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These patients often have distant heart sounds and on examination typically have pulsus para- doxus cheap 100mg zoloft otc. Jugular veins are distended and typically show a prominent x descent and an ab- sent y descent 25 mg zoloft otc, as opposed to patients with constrictive pericarditis generic 100mg zoloft mastercard. In addition, Kussmaul’s sign is absent in tamponade but present in constrictive pericarditis. Echocardiographic findings typically reveal right atrial collapse and right ven- tricular diastolic collapse. Cardiac catheterization will reveal equalization of diastolic pressures across the cardiac chambers. Therefore, the pulmonary capillary wedge pres- sure will be equal to the diastolic pulmonary arterial pressure, and this will be equal to the right atrial pressure. These catheterization findings are also present in a patient with constrictive pericarditis. When beta blockers are ineffective or poorly tolerated, calcium channel blockers are in- dicated for the treatment of stable angina. Adverse effects of the calcium channel block- ers include hypotension, conduction disturbances, and the propensity to exacerbate heart failure due to the negative inotropic effects. In general, verapamil should not be used in conjunction with beta blockers because of the combined effect on heart rate and contractility. Diltiazem should not be used in patients taking beta blockers with conduc- tion disturbances and a low ejection fraction. Immediate-release nifedipine and other short-acting dihydropyridines should be avoided due to the increased risk of precipitat- ing myocardial infarction. Amlodipine and other second-generation dihydropyridines dilate coronary arteries and decrease blood pressure. In conjunction with beta blockers, which slow heart rate and decrease contractility, amlodipine has a favorable effect in the treatment of angina. High-risk cardiac lesions include prosthetic heart valves, a history of bacterial endocarditis, complex cyanotic congenital heart disease, patent duc- tus arteriosus, coarctation of the aorta, and surgically constructed systemic portal shunts. Moderate-risk patients include those with congenital cardiac malformations other than high-risk or low-risk lesions, acquired aortic or mitral valve dysfunction, hypertrophic cardiomyopathy with asymmetric septal hypertrophy, and mitral valve prolapse with valve thickening or regurgitation. Her procedure is an esophageal dilation, which, like dental pro- cedures, calls for prophylaxis in the moderate- to high-risk groups. Generally, men older than 50 are at risk for this condition, and it classically presents with syncope in the setting of shaving, wearing a tight collar, or turning the head to one side. Diagnosis is suggested by carotid sinus mas- sage with prolonged (more than 3 s) asystole. Due to further vasospasm, cold water ingestion may exacerbate the patient’s symptoms. Many infectious, inflammatory, and inherited conditions have been associated with this finding, including syphilis, tubercu- losis, mycotic aneurysm, Takayasu’s arteritis, giant cell arteritis, rheumatoid arthritis, and the spondyloarthropathies (ankylosing spondylitis, psoriatic arthritis, Reiter’s syndrome, Behçet’s disease). In addition, it can be seen with the genetic disorders Marfan’s syn- drome and Ehlers-Danlos syndrome. Chagas’ disease, or American trypanosomiasis, is due to infection with Trypanosoma cruzi and only occurs in the Americas. A minority of chronically infected patients develop seri- ous cardiac or gastrointestinal disease (megaesophagus or megacolon). This diagnosis should be considered in a person from Central or South America presenting with this de- gree of cardiomyopathy with conduction delays (most commonly right bundle branch block) and normal angiogram. Apical aneurysm and thrombus formation are common and may lead to systemic embolization, including stroke. Although medical therapy for acute Chagas’ improves mortality, the role in chronic Chagas’ has not been proven. Treat- ment for coronary vasospasm and aggressive lipid lowering therapy do not have an estab- lished role in the treatment of Chagas’ disease. Since the cardiomyopathy is considered irreversible, cardiac transplantation is the only viable option to improve function. The prognosis after cardiac transplantation tends to be favorable since this form of chronic Chagas’ disease is usually limited to the heart. Many forms of acute viral myocarditis or stress cardiomyopathy are expected to improve with time. The most common cause is sequelae of rheumatic carditis, and symptoms of stenosis usually develop two decades after the onset of carditis. Due to elevated left atrial pressure and concomitant left atrial dilation, these patients are at high risk for developing atrial fibrillation, pulmonary hypertension, and right-ventricular failure. Right-ventricular outflow tract tachycardia is unrelated to val- vular pathology and is common in the young and women. Additionally, multiple systemic