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Estrogen (hormone) Finasteride (5-reductase inhibitor) Mitoxantrone (chemotherapy agent) Nitrofurantoin (antibiotic) Prednisone (corticosteroid) 32 A 54-year-old man has had dysuria with increased frequency and urgency of urination for the past 6 months prostate cancer zoledronic acid buy fincar 5 mg free shipping. Laboratory studies show that expressed prostatic secretions contain 30 leukocytes per high-power field prostate cancer journal articles purchase generic fincar online. Acute bacterial prostatitis Chronic abacterial prostatitis Prostatic adenocarcinoma Prostatic hyperplasia Syphilitic prostatitis 36 A 71-year-old prostate cancer 999 order fincar without prescription, previously healthy man comes to his physician for a routine health examination mens health warrior workout buy fincar 5 mg with mastercard. Which of the following histologic findings is most likely to be found in a subsequent biopsy specimen of his prostate Acute prostatitis Adenocarcinoma Chronic abacterial prostatitis Nodular hyperplasia Prostatic intraepithelial neoplasia 33 A 65-year-old man has had multiple, recurrent urinary tract infections for the past year. Escherichia coli and streptococcal organisms have been cultured from his urine during these episodes, with bacterial counts of more than 105/mL. He has difficulty with urination, including starting and stopping the urinary stream. Which of the following is the most likely condition predisposing him to recurrent infections Epispadias Nodular prostatic hyperplasia Phimosis Posterior urethral valves Prostatic adenocarcinoma Vesicoureteral reflux 37 An 85-year-old man has experienced urinary hesitancy and nocturia for the past year. The blood urea nitrogen concentration is 44 mg/dL, and the serum creatinine level is 3. Microscopic examination shows that more than 90% of the tissue has a pattern of cords and sheets of cells with hyperchromatic pleomorphic nuclei, prominent nuclei, and scant cytoplasm. The study will determine whether symptoms of prostate disease are ameliorated in the individuals who take these drugs. Which of the following diseases of the prostate is most likely to benefit from one or both of these drugs A urologist obtains transrectal biopsy specimens, and microscopic examination shows multifocal areas of glandular hyperplasia and the appearance shown in the figure. Which of the following statements applies best to this clinical and pathologic scenario A Associated with increased risk for invasive cancer B Chronic inflammation from urinary tract obstruction C Normal microscopic finding of the peripheral zone D Related to an inherited tumor suppressor gene mutation E Responsive to 5-reductase inhibitor therapy 39 A 45-year-old man comes to the physician for a routine health maintenance examination. Prostate biopsies are performed and the high power microscopic appearance of a biopsy specimen is shown in the figure. All or part of one or both ureters may be duplicated, but this is usually an incidental finding; granulomatous inflammation in the urinary tract is uncommon. Urachal remnants (embryologic allantois) may predispose to infection but not hydronephrosis; adenocarcinoma may arise in a urachal cyst. Interstitial cystitis is a complication of recurrent bladder infection, most often in women, and characterized by chronic pain. Malakoplakia is a rare response to bacterial infection in which collections of macrophages filled with degraded bacterial products elicit formation of intracellular laminated, calcified concretions called Michaelis-Gutmann bodies. Diverticula may develop in the setting of obstruction and bladder wall 3 C Bilateral hydronephrosis, without hydroureter or bladder dilation, suggests that the problem involves both ureters. Nephrolithiasis could cause ureteropelvic junction obstruction, but bilaterality would be uncommon. Polypoid cystitis results from inflammation but may mimic a tumor mass, and could obstruct one or both ureteral orifices with hydroureter. Renal cell carcinoma is likely to be unilateral, but may cause only focal obstruction. Urothelial carcinomas may be multifocal, but are unlikely to obstruct both ureters simultaneously. Obesity increases the risk for malignancy, but correlation with a specific malignancy is difficult to draw. Schistosomiasis can lead to squamous metaplasia and increased risk for squamous carcinoma of the bladder. Congenital diverticula result from either focal failure in formation of bladder musculature or bladder outlet obstruction, and there is no fistulous tract. Exstrophy refers to failure in development of the lower abdominal wall, leaving an open defect to the bladder. Abnormal reflux of bladder contents into the ureter defines vesicoureteral reflux, which may be due to congenital abnormalities of bladder development, but there is no fistulous tract. A vitelline duct remnant may account for a Meckel diverticulum, or rarely a fistulous tract from small intestine to umbilicus. After absorption, aromatic amines are hydroxylated into an active form, which is detoxified by conjugation with glucuronic acid and then excreted. Urinary glucuronidase splits the nontoxic conjugated form into the active carcinogenic form. Adenocarcinoma is a complication of the