After long discussions with academic teachers of numerous clinical subjects in our University, we have prepared a program of teaching practical clinical skills to . For use with the 17th edition of HARRISON'S PRINCIPLES OF INTERNAL MEDICINE. EDITED BY. CHARLES WIENER, MD. Professor of Medicine and. Kelley's Textbook of Internal Medicine. The new edition of this reorganized text emphasizes practicality and includes expeditious features that enable both.
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The consent of CRC Press LLC does not extend to copying for general refer to frequently as my Handbook of M ACSM's Resources for the Personal Trainer. Approach to Internal Medicine is meant to be a practical field guide. The third edition of Approach to Internal Medicine builds upon previous efforts to create a. Internal medicine is a vast and complicated field that is based on strong of Internal Medicine at the Medical faculty of Addis Ababa University, who has.
Close more info panel Slideset Slideset. There is no abdominal bruit. Since her screening colonoscopy was recently done and was adequate, the likelihood of missed colon cancer would also be very low. Contact Info. You are now leaving the CCO site. He has been feeling well with no complaints and has no history of cardiovascular disease or diabetes.
Bedtime dosing of antihypertensive medications reduces cardiovascular risk in CKD.
J Am Soc Nephrol. Judd E, Calhoun DA. Management of hypertension in CKD: Adv Chronic Kidney Dis. Case 5 A year-old woman has had 5 months of nonproductive cough, which has been quite bothersome to her and has resulted in occasional episodes of urinary stress incontinence.
She is otherwise healthy, and her only medication is levothyroxine for hypothyroidism. She has never smoked. She has no history of allergies and denies any nasal symptoms. She also denies any heartburn or regurgitation. Trials of sedating antihistamine and oral decongestant as well as twice-daily proton pump inhibitor PPI have been ineffective. Her physical examination including lungs and ENT and chest x-ray are both normal, as is spirometry before and after bronchodilator. Question Which of the following tests would be most likely to help provide direction on further management of her cough?
Allergy skin testing, exhaled nitric oxide, eosinophil count on peripheral blood, high-resolution CT scan of chest, sinus x-rays. Many patients with chronic cough will have more than one of these conditions, and most management algorithms advise a sequential strategy of either testing or empiric therapy focused upon these three main causes.
UACS refers to those etiologies of nasal or sinus origin: If the cough is related to UACS, clinical improvement should be evident within 2—4 weeks. Cough variant asthma is the term used for those with that symptom as the primary manifestation of their disease, and many will not have evidence of bronchodilator response on spirometry although almost all of them will have a positive methacholine challenge test.
An elevated ENO level ppb predicts a favorable response to inhaled corticosteroid, regardless of underlying etiology asthma or NAEB , and a low ENO level indicates a greatly reduced chance of response to steroid. Skin testing, peripheral blood eosinophil count, and CT chest would have no diagnostic utility in this case. Some experts recommend CT sinus after failing initial steps in the algorithm though it would be of very low yield in this particular patient , but sinus x-rays are considered too insensitive.
Clinical pearl Exhaled nitric oxide may have a role in identifying patients with chronic cough who are likely to respond to inhaled corticosteroids. Chronic cough: Mayo Clin Proc.
Cochrane Database Syst Rev. She had presented at that time with Class III symptoms of heart failure. She was diuresed and has since done well on a regimen of carvedilol, lisinopril, and spironolactone.
However, she has also had more trouble with DJD in her knee over the past few months and has curtailed her activity for that reason. She wonders if she is simply noticing the effects of deconditioning or if her heart failure has worsened.
She denies any orthopnea or paroxysmal nocturnal dyspnea. On examination, she appears generally well and is breathing comfortably at rest. Normal JVP, B. These have generally involved patients undergoing cardiac catheterization for non-acute reasons e. The optimal technique for performing this maneuver was perfected by Ewy during bedside examination of patients undergoing right heart catheterization.
It involves applying 20 mm Hg of pressure with one hand over the upper mid-abdomen for 10 s while watching for a rise in the level of the JVP, and a sudden drop of at least 3 cm in JVP upon release. Peripheral edema is also insensitive in this setting.
Bedside cardiovascular examination in patients with severe chronic heart failure: J Am Coll Cardiol. Ewy GA. The abdominojugular test: Ann Intern Med. These symptoms begin consistently about 5 days prior to the onset of her menses and resolve within 2 days after the start of her menses. Her menstrual periods are regular, she is otherwise J. She is concerned because these symptoms are beginning to put a mild strain on her relationships with her family and close friends.
Which of the following would be the most appropriate therapy for attempting to alleviate her condition? Discussion This patient has a symptom complex, which would be diagnostic for premenstrual dysphoric disorder PMDD. The chief differential diagnostic consideration would be a mere exacerbation of another disorder major depression, panic disorder, dysthymic disorder, and personality disorder , but in her case there is no history to suggest these, and her symptoms resolve completely after onset of menses.
The selective serotonin reuptake inhibitors SSRI have been shown to be effective in managing this condition. The serotonin—norepinephrine reuptake inhibitor SNRI venlafaxine has been found to be similarly effective. Interestingly, multiple studies have reported that intermittent use of citalopram during the 2 weeks preceding the onset of menses luteal phase dosing is equally effective to use it continuously.
Progesterone and other progestogens are no more effective than placebo and in theory might even be expected to worsen the symptoms.
Mirtazapine has not been studied. An OCP with low-dose estrogen and drospirenone and a shortened pill-free interval is also effective, but generally considered second-line therapy in women who fail SSRI unless, of course, it is used for contraception or another primary indication.
It is reasonable to start with intermittent administration 2 weeks prior to onset of menses. Steiner M, Li T. CNS Drugs. Marjoribanks J, Brown J, et al. He is adherent to his regimen and is following appropriate lifestyle measures. He has no history of cardiovascular disease or symptoms thereof. Physical examination is normal, apart from 2 mm of pitting edema at the mid-tibial levels bilaterally.
There is no abdominal bruit. Doppler of the renal arteries shows no evidence of stenosis.
Question What would be the next best step in management for this patient? Add spironolactone 25 mg per day, add aliskiren 75 mg per day, switch diuretic to torsemide 10 mg per day, catheter-based renal sympathetic denervation, add losartan 50 mg per day.
After non-adherence and white coat hypertension have been excluded, common secondary causes include OSA, renal artery stenosis, and primary aldosteronism PA. The mechanism of this effect is not entirely clear but may relate in part to elevated mineralocorticoid receptor sensitivity. Doses of spironolactone were 25—50 mg once daily. Serum potassium must be carefully monitored e.
Clinical pearl In many patients with resistant hypertension, the addition of low-dose aldosterone antagonist is effective in improving blood pressure control even in the absence of primary aldosteronism.
Vongpatanasin W. Resistant hypertension: J Am Med Assoc. J Hypertens. Vaclavik J, Sedlak R, et al.
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Making the case for general internal medicine. International Perspectives on General Internal Medicine. Update in general internal medicine: Clinical Pearls. Clinical pearls in dermatology. Clinical pearls. Contraceptive counseling by general internal medicine faculty and residents.
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