Professor and Vice Chair, Department of Otolaryngology
Director of Head and Neck Surgery
University of Nebraska Medical Center
Professor, Department of Head and Neck Surgery
Nebraska Methodist Hospital
Omaha, Nebraska
Figure 3 shows the percentage of fee-for-service Medicare benefciaries aged 65 and older that received fu shots diet gastritis erosif generic 200mg pyridium amex, by state gastritis fever buy pyridium without a prescription, in 2004 chronic gastritis outcome generic pyridium 200 mg with visa. Figure 4 displays the percentage of Medi care benefciaries aged 65 and older that had ever received a pneumococcal vaccination as of 2006 gastric bypass diet discount 200mg pyridium free shipping, by state gastritis types buy 200mg pyridium visa. Total immunization rates may be higher in those areas with free or publicly-supported programs gastritis video cheap pyridium 200mg with amex. There is a racial disparity among people ages 65 and older receiving the pneu monia shot which needs to be addressed gastritis diet лунный cheap pyridium 200mg on-line. A number of laboratory tests are available to confrm the diagnosis of infu enza or pneumonia gastritis diet suggestions buy pyridium online, including sputum and blood cultures, chest x-rays and blood tests. Infuenza Health care providers usually will make the diagnosis of infuenza based on symptoms and fndings of a physical examination. These drugs either shorten the duration of the fu, if taken early at the onset of the fu, or prevent the fu. There are currently four infuenza antiviral drugs available in the United States: amantadine, rimantadine, zanamivir and oseltamivir. Oseltamivir or zanamivir should be prescribed if an antiviral drug is indicated for the treatment of infuenza. A recent study found that worldwide resistance to amantadine and rimantadine has increased 12 percent since the mid-1990s. Relenza has not been shown to shorten the length of infuenza for this population and increases their risk of bronchospasm (wheezing) or serious breathing problems. These newer drugs can be used to treat strains from both the Type A and B infuenza viruses. Over-the-counter medications can minimize discomfort associated with fu symptoms, but these medications do not treat the virus infection. Aspirin should not be used to treat fu symptoms in children under 18 years old be cause it may play a role in causing Reye Syndrome, a rare but severe liver and central nervous system condition. Congestion, cough and nasal discharge are best treated with a decongestant, an antihistamine or a combination of these two types of medication. Also, patients who have chronic medical conditions such as thyroid disease or high blood pressure should check with a health care provider before taking over-the-counter drugs for fu symptoms. Adequate liquids and nutrition are necessary for rapid recovery from the fu and to prevent dehydration. Frequent hand washing and mouth covering during coughing and sneezing helps to prevent transmission of the infuenza virus. A swab is dipped into a urine sample and then inserted into a test device, which detects Streptococcus pneumoniae antigen. Test results can enable health care providers to make a probable diagnosis more quickly and start treatment with the appropriate antibiotics sooner. Conventional methods for diagnosing pneumonia, primarily testing sputum or blood, require two days to several weeks for results, are often com plex and are not always reliable. There are no generally effective treatments for most types of viral pneumonia, which usually heal on their own. Early treatment with antibiotics can cure bacterial pneumonia and speed recovery from mycoplasma pneumonia. How ever, the disease has become more resistant to these drugs, making treatment of pneumococcal infections more diffcult. Bird fu vi ruses do not usually infect humans, but several cases of human infection with bird fu viruses have occurred since 1997, especially in Asia. The virus is mainly transmitted to humans by direct contact with live, sick or dead poultry; how ever, it is thought that a few cases of human-to-human spread have occurred. The majority of cases have been reported in children and adults under 40 years of age. Overall mortality is approximately 60 percent and is highest in those 10 to 19 years old. Human infection with bird fu is expected to continue on a sporadic basis due to contact with birds carrying the disease. High rates of illness and death could occur worldwide due to the lack of any pre-existing natural immunity in humans or the availability of an effective vaccine. Fortunately, there has been no indication of such a change in the existing strains of the virus. However, the H5N1 vaccine will not be available for commercial use because all amounts are going to the National Stockpile to ensure adequate supplies in the event of an outbreak. A recent study found that persons 65 years of age and older who received the fu shot had a 27 percent reduction in the risk of hospitalization for pneu monia or infuenza and a 48 percent reduction in the risk of death. This was despite the fact that those receiving fu shots also tended to have more serious medical conditions that should increase their risk of hospitalization or death. Based on other studies that show fewer infuenza outbreaks and deaths in the United States and Japan due to immunization programs, researchers recommend focusing on developing new and more effective vaccines for elderly populations and children as well as increasing the percentage of those receiving fu shots. Another key but disturbing fnding is the low rate of vaccination of health care providers. Because humans have little immunity to the new virus, a worldwide epidemic, or pandemic, can ensue. The best way to protect the elderly is to reduce infuenza in groups of people they have contact with, such as children and health care providers. While this strategy requires more research to validate its effectiveness, increasing fu vaccination of all groups will prevent unnecessary hospitalizations and deaths. American Lung Association volunteers and staff work with different public health organizations, Congress, and other policymakers to improve fund ing for research, surveillance, vaccine supply and public health response to infuenza. The Lung Association also works in coalition to educate the public and policymakers to provide funding, develop resources and plan for a future infuenza pandemic. A study conducted by the American Lung Association Asthma Clinical Re search Centers Network recently found that fu shots are safe for children and adults with asthma. The study puts to rest previous concerns about possible side effects of the fu shot in people with asthma. The study found that people with asthma did not have any higher rates of side effects within 14 days after receiving the fu shot compared with those who received a placebo, or inacti vated fu shot. To join the American Lung Association in the battle against infuenza, pneumonia and other lung diseas es, visit lungaction. Among the more familiar are: Acute bronchitis Acute bronchitis is an infammation of the bronchial tubes, the major airways into the lungs. It may be caused by a variety of bacteria and viruses and may be primary or secondary to an upper respiratory infection, pertussis (whooping cough) or other infection. Bronchiectasis typically occurs as a complication of primary infections such as bronchitis, pneumo nia, pertussis (whooping cough) or tuberculosis. While bronchiectasis usually begins in childhood, symptoms often do not appear until after a number of infections. With effective treatment of bronchitis and pneumonia, and vac cination against pertussis, bronchiectasis has become relatively rare in the United States. In infants, bronchioles are narrower and more easily blocked by mucus and infammation. This fungus is present in the soil of the Southwestern United States, California, and parts of Central and South America. Due to the high incidence rate within the state, it is the center of research on this poorly understood illness. In others, there is an infuenza-like syndrome with fever, weakness, achy joints, cough and chest pain. In a very small number of cases, the infection spreads to other areas of the body, such as the meninges (membranes around the brain and spinal