disorders are associated with sinus bradycar- dia, for instance, hypothyroidism, advanced liver disease, hypoxemia, hypercapnia, acide- mia, and acute hypertension. Finally, several infectious diseases are classically associated with sinus bradycardia, notably typhoid fever and brucellosis. Pulmo- nary hypertension may develop in individuals with a significant left-to-right shunt such as an undiagnosed atrial septal defect. Pulmonary hypertension is the result of increased blood flow across the pulmonary vascular bed, leading to obliteration of the vascular bed. With the development of significant pulmonary hypertension, Eisenmenger syndrome may develop. This occurs when a right-to-left shunt develops as a result of pulmonary hypertension. Erythrocytosis due to chronic hypoxemia is a common feature of cyanotic congenital heart disease with a hematocrit of up to 65–70% commonly seen. However, symptoms of hyperviscosity rarely develop, and phlebotomy is not frequently required. Stroke is greatest in children <4 years of age but is not in- creased in adults unless there is inappropriate use of anticoagulants, concomitant atrial fibrillation, or infective endocarditis. As a result, there is slowing of the upstroke of the action potential as well as reduced duration of repolarization. In a patient with elevated left atrial pressures, the mitral valve opens quickly after closure of the aortic valve (A2) due to the relatively low pressure gradient across the mitral valve in early diastole. If the left atrial pressure were lower, it would take longer for the pressure gradient across the mitral valve to cause mitral valve opening. A short interval between A2 and the opening snap in- dicates very elevated left atrial pressures. Atrial fibrillation, pulmonary vascular conges- tion, pulmonary hypertension, and right-ventricular failure (elevated jugular pressure, pulsatile liver, peripheral edema) are all potential sequelae of severe mitral stenosis. The abrupt onset of severe hyperten- sion or the onset of any hypertension before the age of 35 or after age 55 should prompt evaluation for renovascular hypertension. In addition, patients should be evaluated for secondary causes if previously well-controlled blood pressure suddenly becomes increas- ingly difficult to control as this may indicate the development of renovascular disease. Any symptoms or physical findings of concern should be investigated further as well. In the scenarios presented in Question 27, (B) should signal concern for adult-onset poly- cystic kidney disease and (E) describes a woman with possible Cushing’s disease. Other causes of secondary hypertension include pheochromocytoma, primary hyperaldoster- onism, medication-induced, and vasculitis. Pa- tients with the tachycardia-bradycardia variant of sick sinus syndrome are at risk for thromboembolism. Those at greatest risk include age >65 years, prior history of stroke, valvular heart disease, left ventricular dysfunction, or atrial enlargement. There is no reason to discontinue dypyridamole at this time as she is complaining of no side effects, and the absence of angina argues against the need for cardiac catheterization. The most common causes of cardiac tamponade are neoplasm, renal failure, and idiopathic acute pericarditis. The amount of fluid required to cause cardiac tamponade varies widely, depending upon the acuity with which the ef- fusion develops. Rapid accumulation of pericardial fluid will result in tamponade with as little as 200 mL of fluid, whereas a slow accumulation of pericardial fluid may result in a pericardial effusion of ≥2000 mL. Cardiac tamponade can be rapidly fatal if not recog- nized and treated quickly with pericardiocentesis. Clinical features of pericardial tam- ponade are hypotension, muffled heart sounds, and jugular venous distention, with a rapid x descent but without a y descent. In more slowly accumulating effusions, symptoms may be those of heart failure, with dyspnea and orthopnea common. Normally, blood pressure falls during inspiration, due to an increase in blood flow into the right ventricle with displacement of the interventricular septum to the left, decreasing left-ventricular filling and cardiac output. This fall in blood pressure results in a fall in systolic blood pressure of ≤10 mmHg in normal individuals but is exag- gerated in cardiac tamponade. Echocardiogram is frequently diagnostic, showing a large pericardial effusion with col- lapse of the right ventricle during diastole. A right heart catheterization demonstrates equalization of pressures in all chambers of the heart. This is exemplified in option C where the right-atrial pressure, right-ventricular diastolic pressure, pulmonary artery di- astolic pressure, and pulmonary capillary wedge pressure are equal. Option B would be seen in congestive heart failure, and option D is seen in pulmonary arterial hypertension. These changes are typical of emphysema when the thorax is hyperinflated with air and the flattened diaphragm pulls the heart inferiorly and vertically.