congenital condition known as exstrophy of the bladder. Rhabdomyosarcoma of the pelvis is typically a pediatric neoplasm, and not associated with chemical exposures. Renal cell carcinomas also may manifest as painless hematuria, but exposure to aniline dyes is not a risk factor. Squamous cell carcinoma is the most common malignancy of the urethra, but it is rare and has no relation to carcinogens. Malakoplakia is a reaction to chronic bacterial infections, usually Escherichia coli and Proteus species, and often in the setting of immunosuppression. Chemical carcinogens such as aniline dyes increase the risk for developing urothelial carcinoma, but do not dictate therapy. In an older man, this type of obstruction is most often caused by prostatic enlargement caused by hyperplasia or carcinoma.
Manifestations of sickle cell crisis include vaso-occlusive crisis prostate cancer 30s discount fincar 5 mg, acute chest syndrome mens health depression generic 5mg fincar fast delivery, splenic sequestration crisis androgen hormone 2 ep4 quality fincar 5 mg, and aplastic crisis androgen hormone zyklus discount fincar 5 mg visa. Treatment consists of intravenous opioids, fluid replacement, and blood transfusion. Aggressive fluid therapy, intravenous opioids, and exchange transfusion should be instituted promptly. Thalassemia is a diverse group of autosomal recessive disorders caused by insufficient - or -globin synthesis. Thalassemia major usually presents by early childhood with anemia and failure to thrive. In time, young adult survivors go on to develop severe anemia, hypertrophic facial and long bone deformities, and secondary multiorgan dysfunction from severe transfusion-related hemochromatosis. Extensive endocrine dysfunction can present as hypopituitarism, hypothyroidism, hypoparathyroidism, diabetes, and adrenal insufficiency. Infections are common due to secondary immunodeficiency of hemochromatosis, blood-borne infections, and splenomegaly. Primary treatment includes periodic blood transfusions and iron chelating therapy. Eventual joint deformity, cartilage erosion, and ankylosing, or joint stiffening, develop in patients. Chronic inflammation likely contributes to accelerated atherosclerotic disease, myocarditis, pericarditis, and valvulopathies. Rheumatoid lung disease can manifest as pleurisy, pulmonary nodules, interstitial lung disease, and pulmonary hypertension. Rheumatoid vasculitis can cause widespread organ injury, specifically renal failure and ischemic stroke. Lupus glomerulonephritis, if untreated, can lead to end-stage renal disease and death. Corticosteroids and hydroxychloroquine are first-line therapies for acute flareups. Potent immunosuppressive agents, such as cyclophosphamide or mycophenolate, are used to treat severe glomerulonephritis. Quality-of-life optimization, organ injury prevention, and delay of disease progression are the focuses of treatment. Painful ischemic digits are treated with calcium channel blockers, stress management, and cold temperature avoidance. Active skin disease can be treated with immunosuppressants, such as mycophenolate or cyclophosphamide. Corticosteroids for skin disease should be avoided, because they can lead to a scleroderma renal crisis, manifested by acute hypertension and oliguric renal failure. Dysphagia, esophageal dysmotility, esophageal strictures, gastroesophageal reflux, and delayed gastric emptying are treated with proton pump inhibitors and prokinetics. Calcium channel blockers and other vasodilators may be used to preserve cardiac function. Inflammatory Myopathies Inflammatory myopathies are a rare group of muscle disorders typified by muscle inflammation and weakness. Both conditions are considered autoimmune disorders, with an acute to subacute presentation usually after a systemic infection. Muscle necrosis and inflammatory cells on muscle tissue biopsy confirms diagnosis. Shear stress across skin can result in epidermal layer detachment and painful, bullae formation. The disorder is characterized by painful, epidermal blistering that develops immediately after minimal skin rubbing. This hypersensitivity reaction can be triggered by many medications, such as angiotensin-converting enzyme inhibitors, nifedipine, and penicillin. Anesthesia and Duchenne or Becker muscular dystrophy: Review of 117 anesthetic exposures. Pathophysiologic and anesthetic considerations for patients with myotonia congenita or periodic paralyses. Pre-operative management of the patient with chronic disease: Patients with neuromuscular disorder. The historical evolution of, and the paradigms shifts in, the therapy of convulsive status epilepticus over the past 150 years. Which of the following is a common finding in patients with Duchenne muscular dystrophy A 30-year-old full-term parturient with myasthenia gravis presents for an elective cesarean section. A 16-year-old male with a family history of malignant hyperthermia is undergoing an inguinal hernia repair. A 20-year-old male with sickle cell disease develops acute chest pain and cough 1 hour after a splenectomy. Did You Know Thyroid hormone is a nonsteroid hormone, but behaves more like a steroid hormone. Steroid hormones are lipophilic and able to cross the cell membrane to act directly on cytoplasmic pathways.