cord), bones, skin, and other tissues. Women account for 36 percent of cases and the average age is 38 years (ranging from 10 to 83). It is contracted by inhaling airborne saliva or fecal matter from infected animals, which do not become ill themselves. There is no established therapy, but ribavirin, an antiviral drug used in other parts of the world against related viruses, has been used experimentally. Histoplasma capsulatum is common in most of the Central and Eastern United States. The fungus grows in soil, as well as bird and bat droppings, and is spread by breathing in the spores of disturbed soil. Finally, fbrosis (scarring) begins in the interstitium (tissue between the air sacs), causing the lungs to become stiff. Breathlessness during exercise can be one of the frst symptoms of an intersti tial lung disease. Certain types of interstitial lung disease improve if treated with medication when infammation occurs. Mortality rates for men older than 65 years and women of all ages are expected to be even higher in 2008 than in 2003. There is no effective treat ment for idiopathic pulmonary fbrosis and the median survival after diagno sis is low at three to fve years. Until a therapy changes the natural history of the disease, the cause will remain unknown. It is caused by the bacteria Bordetella pertussis and can be prevented with a vaccine. Recently, the trend has reversed with a peak of 25,000 cases in 2005 and more than 15,000 in 2006. From 2000 to 2004, 90 percent of the total 100 deaths related to pertussis occurred in infants less than four months old. Recommenda tions also call for older adolescents (13 to18 years old) to receive a single dose of Tdap if they have not yet received a Tdap vaccination. Adults under 65 years of age are encouraged to receive one Tdap vaccination instead of a Td (tetanus and diphtheria) booster. It is caused by a virus from the coronaviruses group and is characterized by a fever higher than 100. Several groups of researchers have identifed the genome of the virus and have shown that there are different types of the virus in different parts of the world. Lung cancer is the uncontrolled growth of abnormal cells in one or both of the lungs. While normal lung tissue cells reproduce and develop into healthy lung tissue, these abnormal cells reproduce faster and never grow into normal lung tissue. Lumps of cancer cells (tumors) then form and disturb the lung, making it diffcult for it to work properly. Sometimes a lung cancer may have characteristics of both types, which is known as mixed small cell/large cell carcinoma. Non-small cell lung cancer is much more common and accounts for 87 percent of all lung cancer cases. It usually spreads to different parts of the body more1 slowly than small cell lung cancer. They are named for the type of cells in which the cancer develops: squamous cell carcinoma, adenocarcinoma and large cell carcinoma. This type of lung cancer grows more quickly2 and is more likely to spread to other organs in the body. Lung cancer symptoms may include a persistent cough, sputum streaked with blood, chest pain, and recurring pneumonia or bronchitis. Unfortunately,3 symptoms often do not appear and diagnosis is not made until the disease is in an advanced stage. Nonsmokers who breathe in smoke from otherscigarettes also are at in creased risk of lung cancer. Nonsmokers have a 20 to 30 percent greater chance of developing lung cancer if they are exposed to secondhand smoke at home or at work. Radon is a tasteless, colorless and odorless gas that is pro duced by decaying uranium and occurs naturally in soil and rock. The major ity of these deaths occur among smokers since there is a greater risk for lung cancer when smokers also are exposed to radon. Ra don enters a home through cracks in walls, basement foors, foundations and other openings. The participants included over 1,000 women throughout Iowa, the state with the highest average radon concentrations, who lived in their current home for at least 20 years. Of the participants, 413 had developed lung cancer, while the remaining 614 were controls who did not have lung cancer. The outcomes suggested that cumulative radon exposure in the residential environment is a signifcant risk factor for lung cancer in women. The combination of asbestos exposure and smoking greatly increases the risk of developing lung cancer. Nonsmoking9 asbestos workers are fve times more likely to develop lung cancer than non smokers not exposed to asbestos; if they also smoke, the risk factor jumps to 50 or higher. Figure 1 displays the prevalence of lung cancer for men and women since 2000, and shows that women surpassed men in lung cancer prevalence in 2002. In 2004, women accounted for 183,248 lung cancer cases in the United States while men ac counted for 174,880 cases. The majority of living lung cancer patients have been diagnosed within the last fve years. Utah had the lowest age-adjusted cancer incidence rates in both men and women (37. The rate of new cases in 2004 showed that men develop lung cancer more often than women (73. However, as Figure 2 shows, the rate of new lung cancer cases (incidence) over the past 31 years has dropped for men (14% decrease), while it has risen for women (140% increase). The rate of new cases for women increased further and did not peak until 1998 (52. Lung cancer in people who have never smoked is a major public health prob lem and continued research is needed. Women, compared to men, appear to have higher prevalence rates of lung cancer that is not associated with smok ing; 25 percent of lung cancer occurs in women who are nonsmokers. The study also found little evidence that the lung cancer death rate among people who have never smoked is increasing over time. Please view the Lung Cancer Trend Report, which delineates data on lung cancer mortality, prevalence, incidence, hospitalizations, and survival, at. Person-years is used for counting time when individuals are observed over different periods of time. For example, the number of person years for two people being observed for fve years each is the same as that of ten people observed for one year or ten person-years. The age-adjusted lung cancer incidence rate among Black men is approximately 38 percent higher than for White men, even though their overall exposure to cigarette smoke, the primary risk factor for lung cancer, is lower. Equally disturbing is the fact that the lung cancer in cidence rate for Black women is roughly equal to that of White women, despite the fact that they smoke fewer cigarettes. Over this fve-year period, Hispanics, Asians/ Pacifc Islanders and Native Americans were less likely to develop lung cancer than Blacks or Whites. Hispanics are not mutually exclusive from Whites, Blacks, Asian/Pacific Islanders and American Indians/ Alaska Natives. Lung cancer is the leading cause of cancer deaths among both men and wom en in the United States. In 2007, about 160,390 Americans were expected to die of lung cancer, accounting for approximately 29 percent of all cancer deaths. Lung cancer death rates were higher than death rates due to cancer of other common cancer sites among both men and women. Black men have a far higher age-adjusted lung cancer death rate than White men, while Black and White women have similar rates. The lung can cer fve-year survival rate (15%) is lower than many other leading cancer sites, such as the colon (63. Staging is used to determine whether the cancer has spread and, if so, to what other parts of the body. Stages include localized (within lungs), regional (spread to lymph nodes) and distant (spread to other organs). The fve-year survival rate is 49 percent for cases detected when the disease is still localized. Unfortunately, only 16 percent of lung cancer cases are diagnosed at an early stage. According to the National Insti tutes of Health, cancers cost the United States an overall $206 billion in 2006. All cancer patients beneft from early intervention when the growth is local ized and has not spread to distant parts of the body. Since most symptoms do not appear until advanced stages, lung cancer is diffcult to diagnose in early stages. If the patient has a cough that produces sputum (mucus), it may be examined for cancerous cells. Other diagnostic tests include chest x-ray and fberoptic examination of the airways.
