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By H. Brenton. Western Oregon University. 2017.

The physical examination is usually only significant for splenomegaly cheap cleocin gel 20gm with amex; laboratory studies typically reveal pancytopenia order cleocin gel 20 gm without prescription. The bone marrow aspirate is often dry secondary to fibrosis; biopsy may be needed to make the diag- nosis. In this patient, CLL and CML are unlikely because of the leukopenia. Multiple myeloma is unlikely, given the dry marrow aspirate. Myelofibrosis is unlikely secondary to the normal red cell morphology. Treatment of HCL is indicated only if there is worsen- ing splenomegaly or lymphadenopathy or if there are more than 20,000 hairy cells/µl. In the past, splenectomy was the treatment of choice; however, splenectomy is used less com- monly today. Although splenectomy may improve symptoms, it does not affect the disease itself. The current treatment of choice is either cladribine or the purine analogue pento- statin; both of these agents have been shown to induce remission in 80% of patients, and the choice is based on physician preference. A 76-year-old man presents with back pain and malaise. Initial laboratory results are as follows: WBC, 3,000/µl; hematocrit, 28%; platelet count, 200,000/µl. Serum protein electrophoresis (SPEP) reveals a monoclonal protein level of 3. Bone marrow evaluation reveals sheets of dysplastic plasma cells, and skeletal survey reveals osteolytic lesions in the skull and vertebrae. Interferon alfa Key Concept/Objective: To understand the role of bisphosphonates in the treatment of multiple myeloma This patient has most of the classic symptoms of multiple myeloma, including plasma cell infiltration of the bone marrow, osteolytic bone lesions, anemia, and an M protein level of greater than 3. Chemotherapy with melphalan and prednisone is a reason- able therapeutic option because this combination has been shown to have a higher response rate than monotherapy with either drug. In patients who have bone disease, pamidronate is added to provide protection against skeletal complications; this approach appears to improve quality of life and possibly provides a survival advantage. Therefore, current recommendations are to add bisphosphonates such as pamidronate to the regi- mens for all patients with evidence of bone involvement. A 74-year-old white woman presents to you in clinic for routine follow-up.

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Even without treatment generic cleocin gel 20gm free shipping, almost all patients begin to recover vision within 4 weeks cheap 20gm cleocin gel fast delivery. The relationship of optic neuritis to MS is controversial. Some regard optic neuritis as a distinct entity, but oth- ers consider it part of the clinical continuum of MS. More than half of all patients with MS have optic neuritis at some time during the course of disease. Of patients who present with optic neuritis and who have no other neurologic deficit, almost 40% have one or more ovoid periventricular lesions on brain MRI; clinically definite MS eventually develops in 60%. Patients with completely normal results on MRI and comprehensive CSF evaluation seldom progress to MS. A 44-year-old man comes to the hospital complaining of progressive lower extremity weakness and decreased sensation. He also complains of having difficulties with bowel movements and urination. He recalls having an upper respiratory infection 1 or 2 weeks ago. His physical examination is remarkable for decreased sensation starting at the level of T10, symmetrical severe lower extremity weakness, urinary retention, and decreased rectal tone. The muscle tone and deep tendon reflexes in his lower extremities are diminished. T2-weighted MRI of the spinal cord shows a hyperintense lesion that involves the majority of the cross-sectional area of the cord; the lesion extends from T6 to L3. Of the following, which is the most likely diagnosis? MS Key Concept/Objective: To be able to recognize transverse myelitis Acute transverse myelitis is a syndrome of spinal cord dysfunction.