5 mg sale, 18 dulcolax 5 mg without a prescription; Hct, 61; platelets, 500,000; leukocytes, 17,000. Which of the following is the most appropriate diagnosis for this patient? Chronic myeloid leukemia Key Concept/Objective: To understand the clinical characteristics of polycythemia vera and primary polycythemia and differentiate these characteristics from those of other types of polycythemia Polycythemia vera is an acquired myeloproliferative disorder that is characterized by over- production of all three hematopoietic cell lines with predominant elevation in red cell counts. This overproduction is independent of erythropoietin. Facial plethora is charac- teristic of all patients with polycythemia vera. Polycythemia vera is slightly more common in men than in women and is most frequently diagnosed in persons between 60 and 75 years of age. Patients commonly complain of pruritus, especially after a hot bath. Gaisböck syndrome, also known as relative polycythemia, is usually found in men from 45 to 55 years of age; they are most often obese, hyperten- sive men who may also be heavy smokers. Pickwickian syndrome, or obesity-hypoventi- lation syndrome, is characterized by obesity with hypoxemia and hypercapnia; some patients experience nocturnal obstructive sleep apnea and daytime hypersomnolence. Although polycythemia vera and chronic myeloid leukemia are both classified as myelo- proliferative disorders, the dominant features of chronic myeloid leukemia are dramatic leukocytosis, the presence of the Philadelphia chromosome, and certain evolution to acute myeloid leukemia. A 62-year-old woman presents with a history of intermittent headache and vertigo. She has lost 10 lb over the past 6 months and frequently feels tired. On physical examination, she has facial plethora, her temperature is normal, her blood pressure is 130/80 mm Hg, and her heart rate is 90 beats/min. There is a soft systolic murmur at the lower sternal border, the lungs are clear on ausculta- tion, and the spleen can be palpated 6 cm below the left costal margin. Laboratory evaluation reveals the following: Hct, 60%; WBC, 15,000/mm3; platelets, 400,000/mm3; oxygen saturation, 98%. What is the most appropriate initial treatment for this patient? Anagrelide Key Concept/Objective: To recognize phlebotomy as a frequently used treatment for polycythemia This patient has signs and symptoms characteristic of polycythemia vera; initial treatment might include phlebotomy, although no consensus has emerged about the best treatment approach.
She has asked for exercise recommendations discount dulcolax 5mg, although she does not know whether it will make much difference order dulcolax 5mg overnight delivery. Which of the following would you recommend for this patient? Attendance at a structured aerobic exercise program at least three times a week ❏ B. Membership in the neighborhood YMCA for swimming ❏ C. Walking three times a week, preferably with a partner ❏ D. Contacting a personal trainer to develop an individualized exercise program ❏ E. No additional exercise because she has symptoms of osteoarthritis Key Concept/Objective: To recognize that even modest levels of physical activity such as walking and gardening are protective even if they are not started until midlife to late in life Changes attributed to aging closely resemble those that result from inactivity. In sedentary patients, cardiac output, red cell mass, glucose tolerance, and muscle mass decrease. Systolic blood pressure, serum cholesterol levels, and body fat increase. Regular exercise appears to retard these age-related changes. In elderly individuals, physical activity is also associated with increased functional status and decreased mortality. Although more stud- ies are needed to clarify the effects of exercise in the elderly, enough evidence exists to war- rant a recommendation of mild exercise for this patient, along with counseling concern- ing the benefits of exercise at her age. Walking programs increase aerobic capacity in indi- viduals in their 70s with few injuries. Although structured exercise is most often recom- mended by physicians, recent studies demonstrate that even modest levels of physical activity such as walking and gardening are beneficial. Such exercise is protective even if it is not started until midlife or late in life. Because this patient is used to a sedentary lifestyle 4 BOARD REVIEW and is not strongly motivated to begin exercising, compliance with exercise recommen- dations may be an issue. Lifestyle interventions appear to be as effective as formal exercise programs of similar intensity in improving cardiopulmonary fitness, blood pressure, and body composition.
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