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In this paper discount programs of 5% common to some Delta Dental and Blue Flexible Spending Account: Cross "participating" provider plans are not consid- ered preferred provider organizations buy 100mg zoloft mastercard. Flexible Spending Accounts allow employers and employees to use pretax dollars to pay for certain Dental Health Maintenance Organization personal health care expenses that are not covered (Capitation): by medical or dental insurance cheap 25mg zoloft with mastercard. Funds are reim- bursed to the employee for health care (medical A capitation program is one in which a dentist and/or dental) generic 25 mg zoloft amex, dependent care, and/or legal expens- or dentists contract with the program’s sponsor or es, and are considered a nontaxable benefit. This administrator to provide all or most of the dental includes insurance cost-sharing expenses associated services covered under the program to subscribers in with deductibles and co-insurance. These bursement accounts are primarily funded with plans place providers at risk for some medical (den- employee-designated salary reductions. More expensive elective services are usually provided under a discounted fee-for-service arrange- An indemnity plan is a dental plan where a third ment with substantial patient cost sharing. It is a form Managed Care: of defined contribution in which contribution may come from employers, employees or public funds. This refers to the payment for dental services by Preferred Provider Organizations and Dental Health patients with their own funds. The services is paid by the patient or some designated referral service may be provided free to employees person, usually a relative. For individuals with den- or group members, or a membership fee may be tal prepayment, this refers to the portion the billing charged. These payments may be for noncovered services or as copayments for covered services. Types of copay- References ments include: deductibles, copayments, and ex- penses above the maximum allowed by the plan. A provision of a dental benefit program by which American Dental Association, Survey Center. Chicago: pays 80% of the allowed benefit of the covered den- American Dental Association; 1995. Percentages vary and may apply to of Capitation and Preferred Provider Dental Plans. Foundation- eficiary is responsible before a third party will Sponsored Conference on Primary Care for the assume any liability for payment of benefits. Dental services and oral health: The maximum dollar amount a program will pay United States, 1989. National Center for Health toward the cost of dental care incurred by an individual Statistics. Dental Care Utilization: How saturated is zation for coverage of a level of benefits for a spec- the patient market? Trends in caries among adults 18- members of a group, such as a professional associa- 45 years old. Trends in total caries experience: tion, to a group of participating dentists who will permanent and primary teeth. J Am Dent Assoc provide dental services at a discount from their 2000b Feb;131:223-31. Contrasting the economic outlook for dentistry and America: a report of the Surgeon General. Design and methods of medical expenditure panel sur- Research, National Institutes of Health; 2000. Dental insurance coverage: some considerations on ods for the household survey and the survey of reading estimates. Conference Proceeding: The employer-based health insurance system: repair it or replace it? A comparison of dental care expenditures and office-based medical care expendi- tures, 1987. Prevalence and patterns of tooth loss in United States employed adult and senior populations, 1985-86. As individuals, dentists provide a valued serv- ice in their communities, enjoy strong relationships with their patients and are much regarded for their integrity, compassion and skills. Representatives of dentistry serve on state and regional regulatory boards as advocates for the public welfare. As a profession, dentistry maintains a clear commitment to high per- formance standards, life-long learning and support for strict accreditation standards of dental school pro- grams and state licensure requirements. State licensure requirements and scope of practice regulations, while serving to protect the public, can also have unintended and unfortunate consequences. Conversely, if their new home state defines Scope of Work more restrictively than their training allows, hygienists may not find it financially or professionally rewarding to continue their professional careers. Further, differences among states may discourage the emergence of national consensus on dental curricu- la development. This chapter reviews dental licensure and regulation and identifies strategies to strengthen mechanisms that assure professional conduct and performance. Among qualifica- tions deemed essential are satisfactory theo- The scope of practice in all of dentistry, including retical knowledge of basic biomedical and its specialties, has continually evolved. State board dental sciences and satisfactory clinical definitions of the scope of specialty practices have skill. It is essential that each candidate not kept pace with the dynamic advances in dental for an initial license be required to demon- materials and techniques. Dental board members include dentists, type of license, requirements