The draft that emerged from the consultation meeting was then circulated among the Writing Group and nalized with the help of the technical writer gastritis inflammation buy cheap pyridium on line. Discussion was opened up on the Google website and a conference call was held to resolve issues prepyloric gastritis definition purchase pyridium 200mg amex. Feedback from these groups was considered by the Writing Group gastritis diet аукро cheap pyridium online visa, who then made further revisions diet for gastritis and diverticulitis order genuine pyridium line. Funding the Standards of Care revision process was made possible through a generous grant from the Tawani Foundation and a gift from an anonymous donor gastritis keeps coming back order pyridium 200 mg overnight delivery. Case: 3:18-cv-00309-wmc Document #: 166-8 Filed: 04/24/19 Page 119 of 121 the Standards of Care! Evidence: this evidence-based guideline was developed using the Grading of Recommendations gastritis won't heal purchase pyridium us, Assessment gastritis symptoms depression buy pyridium online now, Development gastritis symptoms mayo purchase pyridium 200 mg, and Evaluation approach to describe the strength of recommendations and the quality of evidence. The task force commissioned two systematic reviews and used the best available evidence from other published systematic reviews and individual studies. Consensus Process: Group meetings, conference calls, and e-mail communications enabled consensus. Endocrine Society committees, members and cosponsoring organizations reviewed and commented on preliminary drafts of the guidelines. Conclusion: Gender affirmation is multidisciplinary treatment in which endocrinologists play an important role. Gender-dysphoric/gender-incongruent persons seek and/or are referred to endocrinologists to develop the physical characteristics of the affirmed gender. Hormone treatment is not recommended for prepubertal gender-dysphoric/gender-incongruent persons. We recommend treating gender-dysphoric/gender-incongruent adolescents who have entered puberty at Tanner Stage G2/B2 by suppression with gonadotropin-releasing hormone agonists. Clinicians may add gender-affirming hormones after a multidisciplinary team has confirmed the persistence of gender dysphoria/gender incongruence and sufficient mental capacity to give informed consent to this partially irreversible treatment. We recognize that there may be compelling reasons to initiate sex hormone treatment prior to age 16 years, although there is minimal published experience treating prior to 13. For the care of peripubertal youths and older adolescents, we recommend that an expert multidisciplinary team comprised of medical professionals and mental health professionals manage this treatment. The treating physician must confirm the criteria for treatment used by the referring mental health practitioner and collaborate with them in decisions about gender-affirming surgery in older adolescents. For adult gender-dysphoric/gender-incongruent persons, the treating clinicians (collectively) should have expertise in transgender-specific diagnostic criteria, mental health, primary care, hormone treatment, and surgery, as needed by the patient. We suggest maintaining physiologic levels of gender-appropriate hormones and monitoring for known risks and complications. When high doses of sex steroids are required to suppress endogenous sex steroids and/or in advanced age, clinicians may consider surgically removing natal gonads along with reducing sex steroid treatment. Clinicians should monitor both transgender males (female to male) and transgender females (male to female) for reproductive organ cancer risk when surgical removal is incomplete. Additionally, clinicians should persistently monitor adverse effects of sex steroids. For gender-affirming surgeries in adults, the treating physician must collaborate with and confirm the criteria for treatment used by the referring physician. Clinicians should avoid harming individuals (via hormone treatment) who have conditions other than gender dysphoria/gender incongruence and who may not benefit from the physical changes associated with this treatment. We recommend against puberty blocking and the criteria for the endocrine phase of gender gender-affirming hormone treatment in pre transition before beginning treatment. We recommend that clinicians evaluate and ad (1 EEss) dress medical conditions that can be exacerbated 1. We recommend that clinicians inform and by hormone depletion and treatment with sex counsel all individuals seeking gender-affirming hormones of the affirmed gender before begin medical treatment regarding options for fertility ning treatment. We suggest that clinicians measure hormone pression in adolescents and prior to treating with levels during treatment to ensure that endog hormonal therapy of the affirmed gender in both enous sex steroids are suppressed and admin adolescents and adults. In adolescents who request sex hormone treat 3 months during the first year of hormone ment (given this is a partly irreversible treatment), therapy for transgender males and females and we recommend initiating treatment using a then once or twice yearly. We suggest that clinicians evaluate transgender informed consent, which most adolescents have persons treated with hormones for cardiovas by age 16 years. We recognize that there may be compelling abetes screening, and/or other diagnostic tools. We suggest that transgender females treated parameters every 6 to 12 months during sex with estrogens follow individualized screening hormone treatment. We advise that clinicians approve genital gender children, adolescents, and adults seeking gender affirming surgery only after completion of at least confirming treatment of their options for fertility preser 1 year of consistent and compliant hormone vation. Prior to treatment, clinicians should evaluate the treatment, unless hormone therapy is not desired presence of medical conditions that may be worsened or medically contraindicated. A multidis Practice Statement) ciplinary team, preferably composed of medical and 5. We advise that the clinician responsible for en mental health professionals, should monitor treat docrine treatment and the primary care provider ments. Clinicians evaluating transgender adults for ensure appropriate medical clearance of trans endocrine treatment should confirm the diagnosis of gender individuals for genital gender-affirming persistent gender dysphoria/gender incongruence. We recommend that clinicians refer hormone hormone levels and metabolic parameters, as well as as treated transgender individuals for genital sur sessments of bone density and the impact upon prostate, gery when: (1) the individual has had a satisfactory gonads, and uterus. We also make recommendations for social role change, (2) the individual is satisfied transgender persons who plan genital gender-affirming about the hormonal effects, and (3) the individual surgery. The task force followed the approach recom mended by the Grading of Recommendations, Assessment, dividual. There is insufficient evidence to rec Development, and Evaluation group, an international group ommend a specific age requirement. The task force Changes Since the Previous Guideline used the best available research evidence to develop the rec ommendations. The task force also used consistent language Both the current guideline and the one published in 2009 and graphical descriptions of both the strength of a recom contain similar sections. Cross filled of Youth and Adults (5), Treatment of Adolescents (6), circles indicate the quality of the evidence, such that Esss Hormonal Therapy for Transgender Adults (4), Adverse denotes very low quality evidence; EEss, low quality; Outcomes Prevention and Long-term Care (7), and EEEs, moderate quality; and EEEE, high quality. The task Surgery for Sex Reassignment and Gender Confirmation force has confidence that persons who receive care according to the strong recommendations will derive, on average, more (6). The section on each recommendation is a description of the evidence and the Case: 3:18-cv-00309-wmc Document #: 166-9 Filed: 04/24/19 Page 6 of 36 doi: 10. In some instances, there are remarks in which the summarized the available evidence regarding the effect of task force offers technical suggestions for testing conditions, sex steroids on bone health in transgender individuals dosing, and monitoring. In transgender males, there was best available evidence applied to a typical person being treated. In transgender females, there emphasize the importance of shared decision making, general was a statistically significant increase in lumbar spine preventive care measures, and basic principles of the treatment of transgender persons. There was minimal information on fracture ered out of the scope of this guideline. The Endocrine Society maintains a rigorous conflict of interest review process for developing clinical practice guide Introduction lines. All task force members must declare any potential