Note that after an infusion of 200 minutes (well within many operative times) man health pay bill pay bill purchase online fincar, hours are required for plasma concentrations of fentanyl and morphine to decrease by 50% prostate cancer vaccine 2016 buy 5mg fincar otc. Figure 10-2 summarizes the variety of clinically important effects of the fentanyl congeners prostate cancer 2 discount 5mg fincar fast delivery. Opioids act on peripheral nerves and in the spinal cord to attenuate noxious stimuli and act centrally by altering the affective response man health recipe cheap 5 mg fincar with amex. Opioids produce sedation and -wave activity on the electroencephalogram that resemble natural sleep. Although increasing doses of opioid reliably produce sedation, they do not reliably produce unresponsiveness and amnesia. Conversely, a bolus dose of an opioid can produce an increase in coughing; this is often noted during induction of anesthesia that includes an opioid. Adverse Effects the agonists suppress ventilatory drive in the medulla and alter the ventilatory response to carbon dioxide and hypoxia. A gradual increase in opioid levels, for example, after morphine administration, will cause progressive respiratory depression and hypercapnia, thus helping to maintain ventilation. Both respiratory rate and tidal volume are decreased, with respiratory rate decreases occurring at lower doses of opioids and tidal volume decreases occurring at higher doses. The fentanyl congeners directly increase vagal tone in the brainstem, sometimes causing bradycardia. Opioids cause arterial and venous dilation without affecting myocardial contractility by decreasing vasomotor activity in the brainstem and by direct action on vessels. In most patients, this is clinically insignificant, but it may cause hypotension in patients with chronic hypertension or congestive heart failure. The rigidity tends to coincide with unresponsiveness and can be prevented with neuromuscular blockers. Metabolism and Active Metabolites Opioids are generally lipid-soluble, highly protein-bound, weak bases that are ionized at physiologic pH. Drug Interactions Sedative-hypnotic agents and opioids are synergistic, with greater analgesia and sedation resulting from combinations than from either alone. Figure 10-5 illustrates this concept in which a small dose of fentanyl and midazolam results in a higher probability of sedation and analgesia in combination than either would alone, while the probability of ventilatory depression is minimal. Pharmacogenetics and Special Populations Although codeine has a limited role in the intraoperative period, its unique pharmacogenomics are clinically significant. There seems to be a decreased analgesic response to tramadol in codeine "poor metabolizers," but the data are less clear with regard to hydrocodone and oxycodone. With the exception of the anhepatic phase of orthotopic liver transplantation, the degree of liver failure encountered in most surgical patients is not usually significant enough to dramatically alter opioid metabolism. However, patients with hepatic encephalopathy may be particularly sensitive to the sedative effects of opioids. Renal failure causes clinically significant accumulation of metabolites of morphine and meperidine. The top simulation illustrates the time to peak plasma concentration of each drug. The middle simulations demonstrate the synergistic effect of combining fentanyl and midazolam for the clinical effects of analgesia and sedation. The bottom simulation illustrates the low probability of ventilatory depression with this combination, in contrast to the high probability of analgesia and sedation. Morphine-6-glucuronide is an active metabolite with similar potency to morphine, and severe respiratory depression can result from its accumulation. Normeperidine is the active metabolite of meperidine, which 180 Clinical Anesthesia Fundamentals Fentanyl peak 2. The middle and