for licensure, and prac- dental allied personnel, and representatives of the tice limitations of each specialty dental practice vary public. Those responsi- of specialty practice and issue some sort of license bilities include evaluating dental professionals for for dental specialists. Twenty-two states set stan- licensure and disciplining errant dentists and dards for announcements by licensed dentists who allied personnel. The type of license issued nosis and treatment a dentist can legally perform for may restrict the specialist’s scope of practice. Another challenge facing dental boards is the The demand for dental hygienists has increased as issue of "dual degrees. The medically States must consider these factors as they address licensed oral and maxillofacial surgeon then per- the freedom of movement for dental hygienists, a forms procedures that are defined in the dental prac- greater uniformity in their scope of practice, and, tice act as the "practice of dentistry. The majority of state dental statutes and regulations do not define "den- The three nationally and professionally recog- tal assisting. The procedures allowed are always procedures that are To protect the health and safety of the public, licens- reversible and do not fall under the definition of the ing jurisdictions regulate certain tasks performed by practice of dentistry or dental hygiene. However, since nei- Dental Hygiene ther formal education nor certification is required many dental assistants are not formally educated, but are Most state dental statutes and regulations define trained while employed by a licensed dentist. The dental hygienist (except Dental Laboratory Technology in Alabama) must be a graduate of an accredited educational program. Although basic functions are population creates an increased demand for fabrica- universal, in some states expanded functions may be tion of fixed and removable prostheses to replace permitted if proof of additional education and train- teeth and related dental structures. Most states do not regulate dental laboratories or Expressing concern about patient welfare, liabili- dental technicians. Generally, laboratories work as ty, and examination variability, a number of inter- directed by prescriptions from licensed dentists. Unfortunately, no simulation techniques are available that duplicate live-patient experience to Every dental licensing jurisdiction in the United the satisfaction of most testing agencies. States accepts the National Board dental examina- tions on the basic biomedical sciences, administered Alternative Approaches to Licensure by the Joint Commission on National Dental Examinations. Some jurisdictions also require addi- In 1997 clinical testing agencies, licensing juris- tional written examinations for licensure, such as a dictions, and organizations within the licensure theory examination and a state jurisprudence exam- community developed The Agenda for Change, ination. Increasingly, states are accepting the which offers 12 objectives to facilitate improve- National Board written dental examination in lieu ments in the clinical licensure process. The remaining 12 jurisdictions continue to State-specific licensure requirements limit profes- examine individually. The Agenda for Change, if coordinated ernmental or private agency accredits dental licens- with a proposed study of scoring practices and post- ing examinations. Promote the interaction of all testing agencies and boards of examiners to explore the concept of more uniform content and methodology in licensure examinations. Develop and promote the acceptance of guidelines for administration of a common content clinical examination and standardized examiner calibration. Encourage testing agencies to work with dental school faculties to develop and participate in calibration activities. Minimize the use of human subjects in clinical licensure examinations, but where human subjects are used, ensure that the safety and protection of the patient is of paramount importance and that patients are procured in an ethical manner. Develop and promote policies and procedures to make clinical licensure examinations more candidate-friendly. Encourage the development of publications, orientation sessions and other methods to better communicate to candidates information regarding clinical examination logistics. Urge the American Association of Dental Schools to encourage all dental schools to offer remediation programs for candidates who fail the clinical licensure examinations. Promote further study of the pregraduation examinations by the clinical testing agencies and encourage the testing agencies and dental schools to work together to offer the pregraduation examinations to the extent possible. Promote the acceptance by all licensing jurisdictions of the National Board Dental Examination in lieu of a separate written examination on oral diagnosis and treatment planning. The objectives were endorsed by the American Dental Association, the American Association of Dental Examiners, the American Association of Dental Schools, and the American Student Dental Association. This allows the candidate to dictions also have created individual requirements utilize more fully the dental school resources during for licensure without examination, thereby reducing the examination and to enter practice more rapidly the uniformity among the requirements.