conflicts of interest by completing a conflict of interest form. The 20th century sures for this guideline and resolved or managed all identified marked the emergence of a social awakening for men and conflicts of interest. Magnus Hirschfeld and Harry Benja amount from commercial interests; grants; research support; consulting fees; salary; ownership interests [e. Magnus Hirschfeld (6) and others (4, 7) have described other types of trans phenomena besides transsexualism. These early Commissioned Systematic Review researchers proposed that the gender identity of these the task force commissioned two systematic reviews to people was located somewhere along a unidimensional support this guideline. Yet such a transgender individuals on lipids and cardiovascular classification does not take into account that people may outcomes. The review identified 29 eligible studies at have gender identities outside this continuum. In transgender males (female to stance, some experience themselves as having both a male male), sex steroid therapy was associated with a statis and female gender identity, whereas others completely tically significant increase in serum triglycerides and renounce any gender classification (8, 9). High-density reports of individuals experiencing a continuous and lipoprotein cholesterol levels decreased significantly rapid involuntary alternation between a male and female across all follow-up time periods. In transgender females identity (10) or men who do not experience themselves as (male to female), serum triglycerides were significantly men but do not want to live as women (11, 12). Specific treatment protocols, however, have not yet more frequent in transgender females. Case: 3:18-cv-00309-wmc Document #: 166-9 Filed: 04/24/19 Page 7 of 36 3874 Hembree et al Guidelines on Gender Dysphoric/Gender Incongruent Persons J Clin Endocrinol Metab, November 2017, 102(11):3869 3903 Instead of the term transsexualism, the current studies across countries that use the same diagnostic and classification system of the American Psychiatric As inclusion criteria, medications, assay methods, and re sociation uses the term gender dysphoria in its di sponse assessment tools. However, more effective endocrinology-based gradually during infant life and childhood. This pro treatments became possible with the availability of cess of cognitive and affective learning evolves with testosterone in 1935 and diethylstilbestrol in 1938. Normative psychological literature, surgery appeared in the press during the second half of however, does not address if and when gender identity the 20th century. The Harry Benjamin International becomes crystallized and what factors contribute to Gender Dysphoria Association was founded in Sep the development of a gender identity that is not con tember 1979 and is now called the World Professional gruent with the gender of rearing. Prior to 1975, few peer-reviewed articles were pub With respect to endocrine considerations, studies lished concerning endocrine treatment of transgender have failed to find differences in circulating levels of sex persons. Since then, more than two thousand articles steroids between transgender and nontransgender in about various aspects of transgender care have appeared. Definitions of Terms Used in this Guideline Biological sex, biological male or female: these terms refer to physical aspects of maleness and femaleness. Typically, transgender people seek to make their gender expression align with their gender identity, rather than their designated gender. For transgender people, their gender identity does not match their sex designated at birth. For some people, their gender identity does not fit neatly into one of those two choices. Not all individuals with gender incongruence have gender dysphoria or seek treatment. Gender-reassignment surgery (gender-confirming/gender-affirming surgery): these terms refer only to the surgical part of gender confirming/gender-affirming treatment. Gender role: this refers to behaviors, attitudes, and personality traits that a society (in a given culture and historical period) designates as masculine or feminine and/or that society associates with or considers typical of the social role of men or women. Sex designated at birth: this refers to sex assigned at birth, usually based on genital anatomy. Sex: this refers to attributes that characterize biological maleness or femaleness. The best known attributes include the sex-determining genes, the sex chromosomes, the H-Y antigen, the gonads, sex hormones, internal and external genitalia, and secondary sex characteristics. Irrespective of their gender identity, transgender people may be attracted to women (gynephilic), attracted to men (androphilic), bisexual, asexual, or queer. Transgender: this is an umbrella term for people whose gender identity and/or gender expression differs from what is typically associated with their sex designated at birth. Transgender male (also: trans man, female-to-male, transgender male): this refers to individuals assigned female at birth but who identify and live as men. Transgender woman (also: trans woman, male-to female, transgender female): this refers to individuals assigned male at birth but who identify and live as women. Transition: this refers to the process during which transgender persons change their physical, social, and/or legal characteristics consistent with the affirmed gender identity. Transsexual: this is an older term that originated in the medical and psychological communities to refer to individuals who have permanently transitioned through medical interventions or desired to do so. In particular, a study by Heylens In summary, although there is much that is still et al. Case: 3:18-cv-00309-wmc Document #: 166-9 Filed: 04/24/19 Page 9 of 36 3876 Hembree et al Guidelines on Gender Dysphoric/Gender Incongruent Persons J Clin Endocrinol Metab, November 2017, 102(11):3869 3903 Natural History of Children With this improves their quality of life. Transgender individuals should be encouraged to During assessment, the clinician obtains information from experience living in the new gender role and assess whether the individual seeking gender-affirming treatment. A strong desire for the primary and/or secondary sex characteristics of the other gender 4. The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning. Follow-up studies in adults surgical and nonhormonal), and if medical treat meeting these criteria indicate a high satisfaction rate ment is desired, provides correct information to with treatment (59). However, the quality of evidence is prevent unrealistically high expectations; usually low. In cases in which severe psychopathology, circumstances, or both seriously interfere with the diagnostic work or make Recommendations for Those Involved satisfactory treatment unlikely, clinicians should assist the in the Gender-Affirming Hormone adolescent in managing these other issues. It assists both the individual and the graded Good Practice Statement) clinician in their judgments about how to proceed (16). The desire to live and be accepted as a member of the opposite sex, usually accompanied by the wish to make his or her body as congruent as possible with the preferred sex through surgery and hormone treatments. Case: 3:18-cv-00309-wmc Document #: 166-9 Filed: 04/24/19 Page 11 of 36 3878 Hembree et al Guidelines on Gender Dysphoric/Gender Incongruent Persons J Clin Endocrinol Metab, November 2017, 102(11):3869 3903 Table 4. The age of majority in a given country (if younger, follow the criteria for adolescents) 4. Mental health concerns, if present, must be reasonably well controlled Reproduced from World Professional Association for Transgender Health (16). Examples of conditions with similar features are social conditions that can impact gender-affirming body dysmorphic disorder, body identity integrity dis hormone therapy, (7) a practice of regularly at order (a condition in which individuals have a sense that tending relevant professional meetings, and (8) their anatomical configuration as an able-bodied person knowledge of the criteria for puberty blocking is somehow wrong or inappropriate) (66), or certain and gender-affirming hormone treatment in ad forms of eunuchism (in which a person is preoccupied olescents. We recommend that clinicians inform and tential benefit these persons believe they may derive from counsel all individuals seeking gender-affirming hormone treatment. This justifies the good practice medical treatment regarding options for fertility statement. If children have temporarily impair spermatogenesis and oocyte matu completely socially transitioned, they may have great ration. Given that an increasing number of transgender difficulty in returning to the original gender role upon youth want to preserve fertility potential, delaying or entering puberty (40). In individual cases, an early complete that sperm production can be initiated following pro social transition may result in a more favorable out longed gonadotropin suppression.