bottom simulations represent the probability of moderate sedation and analgesia, respectively, and illustrate the principle of synergism between opioids and propofol. Studies examining sex differences in responses to opioids have produced mixed results. Authors of three small studies observed a greater respiratory depressant effect of opioids in women than in men. Processed electroencephalogram (used as a surrogate measure of opioid effect) demonstrates that the potency of the fentanyl congeners is directly related to increasing age. In 10 Analgesics 181 patients over age 65, the dose of remifentanil (and presumably other opioids as well) should be reduced by as much as 50%. With the exception of remifentanil, limited work has characterized the behavior of opioids in obese patients. The key to administering opioids to obese patients is the choice of a dosing scalar: dosing an obese patient based on total body weight will reliably result in excessive plasma concentrations, while dosing based on lean body mass or fat free mass may be inadequate. Dosing remifentanil to fat free mass in obese patients most closely mimics total body weight dosing in lean patients. Indications, Doses, and Special Considerations Morphine Morphine is the prototypic opioid and a very effective analgesic. Although this prolonged onset time allows partial pressure of carbon dioxide levels to climb gradually, reducing the risk of acute respiratory depression, it may also result in clinicians inappropriately redosing morphine before the peak effect is achieved. Morphine undergoes extensive first-pass metabolism after oral administration, resulting in high morphine-6-glucuronide levels. This high hepatic extraction ratio means that orally administered morphine has lower bioavailability than parenteral morphine (13). It has a prolonged clinical effect (2 hours) and is suitable for use in patientcontrolled analgesia. Fentanyl Fentanyl can be administered intravenously as well as by the transdermal, transmucosal, intranasal, and transpulmonary routes. Fentanyl has a peak onset 3 to 5 minutes after intravenous administration, and its analgesic effect lasts 30 to 45 minutes. Peak respiratory depression occurs between 3 and 5 minutes after an intravenous dose.
A month ago prostate cancer 911 doctor samadi purchase online fincar, she had pneumonia with Streptococcus pneumoniae cultured from her sputum prostate cancer ribbon cheap fincar 5 mg with mastercard. The next day mens health jeans generic 5 mg fincar mastercard, a fasting blood glucose is 120 mg/dL prostate cancer on t2 mri cheap 5 mg fincar visa, followed by a value of 122 mg/ dL on the following day. She is given an oral glucose tolerance test, and her blood glucose is 240 mg/dL 2 hours after receiving the standard 75-g glucose dose. Each time, she has a prodrome of lightheadedness followed by a brief loss of consciousness. After each episode, she awakens and on examination has no loss of motor or sensory function. Physical examination after the current episode shows that she is afebrile, with a pulse of 72/min, respirations of 17/min, and blood pressure of 120/80 mm Hg. Which of the following pancreatic disorders is most likely to be present in this patient Acute necrotizing pancreatitis Adenocarcinoma Cystic fibrosis Neuroendocrine tumor Pseudocyst 48 A family is followed longitudinally for two generations. Treatment with insulin 50 A 43-year-old man from Stockholm, Sweden, has had low-volume watery diarrhea for the past 3 months. On physical examination, he is afebrile; on palpation, there is no abdominal tenderness and no masses. Three months later, repeat endoscopy shows that the ulcerations are still present. Which of the following analytes is most likely to be increased in his in serum or plasma He has cutaneous striae over the lower abdomen and ecchymoses scattered over the extremities. Laboratory findings show fasting plasma glucose level of 200 mg/dL, serum Na+ of 