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By Q. Steve. Concord College.

There are no visible clinical signs or abnormalities aurogra 100 mg generic erectile dysfunction 3 seconds. The patient should be referred for specialist assessment generic aurogra 100 mg with amex impotence drug. DIFFERENTIAL DIAGNOSIS OF CHIEF COMPLAINTS: THROAT Sore Throat or Throat Pain Sore throat is a very frequent complaint in primary care settings. Most episodes of sore throat are associated with self-limited viral upper respiratory infections, although there are a number of more serious causes. In addition to determining the characteristics of the pain, identifying all associated symptoms is helpful in narrowing the differential diagnosis. It is important to identify any other recent illnesses, as well as recent exposures to others who are ill. Determine whether the patient is experiencing any dys- phagia or respiratory difficulty. Physical Examination The physical examination for sore throat should include comprehensive assessment of the upper and lower respiratory systems, including ears, nose, mouth, throat, and lungs. The neck assessment should include, at a minimum, assessment of the cervical lymph nodes. A more-thorough neck assessment is indicated if carotidynia or thyroiditis is suspected. Diagnostic Studies Strep screens, throat cultures, and mononucleosis screens are common diagnostic studies used to narrow the differential diagnosis of sore throat. Complete blood counts with dif- ferential counts are helpful in determining the cause of sore throat. INFECTIOUS PHARYNGITIS Most cases of pharyngitis are viral in origin, and any number of the respiratory viruses can cause inflammation of the throat. The majority of viral pharyngitis cases are self-limited. Group A beta-hemolytic streptococcal (GABHS) pharyngitis is a bacterial infection of the pharynx, commonly referred to as strep throat. Complications of GABHS pharyngitis, although rare, include rheumatic heart dis- ease and glomerulonephritis and the condition requires prompt diagnosis and definitive treatment. Most patients with GABHS pharyngitis are children and youths. Other bacter- ial causes of pharyngitis include mycoplasmal pneumonia, gonorrhea, and diphtheria. Because pharyngitis is most commonly caused by respiratory viruses, the complaints typically include malaise, headache, rhinitis, and/or cough in addition to the throat pain, which can range from mild scratchy discomfort to severe pain. The onset can be sudden, as with influenza, but symptoms may develop over many hours. In all cases of pharyngitis, the pharynx is reddened and tender lymphadenopathy is often present. Depending on the cause, other findings may be present. The findings asso- ciated with varied causes of non-GABHS pharyngitis are summarized in Table 5-3. The classic symptom of GABHS is a severe sore throat, with sudden onset. The patient often also complains of nausea, vomiting, fever, headache, and malaise. Unlike other forms of pharyngitis, the patient does not usually experience rhinitis or cough. The findings of GABHS include very inflamed pharynx, uvula, and tonsils. The tonsils are enlarged, usually with a white or gray-white exudate. Although some patients with viral pharyngitis may have an exanthem, GABHS can present with a fine scarlatinal rash, often described as “sand paper” rash owing to the tiny, punctate pink-red lesions. With GABHS pharyngitis, a throat culture and/or rapid strep assay is positive. If monospot is performed to rule out mononucleosis, it is negative.

In this case generic aurogra 100mg with mastercard impotence signs, ERCP is the procedure of choice because it will provide not only direct visualization of the common bile duct but also an opportunity to intervene therapeutically trusted aurogra 100 mg best herbal erectile dysfunction pills. If ERCP cannot be performed, transhepatic cholangiography is an alternative method for visualizing the bile ducts. A 49-year-old man presents with right upper quadrant abdominal pain that began 8 hours ago. The pain is constant and is associated with nausea, vomiting, and fever. Over the past few months, he has had intermittent episodes of similar pain, but those were less intense, resolved spontaneously within 1 or 2 hours, and were never associated with vomiting or fever. Results of physical examination are as follows: temperature, 101. The patient looks tired and moderately uncomfortable. Bowel sounds are present, but he has right upper quadrant tenderness. Laboratory results are remarkable for a white blood cell count of 14,000, with a left shift. Bilirubin, amylase, and alkaline phos- phatase levels are normal. Which of the following is the best diagnostic imaging test for this patient? Plain abdominal x-ray Key Concept/Objective: To understand the roles of various imaging modalities in the setting of acute cholecystitis Ultrasound is the imaging test of choice. For detecting gallstones, it has a sensitivity of 88% to 90% and a specificity of 97% to 98%. It is noninvasive and readily available in most areas. If ultrasound results are equivocal, a HIDA scan can be performed to confirm the diagnosis of acute cholecystitis. HIDA scans are highly accurate, but they can be con- founded by cirrhosis and can be misleading in patients who are fasting or who are receiv- ing parenteral nutrition. Because most gallstones are radiolucent, plain x-rays have limited use- fulness. The obese sister of the patient in Question 22 comes in the week after her brother’s visit with severe epi- gastric right upper quadrant pain that has been unrelenting for 24 hours. Results of physical examination are as follows: temperature, 102. There is 4 GASTROENTEROLOGY 15 marked right upper quadrant tenderness but no palpable liver or gallbladder. Laboratory results show a white blood cell count of 16,000 with a left shift. Which of the following represents the diagnosis and best treatment for this patient? Acute cholecystitis; treat with ampicillin-sulbactam B. None of the above Key Concept/Objective: To be able to recognize the characteristic signs and symptoms of cholan- gitis and to select the appropriate antibiotic to cover likely organisms This patient has the classic triad of jaundice, right upper quadrant pain, and fever with rig- ors (Charcot triad), which suggests cholangitis. If she also had shock and mental status changes (Reynold pentad), her prognosis would be grave: mortality in such patients approaches 50%. In addition to antibiotics and supportive care, patients who are very ill should be considered for biliary tract decompression (percutaneous or surgical decompres- sion, or decompression with ERCP). The organisms that most commonly cause cholangitis are Escherichia coli, Klebsiella, enterococci, and Bacteroides fragilis. Ceftriaxone is not rec- ommended in this case because it does not cover enterococci and has been associated with the development of gallbladder sludge. A 75-year-old man presents with gradually worsening pruritus, jaundice, and vague right upper quad- rant abdominal ache. On exam, he has normal vital signs, scleral icterus, and hepatomegaly.

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