The education patients receive in these groups may help them to avoid preventable hospitalizations and emergency room visits gastritis diet dr oz safe pyridium 200 mg. Join the American Lung Association in its advocacy work by visiting lungaction gastritis diet soy milk buy 200 mg pyridium otc. In addition to its advocacy efforts atrophic gastritis symptoms nhs cheap pyridium line, the Lung Association offers smoking cessa tion programs such as Freedom From Smoking and Not On Tobacco gastritis diet lentils discount pyridium 200 mg, as well as self-help programs to assist smokers who want to quit gastritis diet juice buy pyridium 200 mg online. In the lungs gastritis diet of augsburg discount 200mg pyridium with mastercard, this mucus blocks the airways gastritis ibuprofen buy 200mg pyridium otc, causing lung damage and making it hard to breathe gastritis diet чндекс buy discount pyridium 200mg line. In the pancreas, it clogs the pathways leading to the digestive system, interfering with proper digestion. Cystic fbrosis is the second most common inherited disorder occurring in childhood in the United States, behind sickle cell anemia. More than 10 million Americans are unknowing, symp tomless carriers of the defective cystic fbrosis gene. Each time two carriers of the defective gene conceive, there is a 25 per cent chance that their child will have cystic fbrosis; a 50 percent chance that the child will be a carrier of the gene; and a 25 percent chance that the child will not have the gene at all. The severity and symptoms of the disease vary considerably due to different muta tions of the gene. Diagnosis is sometimes delayed for decades because of the3 mildness of the symptoms or failure to recognize them. Only about 10 percent to 15 percent of babies with cystic fbrosis have symptoms at birth. It is estimated that 1 in 2,500 White births are affected in comparison to 1 in 13,500 Hispanics, 1 in 15,100 African Americans, and 1 in 31,000 to more than 100,000 Asians. Note: * Comparisons should only be made between groups and diseases using rates, not number of cases, as these do not take into account differences which may exist in population size or demographics. Please view the State of Lung Disease in Diverse Communities: 2007 report at. In 2004, 460 Americans died of cystic fbrosis, an age-adjusted mortality rate of 1. In 2001, the American College of Obstetricians and Gynecologists recommended that pregnant women be offered screening for genetic mutations. It only has a detection rate of 70 percent to 75 percent for potentially defective genes. The Phase I (safety) trial involved 12 patients, all of whom completed the trial with out any major problems. The treatment was well tolerated, according to re searchers at Case Western Reserve University, University Hospitals of Cleveland and Copernicus Therapeutics. The prescription drug does not replace standard therapies but is used in addition to them. Bronchodilators have helped to deal with chronic lung dysfunction, and state of-the-art diagnostic techniques, such as nuclear imaging, have permitted more accurate assessment of patient status. Corticosteroids and other anti infammatory drugs have been evaluated in several studies. In some cases, lung transplantation has been attempted and over the past 10 years double-lung transplantation has replaced heart-lung as the preferred pro cedure. There has been steady improvement in the outlook with refnements in both surgical techniques and anti-rejection measures. As in other areas of medi cine, there is a lack of donors and there are long waiting lists. However, by focusing on the research outcome measures of clinical effcacy and biomarkers, scientists already have identifed several encouraging drug candidates. Future research using these methods will provide defnitive effcacy and safety data needed to make drugs available to patients and clinics. The American Lung Association is currently funding several studies on cystic fbrosis. It is passed from one person to another through blood, bodily fuids and sexual contact. T cells belong to the immune system and protect the body from germs and other disease-causing agents. As these important cells die, the body becomes more and more vulnerable to other diseases. Most cases are found in Africa, but the disease is spreading most rapidly in Eastern Europe and Asia. However, the number of cases in Blacks decreased the most compared to all other races since 2001 until recently when a rise was noted. These disparities show the need for an increase in preven tion programs and development of new and culturally appropriate interven tions. As improved treatment has reduced the risk of premature death from these diseases, other chronic complications such as pulmonary hypertension also have emerged. This disease is caused by the Pneumocystis jiroveci germ, formerly known as Pneumocystis carinii. In the lungs, it may set up infections in previously injured areas, such as bronchiectasis. A number of antifungal drugs are used to treat these infections and others are under investigation. Major causes of viral pneumonia in persons with weak immune systems are members of the herpes virus family, which are stubbornly resistant to treatment. Bacterial pneumonia can be caused by various bacteria strains such as Haemophilus infuenzae, but can be treated with antibiotics. Over time, the in creased blood pressure requires the heart to work harder, causing it to weaken and pump less blood than the body needs, resulting in heart failure. A health care provider will decide which drug regimen is right for each individual patient. While reasons for this outcome currently are unknown, researchers continue gathering information from the trials even though no new volunteers are being accepted. When regular medical staff offered testing, patients were less likely to accept (52. But since many more people were offered testing using this method, the actual number of those tested was higher. Join the Lung Association to win the battle against lung disease by visit ing lungaction. Infuenza (fu) is a highly contagious viral infection that is one of the most severe illnesses of the winter season. The reason infuenza is more prevalent in the winter is not known; however, data suggest the virus survives and is transmitted better in cold temperatures. Infuenza is spread easily from person to person, usually when an infected person coughs or sneezes. A person can have fu more than once because the virus that causes the disease may belong to different strains of one of three different infuenza virus fami lies, A, B or C. Type A viruses tend to have a greater effect on adults, while Type B viruses are a greater problem in children. The air sacs fll with pus and other liquid, block ing oxygen from reaching the bloodstream. Pneumonia can have over 30 different causes which include various chemicals, bacteria, viruses, mycoplasmas and other infectious agents such as pneumo-I cystis (fungi). The most common cause of community-acquired (compared to hospital acquired) pneumonia is the pneumococcus bacterium; infection by this bacte rium is known as pneumococcal disease. The pneumococcal bacterium also2 causes meningitis, bacteremia, otitis media and sinusitis. I Mycoplasma is an infectious organism which has characteristics of both bacteria and viruses. People most at risk from these infections and their complications are those whose defenses against disease are not operating well. In4 the United States, infuenza generally strikes between December and March, although it may appear a little earlier. Along with other respiratory conditions, such as the common cold and acute bronchitis, these disorders are major causes of days lost from work and school. In 2005, these conditions ranked as the eighth leading cause of death in the United States and the sixth leading cause in people over 65 years of age. Close to 90 percent of infuenza and pneumonia deaths occurred in per sons aged 65 and over. According to preliminary data, there were 62,804 deaths6 due to infuenza and pneumonia in 2005, an age-adjusted rate of 20. Infuenza and its complications are responsi-8 ble for an average of 226,000 hospitalizations and 36,000 deaths in the United States each year. The number of infuenza deaths includes associated under-9 lying respiratory and circulatory deaths in order to provide a more specifc estimate of the total burden of infuenza. Data from 2005 show that persons aged 65 and older ac counted for 60 percent of the total number of pneumonia hospital discharges (the diagnosis made upon leaving a hospital stay). All-cause pneumonia hospital admission rates for