150 mmol/L, and serum K+ of 3. Administration of low and high doses of dexamethasone fails to suppress the plasma cortisol level and excretion of urinary 17-hydroxycorticosteroids. Adenohypophyseal adenoma Adrenal cortical adenoma Extra-adrenal pheochromocytoma Small cell carcinoma of the lung Thyroid medullary carcinoma the Endocrine System 379 52 A 43-year-old woman has had absent menstrual cycles along with increasing weakness and weight gain over the past 5 months. A radiograph of the spine shows decreased bone density with a compression fracture at T9. Which of the following radiographic findings is most likely to be present in this patient Physical examination shows muscle wasting and 4/5 motor strength in all extremities. A chest radiograph shows a 6-cm perihilar mass on the right and prominent hilar lymphadenopathy. Amyloidosis Ectopic corticotropin syndrome Meningococcemia Metastatic carcinoma Pituitary adenoma 54 A 28-year-old, otherwise healthy man has had headaches for the past 2 weeks. Physical examination yields no remarkable findings except for a blood pressure of 174/116 mm Hg. A right adrenalectomy is done; the figure shows the gross appearance of the specimen. Which of the following laboratory findings in his blood was most likely reported in this patient before surgery Hyperglycemia Hyperkalemia Hyponatremia Low corticotropin level Low insulin level Low renin level 55 A 40-year-old woman has experienced increasingly frequent episodes of weakness accompanied by numbness and tingling in her hands and feet for the past year. Which of the following radiologic findings is most likely to be present in this woman Laboratory studies include a serum cortisol level of 3 g/mL at 8:00 am with a serum corticotropin level of 65 pg/mL. Type 2 diabetes mellitus Classic polyarteritis nodosa Hashimoto thyroiditis Systemic lupus erythematosus Ulcerative colitis 56 A 5-year-boy has developed features that suggest puberty over the past 6 months. On physical examination, the boy has secondary sex characteristics, including pubic hair and enlargement of the penis. Which of the following morphologic features is most likely to be seen in his adrenal glands Cortical atrophy Cortical hyperplasia Cortical nodule Medullary atrophy Medullary hyperplasia Medullary nodule 57 A female infant is born at term to a 41-year-old Yupik woman after an uncomplicated pregnancy. Which of the following enzyme deficiencies is most likely to be present in this infant Aromatase 11-Hydroxylase 21-Hydroxylase 17-Hydroxylase Oxidase 61 A 44-year-old woman has become increasingly listless and weak and has had chronic diarrhea and a 5-kg weight loss over the past 7 months. She also notices that her skin seems darker, although she rarely goes outside because she is too tired for outdoor activities. Adenohypophyseal adenoma Autoimmune destruction of the adrenals Pancreatic neuroendocrine tumor Metastatic carcinoma with lung primary Neisseria meningitidis infection of the adrenals Sarcoidosis of the lung and adrenals 58 A 19-year-old, previously healthy woman collapsed after complaining of a mild sore throat the previous day. Imaging studies show her adrenal glands are enlarged, and there are extensive bilateral cortical hemorrhages. Cytomegalovirus Histoplasma capsulatum Mycobacterium tuberculosis Neisseria meningitidis Streptococcus pneumoniae 62 A 37-year-old woman states that, although most of the time she feels fine, she has had episodes of palpitations, tachycardia, tremor, diaphoresis, and headache over the past 3 months. When her symptoms are worse, her blood pressure is measured in the range of 155/90 mm Hg. She collapses suddenly one day and is brought to the hospital, where her ventricular fibrillation is converted successfully to sinus rhythm. On postoperative day 2, she becomes somnolent and develops severe nausea and vomiting. Blood cultures are negative, and laboratory studies now show Na+ of 128 mmol/L, K+ of 4.
