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Other patients have lupuslike symptoms together with findings suggestive of rheumatoid arthritis cheap levitra plus 400mg without a prescription erectile dysfunction unable to ejaculate, dermato- myositis generic levitra plus 400mg visa erectile dysfunction treatment for diabetes, or scleroderma. Those with no definable serology and a nondescript clinical pic- ture are defined as having UCTD. Other patients have inflammatory myositis, Raynaud phenomenon, and sclerodactyly together with very high titer antibodies to the ribonucle- oprotein antigen (U1 RNP) and no anti-DNA or anti-Sm antibody. The differentiation of SLE from UCTD, MCTD, and Sjögren syndrome depends on the extent and pattern of different organ involvement (glomerulonephritis is rare in all these disorders except lupus) and on the accompanying serologic abnormalities. This patient presents with several complaints consistent with a connective tissue disease, including serositis, arthralgias, myalgias, and a nonspecific skin rash affecting predomi- nantly the hands. The combination of a low-titer ANA and negative anti-dsDNA and anti- Sm makes the diagnosis of SLE questionable. More importantly, the presence of high-titer anti-RNP is consistent with the diagnosis of MCTD. A 31-year-old woman comes to your clinic for follow-up. For the past several years, her lupus has been well controlled without systemic medications. She is employed full-time, and she and her husband have been contemplating pregnancy. Last month, however, she presented to your office complaining of fever, severe arthralgias, myalgias, and a diffuse erythematous rash. Results of urinalysis and renal function testing were normal. After a failed trial of NSAIDs, you started her on prednisone, 60 mg/day. At follow-up, she reports that all of her symptoms have improved significantly. Of the following, what is the most appropriate step to take next in the treatment of this patient? Discontinue her steroids and try another trial of NSAIDs B. Taper her steroids and add high-dose oral calcium and vitamin D C. Taper her steroids and add high-dose calcium, vitamin D, and a bis- phosphonate D. Discontinue her steroids and switch to oral cyclophosphamide Key Concept/Objective: To understand the importance of bone-protective therapies and the con- traindications to those therapies for patients on long-term steroid regimens This patient has experienced a flare of her SLE. She had a good response to high-dose cor- ticosteroids and is likely to require steroid therapy for the next several months. High-dose corticosteroid therapy is used for patients with severe systemic symptoms, renal disease, or other visceral disease that is potentially life-threatening. Treatment should be initiated in split doses during the day, maintained for 4 to 6 weeks, and then tapered; too-early reduc- tion in the dosage usually results in recurrence of disease activity. Osteoporosis follows long-term corticosteroid therapy with sufficient frequency that all patients receiving such therapy should receive prophylaxis for this complication.

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Another source of statistics and the one that has been most widely used and available for applica- tion to the reasoning process includes the recall or estimation based on a provider’s experi- ence buy levitra plus 400 mg without a prescription erectile dysfunction treatment muse, although these are rarely accurate cheap levitra plus 400mg on line erectile dysfunction quizlet. Over the past decade, the availability of evidence on which to base clinical reasoning is improving and there is an increasing expectation that clinical reasoning be based on scientific evidence. Evidence-based statistics are also increas- ingly being used to develop resources to facilitate clinical decision-making. CLINICAL DECISION-MAKING RESOURCES Clinical decision-making begins when the patient first voices the reason for seeking care. Expert clinicians immediately compare their patients’ complaints with the “catalog” of knowledge that they have stored about a range of clinical conditions and then determine the direction of their initial history and symptom analysis. It is crucial that the provider not jump to conclusions or be biased by one particular finding; information is continually processed to inform decisions that guide further data collection and to begin to detect pat- terns in the data. Depending on the amount of experience in assessing other patients with the presenting complaint, a diagnostician uses varied systems through which information is processed and decisions are made. Through experience, it is possible to see clusters or patterns in com- plaints and findings, and compare against what is known of the potential common and urgent explanations for the findings. Experience and knowledge also provide specifics regarding the statistics associated with the various diagnostic options. However, experience is not always adequate to support accurate clinical decision-making, and memory is not perfect. To assist in clinical decision-making, a number of evidence-based resources have been developed to assist the clinician. Resources such as algorithms and clinical practice guidelines assist in clinical reasoning when properly applied. Algorithms are formulas or procedures for problem solving and include both decision trees and clinical prediction rules. Decision trees provide a graphic depiction of the decision-making process, showing the pathway based on findings at various steps in the process. A decision tree begins with a chief complaint or physical finding and then leads the diagnostician through a series of decision nodes. Each decision node or decision point provides a question or statement regarding the presence or absence of some clinical find- ing. The response to each of these decision points determines the next step. In this book, an example of a decision tree is Figure 12-5, which illustrates a decision-making process for amenorrhea. These devices are helpful in identifying a logical sequence for the decisions involved in narrowing the differential diagnosis and also provide cues to recommended questions/tests that should be answered through the diagnostic process. A decision tree should be accompanied by a description of the strength of the evidence on which it has been developed, as well as a description of the settings and/or patient population to which it relates. Clinical decision (or prediction) rules provide another support for clinical reasoning. Clinical decision rules are evidence-based resources, which provide probabilistic statements regarding the likelihood that a condition exists if certain variables are met and/or the prog- nosis of patients with specific findings. Decision rules use mathematical models and are Copyright © 2006 F. Assessment and Clinical Decision-Making: An Overview 7 Box 1-1 Online Sources of Medical Calculators Emergency Medicine on the Web: www. They are used to express the diagnostic statistics described earlier.