children under two years in age in 2004 were 39 68 This decrease was due to the release and broad administration of a new pneumonia vaccine in 2000. This age group also was responsible for 95 clinic and 27 emergency department visits per 1,000 children during the 2003-2004 fu season. Despite the usefulness of rapid infuenza tests, only 28 percent of hospitalizations and 17 percent of outpatient visits had a discharge diagnosis of infuenza among children with laboratory-confrmed infuenza. Improving these rates will offer the opportunity for improved infection con trol, increased use of antiviral therapy, and education about vaccination. Over a quarter (26%) of all hospitalizations in 2005 for this age group was due to respi ratory diseases; almost a third (31%) of those were due to pneumonia. Please view the Trend Report on Pneumonia and Infuenza, which includes information and statistics on morbidity and mortality attributed to pneumonia and infuenza available from national surveys and vaccine recommendations to prevent pneumonia and infuenza, at. This fgure includes more than $6 billion due to indirect costs (such as time lost from work) and $34. Infuenza Infuenza viruses change constantly and different strains circulate around the world every year. The fu vaccine is modifed on the assumption of which strain will most likely be dominant throughout the season. However, this prediction may not be 100 percent accu rate, as has been the case with the 2007-2008 fu season. This change will take effect as soon as feasible, but no later than the 2009-2010 infuenza season. FluMist is approved to prevent infuenza illness due to infuenza A and B virus es in healthy people aged 2 to 49 years only. In healthy adults aged 18 to 49 years, FluMist was effective in reducing severe illnesses with fever, and upper respiratory problems which may be caused by infuenza infection. FluMist is not recommended for children under two years of age, children under fve with recurrent wheezing or adults over 49 years of age. Initial results from the 2006-2007 infuenza season indicate that children 6 to 59 months of age are under-vaccinated. Less than 30 percent of children 6 to 23 months of age were fully vaccinated during that past fu season, while less than 20 percent of children 24 to 59 months old were fully vaccinated. In 2006, among people ages 65 and older, non-Hispanic Whites were more likely to report receiving a fu shot (66. The National Lung Screening Trial has enrolled around 50,000 current or former smokers and monitored them at more than 30 sites throughout the United States. Research has indicated that 25 to 60 percent of scans may show abnormalities in both smokers and former smokers. That can cause the patient added anxiety and unnecessary biopsies or surgery and their related risks. While complications from biopsies and surgery rarely occur, they can include partial collapse of the lung, bleeding, infection, pain and discomfort. It is hoped that the trial will determine whether the benefts of potential, earlier lung cancer detection outweigh these limitations and if widespread use is cost-effective. Scientists currently are exploring the link between lung disease and lung can cer in nonsmokers. A study was conducted between 1998 and 2002 to deter mine the association between lung cancer and occupation, independent of smoking. The fndings suggest that women in suspected high-risk occupa tions have an increased risk of lung cancer. Research on this topic has been extensive since that time, along with work on other nutritional fac tors. However, a review of the best studies from the feld found that no protec tive effect was offered by beta-carotene, vitamin E, retinol or any combination of the three. Some trials even reported increased rates of lung cancer, total deaths and cardiovascular deaths due to the use of beta-carotene, alone or with vitamin E or retinol. Patients were more likely to respond to erlotinib if their tumors contained a cer tain protein or had many copies of a particular gene. The study also confrmed that patients most likely to beneft from the drug included women, nonsmok ers, Asians and those with an adenocarcinoma (cancer associated with glands). While most of its education and advocacy efforts focus on prevention, there are several ways the American Lung Association addresses the needs of those living with lung cancer. The American Lung Association Lung HelpLine, staffed by registered nurses, respiratory therapists and quit-smoking specialists offers free counseling and support to callers, including those seeking information about lung cancer. In addition, the American Lung Association has helped millions through its Better Breathers Clubs. These support groups are located through out the United States and meet regularly to provide peer support and educa tion needed to understand and better manage their disease. Groups may invite medical professionals to share their expertise on topics including nutrition, exercise, breathing techniques, new treatments, stress and depression, and medical equipment. The education patients receive in these groups may help them to avoid preventable hospital izations and emergency room visits. Many hospitals may offer similar support groups for people with chronic lung disease. The American Lung Association also provides information on treatment op tions through the NexCura profler on lung cancer. The lung cancer NexPro fler helps asthma patients and their physicians make better-informed treat ment decisions using information from evidence-based, peer-reviewd medical literature. As part of this partnership, the Lung Cancer Discovery Award was creat ed in 2004 to provide funding for investigators and to support clinical, labora tory, epidemiological and other lung cancer research. American Lung Association volunteers and staff also advocate for policies at the federal, state and local levels that can reduce lung cancer by decreasing the number of Americans who smoke and protecting everyone from exposure to secondhand smoke. Such policies include comprehensive state and local smokefree laws; granting the U. Food and Drug Administration regula tory control over the manufacturing, distribution and advertising of tobacco products; increasing funding for comprehensive tobacco control and cessation programs at the state level; and increasing cigarette excise taxes. To join the American Lung Association in the battle to reduce the number of lung cancer deaths, please go to . The American Lung Association also advocates for clean air through enforce ment of the Clean Air Act, tighter air pollution standards and reduced radon exposure, a leading cause of lung cancer. In addition to its advocacy efforts, the American Lung Association offers pro grams to help smokers who want to quit, including Freedom From Smoking and Not On Tobacco (N-O-T), a program to help teenagers quit smoking. This blocking of the airways can cause a person to stop breathing or have problems with breathing for 10 to 20 seconds or longer many times a night. Other risk factors include collar size of snoring patients (greater than 17 inches for men, 15 inches for women), physical nasal obstruction, underactive thyroid and excessive fat around the neck area. It5 occurs in all age groups and both sexes, but it is more common in men than women, evidently due to hormonal differences (sleep apnea is rarely seen in pre-menopausal women). Sleep apnea causes daytime sleepiness in an estimated6 1 out of 25 (4 percent) middle aged men and 1 out of 50 (2 percent) middle aged women. According to a study that looked at risk factors for sleep-disordered breathing, African-American children, espe cially those living in a neighborhood of poor socioeconomic status, were more likely than children of other races to develop obstructive sleep apnea. One8 study found shared and unshared genetic factors that may impact the risk of both obesity and sleep apnea in African Americans. Sleep apnea also may cause impaired mental functioning, delayed reaction times and diffculty maintaining concentration. New research suggests an independent and additional link between sleep ap nea and metabolic disorders, including insulin resistance and high blood cho lesterol. Sleep apnea may act as the frst piece in a domino chain of undesired health outcomes (including hardening of the arteries, plaque buildup in the arteries, heart attack and stroke), while acting through both the metabolic and cardiovascular systems independent of underlying obesity. In the presence of other cardiovascular risk factors such as hypertension or high cholesterol, the impact of sleep apnea may be greater.
