By E. Vatras. Antioch College. 2018.
Renal biopsy results are not diagnostic of Henoch-Schonlein purpura buy 1mg estradiol mastercard, as such results can be identical with the results obtained in cases of IgA nephropathy with IgA depo- sition in the mesangium and in cases involving severe crescent formation best estradiol 2mg. Skin biopsy results also show IgA (not IgG) deposition on immunofluorescence. This patient does not have any risk factors or signs of sepsis; if there is any suspicion that gonococcal or rickettsial infection is causing the palpable purpura, empirical therapy should be start- ed immediately. Most cases of Henoch-Schonlein purpura resolve spontaneously, although prednisone and cyclophosphamide should be considered for use in the few patients with acute renal failure. A 67-year-old black man with a history of tobacco abuse and ethanol abuse is admitted for gradually worsening esophageal dysphagia complicated by a 1-day history of shortness of breath, productive cough, and fever. On examination, the patient has a temperature of 101. Chest radiography reveals a right lower lobe infiltrate consistent with aspiration pneumonia. He is placed on piperacillin-tazobactam and oxy- gen, and he gradually improves. By hospital day 3, he experiences defervescence, but on hospital day 10 he is noted to again have a fever (100. In addition, the patient has a rash, and peripheral blood eosinophilia and acute renal insufficiency are present. This patient will likely progress to end-stage renal disease 22 BOARD REVIEW B. Standard of care would include stopping the piperacillin-tazobac- tam and starting high-dose I. Another β-lactam antibiotic can be safely substituted for piperacillin D.
His complete blood count estradiol 1 mg cheap, serum electrolyte levels purchase estradiol 1mg with amex, and serum calcium level are all within normal limits. He is referred for an upper GI series and is found to have a recurrent duodenal ulcer. The patient’s fasting gastrin level is 500 pg/ml (normal value, < 100 pg/ml). For this patient, which of the following statements is true? An upper GI series that is diagnostic of a bulbar duodenal ulcer will preclude endoscopy B. Treatment failure with clarithromycin-based regimens occurs in approximately 30% of cases of H. A positive serum antibody test (sensitivity and specificity > 90%) would indicate persistent infection and require retreatment with metronidazole, tetracycline, and bismuth, as well as continuation of a proton pump inhibitor D. Ulcers refractory to pharmacotherapy are seen in acid hypersecretory states; this patient’s fasting gastrin level is diagnostic of the Zollinger- Ellison syndrome Key Concept/Objective: To understand the diagnostic modalities used in peptic ulcer disease Despite having a lower sensitivity and specificity than endoscopy, an upper GI series using barium and air (double contrast) may be favored by primary care physicians and patients over referral for endoscopy for suspected uncomplicated ulcer. An upper GI series offers lower cost, wider availability, and fewer complications. However, for troublesome and undiagnosed dyspepsia, an upper GI series may be superfluous, because a normal result will often necessitate endoscopy (endoscopy is more sensitive than radiography) and because an upper GI series showing a gastric ulcer will also necessitate endoscopy and biopsy to exclude gastric malignancy. In many patients, only a finding of a duodenal bul- 4 BOARD REVIEW bar ulcer on an upper GI series will preclude endoscopy. A 2-week course of a three-drug regimen that includes a proton pump inhibitor, clarithromycin, and amoxicillin has a success rate approaching 90%. The major causes of treatment failure are poor compliance with the reg- imen and clarithromycin resistance; the latter occurs in around 10% of current strains and is increasing with increased macrolide use in the population. Breath testing is more useful than serology in diagnosing failure of eradication of H. A fasting serum gastrin concentration can be used to screen for an acid hypersecretory state resulting from Zollinger-Ellison syndrome. Antisecretory drugs (especially proton pump inhibitors) can also raise serum gastrin levels modestly (to 150 to 600 pg/ml).