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After initial surgical intervention generic levitra plus 400 mg with visa erectile dysfunction cause, the patient experiences rapidly pro- gressive buy levitra plus 400mg erectile dysfunction treatment in urdu, symptomatic recurrence of the cancer B. The cancer involves either ovary on initial evaluation C. The cancer involves distant sites such as lung or bone E. All of the above Key Concept/Objective: To understand the evaluation and treatment of uterine cancer For rapidly progressive, symptomatic recurrence of uterine cancer, platinum-based chemotherapy is a reasonable treatment. There is no proven survival advantage associat- ed with the use of adjuvant hormonal therapy (e. If the endometrial biopsy establishes the presence of uterine cancer, surgery for definitive resection and staging is the next most common step in management. For patients who are not optimal surgical candidates, primary radiotherapy is an option that can produce long- term survival in selected patients. Postoperative pelvic radiotherapy is considered when certain features confer an increased risk of local pelvic failure. These features include (1) deeply invasive, high-grade, early stage lesions (e. The use of tamoxifen, a drug traditionally thought of as an estrogen antagonist, is also associated with an increased uterine cancer risk. This is in part caused by the tissue-specific action of tamoxifen, which has antagonistic effects on proliferation of breast epithelium but agonistic effects on bone mineral density, lipid metabolism, and endometrial proliferation. However, the benefits of tamoxifen in the adjuvant breast cancer setting far outweigh the small risk of uterine can- cer development. A 50-year-old white woman with a history of fibrocystic breast disease and arthritis presents with abdom- inal pain of new onset. The pain is mild and suprapubic and does not radiate. A urine dipstick evaluation performed in the clinic reveals that she has a urinary tract infection. The patient, however, is concerned that she may have ovarian cancer, because her mother died of ovarian cancer at age 59. For this patient, which of the following statements is consistent with a diagnosis of ovarian cancer? Approximately 30% of women present with advanced disease B. Patients with advanced disease commonly complain of a progressive increase in abdominal girth and bloating C. The primary lymphatic drainage site of ovarian cancer is the inguinal lymph nodes D. The most common paraneoplastic syndrome associated with ovarian cancer is hypercalcemia Key Concept/Objective: To understand the common clinical features of ovarian cancer The ovary contains three distinct cell types, known as germ cells, stromal cells, and epithe- lial cells. The type of ovarian tumor that most commonly affects adult women, however, is derived from the epithelial cells that cover the ovarian surface. Epithelial ovarian can- cer occurs at a mean age of 60 years in the United States and is the most lethal of gyneco- logic tract tumors. In approximately 70% of women, the tumor has spread beyond the pelvis by the time of diagnosis and cannot be completely resected at the time of explorato- ry laparotomy. Early-onset ovarian cancer that is restricted to the pelvis usually produces no signs or symptoms. Unfortunately, approximately 70% of women present with advanced disease that has extended beyond the pelvis to involve other areas, such as the upper abdomen (stage III) and the pleural space (stage IV). Women with advanced disease often note a progressive increase in abdominal girth and bloating for several months before they are diagnosed.

These antibodies tend to correlate with some specific clinical presentations order levitra plus 400 mg line erectile dysfunction treatment prostate cancer, responses to therapy purchase 400mg levitra plus otc being overweight causes erectile dysfunction, and prognoses. Three groups of patients can be defined by the MSA specificities. The first group is defined by the presence of antibodies directed against aminoacyl-tRNA synthetases. These patients are generally characterized by an acute onset of muscle disease, with a high incidence of associated interstitial lung disease. They may also have arthritis and a hyperkeratotic rash on the hands, known as mechanic’s hands. This description fits the patient presented in this case. The second group includes patients with anti-SRP antibodies; these patients tend to have an abrupt onset of weakness, and they may have cardiac disease. The third group is identified by the presence of antibodies against Mi-2; these patients have a dermatomyositis with the so-called shawl sign. A 58-year-old man is seen in your clinic for the first time. He says he has decided to see a doctor because over the past 2 years he has noticed some weakness of his arms and legs. He says these symptoms were not bothering him ini- tially but that, over the past few months, he has noticed more weakness in his left arm. On physical examination, there is no rash; his strength is 5/5 on the right side of his body, 5/5 in his left leg, and 3/5 in his left arm. His distal strength and proximal strength are quite sim- ilar. Neurologic examination results are otherwise normal. His creatine kinase (CK) level is moderately elevated. Which of the following is the most likely diagnosis for this patient? Inclusion body myositis (IBM) Key Concept/Objective: To understand the presentation of inclusion body myositis This patient is a middle-aged man with slow-onset muscle weakness. Dermatomyositis is defined by the presence of an inflammatory myopathy and a characteristic rash. Polymyositis is characterized by weakness that is symmetrical and predominantly proxi- mal, and the clinical course is more aggressive than the one described here. Sarcoidosis can cause a myopathy but usually is accompanied by other manifestations that are absent here. This patient’s symptoms are more consistent with IBM. The pattern of severity of muscle weakness in IBM differs from that seen in other idiopathic inflammatory myopathies. In addition to the presence of proximal weakness, distal muscles may be involved, and in some cases, muscle abnormalities are asymmetrical. Unlike most of the other inflammatory muscle disorders, IBM affects more men than women. Electron microscopy may be required to demonstrate the inclusion bodies that define IBM.

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