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A 29-year-old woman presents to your clinic com- tion and treatment of this patient? On physical examination purchase 50 mg zoloft mastercard, she is noted to have a and potassium levels small goiter that is painful to the touch purchase zoloft 100mg otc. Laboratory studies are sent purchase 50 mg zoloft with mastercard, and reveal a white blood cell count of 14,100 cells/µL with a normal differ- X-19. What is the most likely copious watery diarrhea that has not abated with the use diagnosis? What is the most appropriate treatment for the pa- ical examination is notable for blood pressure of 100/70, tient described above? All the following would be important Na 146 meq/L + initial steps in the clinical assessment of this patient except K 3. A patient visited a local emergency room 1 week ago stool osmolality is 170 mosmol/L. Diagnose her with subclinical pan-hypopituitarism, sion, she is found to have a calcium level of 19. A 16-year-old previously healthy teenage boy pre- sents to the local emergency room with a headache that A. Continue therapy with large-volume fluid adminis- has been worsening over the course of 2 months. Continue therapy with large-volume fluid adminis- over the past 2 weeks has been complaining of double vi- tration, but stop furosemide and treat with hydro- sion. Differentiating primary dysmenorrhea from other causes of the following is the most likely cause? Which of the following is the most common site for a treatment of the hypertensive crisis. Postmenopausal estrogen therapy has been shown to lowing physiologic alterations will cause an increase in re- increase a female’s risk of all the following clinical out- nin secretion except comes except A. All the following therapies have been shown to re- finding a pituitary microadenoma at autopsy in the gen- duce the risk of hip fractures in postmenopausal women eral population? A 33-year-old woman presents to the emergency room complaining of headache, palpitations, sweating, and anxi- X-29. These feelings began abruptly about 30 min ago, and she cytoma after presentation with confusion, marked hyper- reports intermittent symptoms similar to these that occur tension to 250/140 mmHg, tachycardia, headaches, and perhaps once per month. His fractionated plasma metanephrines show a with panic attacks and has been prescribed paroxetine 20 normetanephrine level of 560 pg/mL and a metaneph- mg daily. Her symptoms have not improved since initiation rine level of 198 pg/mL (normal values: normetaneph- of this drug, and she believes that her episodes of palpita- rine: 18–111 pg/mL; metanephrine: 12–60 pg/mL). Which of the following statements past year for which she has been prescribed ibuprofen, 600 is true regarding management of pheochromocytoma is mg as needed. Her blood pressure while lying cardia even after adequate alpha-blockade has been down is 170/100 mmHg with a heart rate of 90 beats/min. Immediate surgical removal of the mass is indicated, with a heart rate of 112 beats/min. Her respiratory rate is 22 because the patient presented with hypertensive cri- beats/min, and her temperature is 37. Salt and fluid intake should be restricted to prevent following is most likely to correctly diagnose this patient? No testing is necessary; the patient is suffering from seek medical attention at that time. The mineralocorticoid receptor in the renal tubule is though his appetite has increased lately. His wife adds that responsible for the sodium retention and potassium wast- he has recently taken some time off work due to fatigue; ing that is seen in mineralocorticoid excess states such as despite his time off he has not been able to relax and has aldosterone-secreting tumors. He is admitted to the hospital and screen- characteristic of the mineralocorticoid-glucocorticoid ing tests reveal an undetectable thyroid-stimulating hor- pathways explain this finding? Hyperthyroidism leads to a high-output state for the cently started on methimazole. The patient described above is started on atenolol some low-grade fevers, arthralgias, and general malaise. Which of the fol- Laboratories