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By L. Marius. Quinnipiac College.

The confusingly named superficial femoral vein is in fact in the deep system and war- rants therapy buy super viagra 160mg. A 58-year-old woman is 2 days’ status post–total hip replacement order super viagra 160 mg without a prescription. She has been receiving subcutaneous heparin as prophylaxis for DVT. You are asked to see the patient to evaluate new-onset dyspnea. On examination, the patient is tachypneic, tachycardic, and diaphoretic. She is agitated and complains of substernal chest pain. Cardiac, abdominal, and extrem- ity examinations are normal except for her surgical wounds, which seem to be healing well. ECG reveals a 2 mm ST depression in leads II, III, and aVf; and chest x-ray is normal. Which of the following is the best course of action for this patient at this point? Switch to low-molecular-weight heparin (LMWH) subcutaneously while arranging further diagnostic testing D. Stop all heparin, and anticoagulate with hirudin while arranging fur- ther diagnostic testing Key Concept/Objective: To understand heparin-induced thrombocytopenia and its therapy This patient is status post-hip surgery and has been receiving heparin for 2 days. She now presents with a clinical scenario that suggests pulmonary embolism or myocardial ischemia, or both, as well as a platelet count of 54,000/µl. In this setting, one should be highly suspicious of heparin-induced thrombocytopenia, which can present with venous or arterial thrombosis. While the next diagnostic test is a matter of clinical judgment, the crucial first step is discontinuing all heparin, including I. Other alternatives would be lepirudin or danaparoid. LMWH, unfortunately, is not con- sidered safe in the setting of heparin-induced thrombocytopenia and would not be a good alternative in this setting. A 68-year-old man presents with new onset of right-sided DVT without apparent risk factors. Therapy is initiated, and the possibility of underlying cancer is raised. You are consulted regarding appropriate eval- uation for occult malignancy. Careful history, physical examination, routine blood counts and chemistries, chest x-ray (CXR), fecal occult blood testing (FOBT), and prostate-specific antigen (PSA); if these are not revealing, no further evaluation is necessary B. Careful history, physical examination, routine blood counts and chemistries, CXR, FOBT, and PSA; if these are not revealing, proceed with colonoscopy C. Careful history, physical examination, routine blood counts and chemistries, CXR, FOBT, and PSA; if these are not revealing, proceed with CT scan of the chest, abdomen, and pelvis D.

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In some circumstances discount 160 mg super viagra visa, the monitoring of drug levels may be useful in determining prescription compliance or to explain changes in seizure control or drug toxicity generic 160 mg super viagra with amex. This patient’s seizures are adequately controlled, and there are no clinical symptoms or signs of toxicity; therefore, changes in the dosage are not indicated, and phenytoin levels should not be followed. A 48-year-old man presents to your clinic complaining of excessive daytime somnolence. They have slowly progressed to the point where he falls asleep frequently throughout the day. The patient also reports having early morning headaches. He has tried taking naps during the day, without relief of his somnolence. His physical examination is significant for obesity and hypertension. Which of the following tests would provide the most helpful information for the diagnosis and treat- ment of this patient? Magnetic resonance imaging of the brain Key Concept/Objective: To understand the tests used to evaluate sleep disorders The two most important laboratory tests for sleep disorders are the all-night PSG study and the MSLT. This patient’s presentation is consistent with obstructive sleep apnea syndrome (OSAS); the best diagnostic test for OSAS is PSG, because it provides both diagnostic and therapeutic information. The all-night PSG study simultaneously records several physio- logic variables by use of electroencephalography (EEG), electromyography (EMG), electro- oculography (EOG), electrocardiography, airflow at the nose and mouth, respiratory effort, and oxygen saturation. Such studies are important in confirming a diagnosis of excessive daytime somnolence (EDS) or OSAS, and they also document the severity of sleep apnea, hypoxemia, and sleep fragmentation. Overnight PSG determines the optimal pressure for continuous positive airway pressure (CPAP)—a treatment for OSAS—and is also helpful for supporting the diagnosis of narcolepsy and the parasomnias. Overnight PSG with simul- taneous video recording can confirm rapid eye movement (REM) sleep behavior disorder and is particularly useful for the documentation of unusual movements and behavior dur- ing nighttime sleep in patients with parasomnias and nocturnal seizures. The MSLT is essential in documenting pathologic sleepiness (sleep-onset latency of less than 5 minutes) and in diagnosing narcolepsy; the presence of two sleep-onset REMs with four or five naps and pathologic sleepiness strongly suggest narcolepsy. Another important laboratory test for assessing sleep disorders is actigraphy. This technique utilizes an actigraph worn on the wrist or ankle to record acceleration or deceleration of body movements, which indirect- ly indicates sleep-wakefulness. Actigraphy employed for days or weeks is a useful labora- tory test in patients with insomnia and circadian rhythm sleep disorders, as well as in some patients with prolonged daytime sleepiness.

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CML is a myeloproliferative disorder (MPD) and represents a clonal disorder of the pluripotential hematopoietic stem cell B trusted 160mg super viagra. The CBC often reveals thrombocytosis 160 mg super viagra with amex, neutrophilic leukocytosis, and basophilia C. The presence of the Philadelphia chromosome (Ph) is characteristic of CML and is a poor prognostic sign D. The three main phases of CML are the chronic phase, the accelerated phase, and the blast phase Key Concept/Objective: To understand the pathogenesis and clinical course of CML MPDs represent clonal disorders of the pluripotential hematopoietic stem cell and include CML, polycythemia vera, essential thrombocythemia, myeloid metaplasia, and idiopathic myelofibrosis. CML accounts for 15% of all cases of leukemia in adults. Males are affected more often than females, and the median age at presentation is 45 to 55 years. CML is caused by the transforming capability of the protein products resulting from the Ph translocation t(9;22). Up to 95% of patients with CML express Ph, which results from a reciprocal translocation between the long arms of chromosomes 9 and 22. Patients with CML who do not have Ph translocation have a significantly worse prognosis than do patients who test positive for the bcr-abl gene. CML is characterized by expansion of myeloid progenitor cells at various stages of their maturation, by the premature release of these cells into the circulation, and by their tendency to home to extramedullary sites. Symptoms at presentation reflect the increase in mass and turnover of the leukemic cells. Patients may complain of lethargy and weakness, night sweats, and weight loss. Occasionally, the spleen enlarges, causing an increase in abdominal girth and abdominal discomfort. The prognosis for patients with CML has changed significantly in the past 2 decades. Patients who are diagnosed with chronic-phase CML can expect a median sur- vival of 5 to 7 years. A 63-year-old woman presents to your clinic with a complaint of increasing abdominal girth; hepatosplenomegaly is detected on examination. CBC reveals a hematocrit of 52% and a platelet count of 900,000 cells/mm3. The increase in red blood cell (RBC) mass is mainly the result of an increase in the level of erythropoietin B. Thrombotic complications are rare in PV 12 ONCOLOGY 43 C. To diagnose PV, independent determination of RBC mass and plasma volume by isotope dilution is mandatory D.

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