The other listed antiretroviral drugs or antimicrobials are far less likely to cause skin reactions prostate 89 psa trusted fincar 5mg. Atopy increases the risk for allergic reactions mediated by type I hypersensitivity reactions mens health 30 minute workout order generic fincar on line, often with urticarial skin lesions that dissipate within hours mens health 7 day diet plan buy discount fincar line. Autoantibodies to desmoglein in pemphigus vulgaris cause suprabasal blister formation prostate 5lx amazon order fincar 5mg mastercard. Plant allergens such as urushiol in poison oak cause a contact dermatitis that typically fades in days. Herpes simplex virus infection can produce vesicular eruptions, or it may underlie erythema multiforme manifested by targetoid lesions. The lesions of lichen planus are typically self-limited, although the course can run for several years. Although a lymphocytic infiltrate is present, an infection or autoimmunity is not implicated. A drug eruption would not last this long, and lichen planus is not a hypersensitivity reaction. Lesions of erythema multiforme are more likely to follow infections, drugs, autoimmune diseases, and malignancies. Skin adnexal tumors are typically benign; often have apocrine differentiation; and arise in areas were apocrine glands are prevalent, such as scalp and axilla. Acanthosis refers to epidermal hyperplasia, in which the thickness of the entire epidermis is increased. Hyperkeratosis is increased thickness of stratum corneum with abnormal keratin; a callus would refer to thickened stratum corneum in response to mechanical forces, such as the hands of a carpenter working with tools, or the soles of the feet of a child going barefoot. The antibody deposition disrupts intercellular bridges, causing the epidermal cells to detach from each other (acantholysis). Staining with anti-IgG illuminates intercellular junctions at sites of incipient acantholysis. Darkfield microscopy is used almost exclusively to identify spirochetes in cases of syphilis. Type I hypersensitivity with IgE fixed to mast cells and urticaria does not produce an acantholytic vesicle. Herpes simplex viral infections can produce crops of vesicles, but such a wide distribution would be unusual. The lamina densa of the basement membrane is not directly involved, and the actual blister of bullous pemphigoid forms in the lamina lucida. In contrast, the antibodies in pemphigus vulgaris attack the desmosomes that attach the epidermal keratinocytes. Antibodies directed against nuclear antigens are more typical for systemic autoimmune diseases such as systemic lupus erythematosus. The antigliadin antibodies of dermatitis herpetiformis cross-react with dermal reticulin, and there are microabscesses at the tips of dermal papillae. Propionibacterium acnes organisms break down sebaceous gland oils to produce irritative fatty acids, and this may promote the process. The food on the cruise probably did not play a role, but stress causes the lesions to worsen. Staphylococcus aureus and group A streptococci are implicated in the inflammatory skin condition known as impetigo, which can include pustules and a characteristic pale yellow-brown crust. Herpes simplex virus produces vesicular skin eruptions, most often in a perioral or genital distribution. Mycobacterium leprae causes leprosy, which is a chronic condition that can produce focal depigmentation and areas of skin anesthesia. The IgA or IgG antibodies formed against the gliadin protein in gluten that is ingested (commonly in wheat, rye, and barley grains) cross-react with reticulin. Reticulin is a component of the anchoring fibrils that attach the epidermal basement membrane to the superficial dermis. This explains the localization of the IgA to the tips of dermal papillae and the site of inflammation. Bullous pemphigoid can occur in older individuals, with antibody directed at keratinocytes to produce flaccid bullae, but there is no association with celiac disease. Discoid lupus erythematosus is seen on sun-exposed areas and has the appearance of an erythematous rash. Erythema multiforme is a hypersensitivity response to infections and drugs; it produces macules and papules with a red or vesicular center, but it is probably mediated by cytotoxic lymphocytes and not by immunoglobulin deposition. Pemphigus vulgaris is an autoimmune disease in which IgG deposited in acantholytic areas forms vesicles that rupture to form erosions; it is not related to celiac disease. Acne vulgaris is most likely to appear on the face and upper trunk, centered around hair follicles; it often resolves with scarring. Celiac disease is associated with dermatitis herpetiformis, and the antigliadin antibodies can cross-react with dermal reticulin, producing microabscesses at the tips of dermal papillae. Impetigo is seen on the face and hands with crusting lesions from Staphylococcus aureus and -hemolytic streptococcal infections producing subcorneal pustules. The lesions of molluscum contagiosum are firm nodules that microscopically contain pink cytoplasmic inclusions, called molluscum bodies. Dermatitis herpetiformis associated with celiac disease has IgA antibodies deposited at tips of dermal papillae. Dysplastic nevi develop in relation to mutations in genes encoding for growth control proteins. Early lesions of discoid lupus erythematosus appear as well-demarcated scaly purple macules or papules, and later expand into discoid plaques.
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