Syndromes
Avoiding jumping or running, which can cause more urine to leak
Skin redness
Older age
Pericarditis or myocarditis
Laxative
Internal areas will be dark to black if there is a lesion and bleeding has occurred (because blood does not transilluminate).
Dizziness
Yellow eyes
Light-headedness, dizziness
Chronic skin changes such as lichen sclerosis or squamous hyperplasia in women over age 50
The obturator or Cope sign is a classic medical lab tests would you perform in order to confirm or (A) Community-acquired pneumonia sign for which of the following disorders Which of the following medications is appropriate (E) Pancreatitis (E) Troponin from this electrocardiogram Which of the following glomerular filtration rate Sigmoidoscopy reveals colonic dilatation gastritis diet 14 order pyridium without a prescription, con 66 gastritis diet фрив purchase cheap pyridium line. A 26-year-old female presents with abdominal values are indicative of impaired renal function A newborn male infant presents with extreme is the most appropriate course of treatment Auscultation of (C) Electrical defibrillation dizziness when going from a sitting to a standing 67 gastritis symptoms upper back pain discount pyridium 200mg online. Blood pressure in the standing (A) Celiac disease examination gastritis diet замунда order pyridium 200mg mastercard, which of the following is the proper position is 110/70 mmHg gastritis sore throat pyridium 200mg mastercard. Which of the following gastrointestinal disorders (B) Micturition syncope (C) Chronic pancreatitis (E) Ventricular outflow tract obstruction can effectively be treated with Ursadiol A 47-year-old active white female reports that she (E) Gastric ulcer (B) Duodenal ulcer (E) Vasovagal reaction has been experiencing lower leg pain with exercise gastritis symptoms images order cheap pyridium on-line. An ultrasound examination revealing bilateral (C) Gallstones Pain is relieved with rest gastritis for dogs cheap pyridium 200 mg online. Auscultation of the legs fluid-filled renal cysts is a classic diagnosis for (D) Pancreatitis reveals a weak femoral pulse with an aortic bruit gastritis wiki discount pyridium online american express. Which of the following medications would you prescribe to effectively treat infections of the diagnosis of which of the following disorders Which of the following laboratory values are weight loss, muscle aches, and peripheral neu (E) Hypothyroidism 88. Macrocytic anemias are characterized by a mean indicative of a seminomatous germ cell testicular ropathy. A 44-year-old female presents with facial pain (D) Normal levels of a-fetoprotein and a-human (C) Polyarteritis nodosa (E) Ulcerative colitis while eating. She also states she feels a click or pop chorionic gonadotropin (D) Scleroderma in her jaw while she eats. Which of the following clinical interventions is presentation, which of the following is the most required for a kidney stone measuring 5-10 mm He reports previa presents three days post-caesarian section (A) Extension injury (B) Elective ureteroscopy that the pain is relieved by lying down. Which of Physical exam reveals peritoneal irritation, ovarian (C) Rheumatoid spondylitis (D) Percutaneous nephrostomy the following courses of treatment would you tenderness, and decreased bowel sounds. White (D) Temperomandibular joint disorder (E) Ureteral stent suggest for treatment of this disorder A 41-year-old pregnant female, with 6 previous (B) Intravenous anticoagulants following is the most appropriate diagnosis Mesalamine is an anti-inflammatory agent that is sentation, and test results, which of the following (E) Leiomyomata (A) Avascular necrosis also an effective maintenance therapy for which is the most likely diagnosis Which of the following types of medication (E) Placenta previa (E) Ulcerative colitis (C) Increased fluid intake is required for maintenance therapy for ulcer 91. Which of the following clinical interventions is (D) Percutaneous nephrostomy ative colitis if the disease does not respond to 76. Which of the following medications is effective required for kidney stones measuring over 10 mm (E) Ureteral stent aminosalicylates Which of the following medications is used in (A) Elective lithotripsy (B) Corticosteroids (B) Desmopressin acetate combination with doxycycline to treat epididymitis (B) Elective ureteroscopy (C) Immunodilators (C) Doxycycline that occurs as a result of a sexually transmitted (C) Increased fluid intake (D) Mesalamine (D) Fluoroquinolone disease such as gonorrhea and chlamydia Which of the following is of which following families of medications for presents with stiffness in the jaw and neck, dif (B) Catheterization the proper diagnosis based on this information Physical exami (C) Imipramine (A) Blepharitis (A) 5-alpha-reductase inhibitors nation reveals muscle spasms of the jaw and face. A 26-year-old female presents with complaints (D) Fluoroquinolones appropriate diagnosis Echocardiogram reveals (E) Tetanus (B) Presbycusis examination, which of the following is the most inflammation of the sac around the heart. Which of the following clinical interventions is following treatment options would you suggest (D) Syphilis (D) Pericarditis required for a patient with hypernatremia with a for this patient Which of the following classes of hypertensive (B) Administration of electrolytes (B) Increase intake of water maintenance therapy for overactive bladder Body dysmorphic disorder is an example of a (D) Doxycycline (B) Alpha-adrenergic antagonists 95. Adopting a high-fiber diet is proper maintenance somatoform psychological disorder. Fluoxetine and (E) Oxybutynin (C) Beta-adrenergic antagonists therapy for which of the following gastrointestinal clomipramine have been proven effective in the (D) Calcium channel blockers disorders Glyburide is a medication that acts to increase treatment of body dysmorphic disorder. Which of the following is the proper course of (A) Antipsychotic medications (C) Diverticulitis the following disorders is glyburide the indicated treatment for individuals with recurrent bladder (B) Monoamine oxidase inhibitor medications (D) Irritable bowel syndrome treatment The condition of hypermagnesemia is most effec (E) Tricyclic antidepressant medications (C) Chronic pancreatitis (C) Intravesical instillation of thiotepa tively treated by intravenous administration of 101. Cerebrospinal fluid evaluations that reveal (D) Diabetes insipidus (D) Radiation therapy which of the following medications A 75-year-old female presents with dribbling after (E) Subarachnoid hemorrhage (D) Miglitol (A) Arteriogram urination for a prolonged period of time. A 50-year-old female presents with sudden, diagnose this patient with overflow incontinence. A 29-year-old female presents with hearing rated lesion deep from the palpebral margin. Miglitol is a member of the class of anti-diabetic (C) Dacrycystostenosis following is the most accurate diagnosis A 52-year-old female who has previously (A) Decreasing production of hepatic glucose (D) Silicosis undergone thyroidectomy presents with irritability (B) Delaying absorption of carbohydrates from 128. A 23-year-old female presents with cough, excess (E) Tuberculosis and distal extremity tingling. Physical examination reveals clubbing and apical what is the most appropriate initial diagnosis By which of the following mechanisms does (C) Pneumonia often used for initial therapy of essential hyper (E) Temporal lobe exenatide