are notable for a mild transaminitis and a lowing additional therapies is indicated? A patient presents to his primary care physician com- plaining of fatigue and hair loss. A 60-year-old woman is referred to your office for since his last clinic visit 6 months ago but notes markedly evaluation of hypercalcemia of 12. On review of systems, he reports that found incidentally on a chemistry panel that was drawn he is not sleeping well and feels cold all the time. Despite still able to enjoy his hobbies and spending time with his fluid administration in the hospital, her serum calcium at family, and does not believe that he is depressed. Which of the statements re- constipation or bone pain and is now 8 weeks out from garding that diagnosis is correct? Absence of a goiter makes autoimmune hypothy- for Stage 1 hypertension and body mass index of 30 kg/ roidism unlikely. Viral thyroiditis does not induce subsequent au- mia due to the clinical and laboratory findings. Congo red staining of xanthoma biopsy able to extracellular molecules of all size and charge. The parents of a 14-year-old boy want your opinion about treatment of their child’s lipid disorder. A patient is asked to undergo a testing protocol to as- emigrated from South Africa to the United States recently. After 5 days of severe so- The child has had cutaneous xanthomas on the hands, el- dium restriction (10 mmol/day), blood is drawn for bows, heels, and buttocks since childhood. Which hormone abnormality may be detected rica, he underwent thoracotomy for a problem with his using this protocol? Mineralocorticoid excess lipid profile shows a total cholesterol of 734 mg/dL and a E. Genetic test for familial defective apoB100 doctor complaining of fatigue and irritability. Rule out congenital syphilis these symptoms have been worsening over a period of sev- C. Physical examination reveals a drome resting heart rate of 105 beats/min, blood pressure of 136/ 72 mmHg, bilateral proptosis and warm, moist skin. A 16-year-old male is brought to your clinic by his Screening tests are sent and reveal a thyroid-stimulating parents due to concern about his weight. Thyroid-stimulating antibody screen cause of the risk of birth defects associated with its use C. Unbound T3 ring is found, in vitro fertilization should be strongly considered to decrease the risk of ectopic X-47. The prolonged use of oral contraceptives for >10 you began an evaluation for secondary amenorrhea. A 22-year-old male seeks evaluation from his primary roid-stimulating hormone is 3. Serum prolactin care doctor for gynecomastia that has developed over the is elevated. Primary ovarian failure girlfriend is increasingly frustrated by his lack of sexual D. She is having menstrual cycles approximately tional classes to assist him with reading and mathematics. His facial, axil- derness about 2–3 weeks after the start of her menstrual cy- lary, and genital hair is sparse. When she was in college, she was treated for Neisseria The testes are small, measuring 2. What is gonorrhoeae that was diagnosed when she presented to the the most likely diagnosis in this patient? Androgen insensitivity syndrome (testicular femini- erwise has no medical history. All the following drugs may interfere with testicular for about 15 months, but were unsuccessful. At that time, function except he was smoking marijuana on a daily basis and attributed their lack of success to his drug use. A 65-year-old man with a central left upper lobe lung and likelihood of success in conception? Which of the following laboratory tests is most likely ative of ovulation to establish a diagnosis? A 62-year-old woman presents to your clinic com- X-51 will most likely show: plaining of fatigue and lethargy over a period of 6 months. Bronchoalveolar lung carcinoma started, but feels that they are worsening with time. Poorly differentiated adenocarcinoma On examination she is mildly bradycardic at 52 beats/min D. Squamous cell carcinoma There are areas of alopecia and mild lower extremity X-53. A 45-year-old Caucasian woman seeks advice from unit with 1 week of fever and cough.

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