function to decrease blood glucose A 75-year-old female presents with her eyelids per (E) Tuberculosis reduces peripheral resistance A 28-year-old male presents with pain in the left is the proper diagnosis based on this information Physical examination reveals a rust ring on (A) Chalazion (C) Beta-adrenergic antagonists (D) Promoting the breakdown of carbohydrates the cornea, indicating the presence of a metallic (B) Ectropion (D) Calcium channel blockers (E) Stimulating insulin secretion foreign body. Which of the following course of (C) Entropion (E) Diuretics treatment would you suggest for this condition A polysomnogram assesses bodily functions under (A) Application of ophthalmic antibiotics 116. The administration of a combination of beta (E) Pterygium which of the following conditions A 58-year-old male with a history of cystic fibrosis (C) Removal with moistened cotton-tip swab and symptom-specific medications constitutes the (B) Ingestion of food presents with foul-smelling, purulent sputum, (D) Removal with rotating burr treatment for which of the following endocrine (C) Rest hemoptysis, and chronic cough. Chest X-ray reveals crowded bronchial markings and basal cystic spaces, tram-track lung markings, honeycombing, and atelectasis. Oral administration of 1 mg of folic acid per day times per day is appropriate maintenance therapy (E) Tuberculosis cerous whitish-gray, thick, hard, and slightly raised is proper maintenance therapy for which of the for which of the following forms of anemia A 54-year-old male presents with intermittent (A) Folate-deficiency anemia (A) Aphthous ulcers (A) Folate-deficiency anemia heart palpitations, fatigue, and dizziness. A 40-year-old male presents with proximal traindicated for individuals with which of the shortness of breath. A 27-year-old pregnant female presents with block (E) Tuberculosis (B) Contact dermatitis abnormal vaginal bleeding, uterine size greater (D) Sinus arrhythmia (C) Seborrheic dermatitis 141. A 59-year-old man presents with intermittent dizzy than normal, nausea, vomiting, and hypertension. Desmopressin acetate is the indicated medication (E) Otitis media (B) Hyperglycemia Which of the following abnormalities is perceived for treatment of which of the following disorders A 62-year-old male presents with progressive (D) Hypotension (A) Brugada syndrome (B) Chronic pancreatitis dyspnea. Physical (C) Left bundle branch block (D) Diabetes mellitus examination reveals inspiratory crackles. Which of the following is the clinical intervention results, which of the following is the most accurate (C) Pigment changes for presbycusis Electrocardiogram was (E) Spontaneous abortion cardiogram is performed and is shown below. A 6-year-old female presents with sudden high (A) Brugada syndrome Which of the following describes this cardiac Which of the following abnormalities is perceived fever, difficulty swallowing, sore throat, and (B) Left axis deviation arrhythmia A lateral X-ray of the neck was obtained (C) Left bundle branch block (A) Atrial fibrillation (A) Complete heart block and a thumb sign was noted. A 44-year-old male presents with bluish discol (E) Tracheal obstruction victims is required if the internal or common (B) Anticholinergics oration under the eyes, clear and watery nasal carotid artery proves to have 70%-99% stenosis A 58-year-old female presents with nasal stuffiness (C) Beta-adrenergic antagonists discharge, and itchy eyes. She states this occurs when she is (D) Calcium channel blockers when he is exposed to pollen or mold. Based on the (B) Anticoagulant therapy exposed to changes in temperature and humidity. A 27-year-old male presents with an abnormal (D) Endarterectomy lowing is the most appropriate diagnosis The patient (E) Thrombolytic therapy (A) Allergic rhinitis (A) Allergic rhinitis also tends to act hostile, angry, and blame problems (B) Chronic atrophic rhinitis (B) Chronic atrophic rhinitis 152. The which of the following is the most appropriate (D) Sinusitis (D) Sinusitis patient also has a fever. A 50-year-old African-American woman presents which of the following is the most appropriate history of aspiration of stomach contents presents (C) Narcissistic personality disorder with chest discomfort, cough, and shortness of diagnosis Lab work reveals eosinophilia, elevated (A) Calcium pyrophosphate dehydrate disease examination reveals tachypnea, frothy red sputum, (E) Paranoid disorder erythrocyte sedimentation rate, and hypercalcemia. Chest urination associated with a profuse, creamy, bloody, (D) Rheumatoid arthritis which of the following is the most accurate X-ray shows symmetric bilateral hilar adenopathy. Gynecological (A) Chlamydia (C) Septic shock (A) Asbestosis exam reveals an open cervix. A healthy 55-year-old male presents for his annual (E) Trichomoniasis (E) Tuberculosis (B) Gestational trophoblastic disease office visit. Which of the following abnormalities is perceived (A) Adjustment disorder (A) Fibrous dysplasia on this electrocardiogram A 44-year-old female presents with a painful (B) Osteomalacia (A) Atrial bigeminy (C) Narcissistic personality disorder macular, fiery red rash with well-defined borders (C) Osteoporosis (B) Atrial fibrillation (D) Obsessive-compulsive disorder on her face. A 14-year-old female presents with low-grade fever, (E) Ventricular bigeminy diagnosis When treating a patient who exhibits signs of shock, malaise, headache, and muscle aches. Which of the following interventions is the most exam reveals erythematous macules that appear (B) Chlamydia glucose, urinalysis, and serum creatinine will assist appropriate treatment for scabies Which of the following medications is most (D) Severity of shock (E) Topical insecticides (C) Lyme disease effective for the treatment of chronic thrombocyto (E) Type of shock (D) Molluscum contagiosum penia secondary to systemic lupus erythematosus Which of the following medications would you (E) Varicella zoster (A) Erythropoietin 165. A 32-year-old male presents with sore throat that prescribe for the treatment of subacute thyroiditis A 37-year-old female presents with itchy, bleeding, (C) Prednisone symptoms of a head cold. Physical exam reveals (B) Antibiotics non-healing lesions on the lips, mouth and tongue. Strep screen was (C) Corticosteroids Biopsy of affected areas reveals the presence of (E) Vitamin D negative. Which of the following physical examination, which of the following is (E) Thyroid hormone courses of treatment would you prescribe for this 178. The electrocardiogram shown below was obtained (A) Peritonsillar cellulitis (A) Chemotherapy suffer from chronic illness and are at increased from a middle-aged patient admitted to the emer (B) Sinusitis (B) Complete eradication of the lesions risk for community-acquired pneumonia Minimizing exposure to ultraviolet radiation is (E) Polyvalent pneumococcal vaccine signs of respiratory distress. A 22-year-old female is underweight and ema (D) Transient tachypnea (E) Tuberculosis (B) Right-sided congestive heart failure ciated. Electrocardiogram performed in the which of the following is the accurate diagnosis Which of the following medications is administered (B) Atrial fibrillation (E) Malingering rhonchi. Chest X-ray was performed and appeared to a hypertensive pregnant female who must deliver (C) Atrial flutter 189. Which of the following medications is approved her baby early, to ensure fetal lung maturity
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