By J. Vigo. University of Mary Hardin-Baylor.
Acute paralytic poliomyelitis causes fatal respi- Fig cheap apcalis sx 20 mg visa. C Very often involve- ment of the lower limbs is asym- metric (om this case right calf is more atrophic than left) 449 ratory or cardiovascular problems in 5–10% of cases purchase 20 mg apcalis sx with visa, or as high as 60% of cases with bulbar involvement. Encephalitic poliomyelitis is extremely rare and has a high mortality associated Encephalitic poliomyelitis with autonomic dysfunction. Patients present with confusion and agitation, which may progress to stupor and coma. Post-polio syndrome (PPS) occurs 10 years or longer after the initial polio Post-polio syndrome infection, and is characterized by slowly progressive, asymmetric increases in weakness and muscle atrophy (Fig. Patients may complain of joint and muscle pain, and fatigue. It is believed that surviving motor neurons that have reinnervated muscle fibers become incapa- ble of maintaining all the connections in their enlarged motor units, and begin to lose some connections. Some clinicians have suggested that excessive exercise aimed at keeping diseased muscles strong leads to this “burn-out”, but studies show that the primary associative factor for PPS is the severity of disease during the acute phase of the infection. PPS may lead to weakness in muscle groups previously thought to be unaffected, but typically these muscles were originally affected and the patient developed sufficient strength and adaptation to mask the deficits until the onset of PPS. Laboratory: Diagnosis Virus recovery from stool cultures during the first 2–3 weeks of disease is considered diagnostic for poliomyelitis. Virus may also be detected in throat washings, and occasionally from CSF or blood. Neutrophils, and then lymphocytes, may be found in the CSF prior to neurological impairment. Slight to severe protein elevation with normal glucose may be detected. EMG: Early on, there is decreased recruitment and interference, with decreased motor unit action potential amplitudes. In 2–4 weeks, fibrillations will develop, with possible fasciculations. Over time, reinnervation will lead to polyphasic motor units. Nerve conduction velocities and sensory studies are normal. Imaging: Inflammation of the anterior spinal cord may be detected with MRI. Post-polio syndrome: The diagnosis of PPS is by exclusion of other conditions and demonstration of progressive weakness over time. Encephalitis caused by echovirus or coxsackie virus Differential diagnosis Meningitis Guillain-Barre syndrome Motor polyneuropathies Acute transverse myelitis 450 Therapy Vaccination programs have tremendously decreased the incidence of poliomy- elitis in developed countries. However, rare cases are still reported in countries with good vaccine programs, frequently in isolated cultures that reject modern medical care. In countries without adequate vaccination, poliomyelitis is still common. Once a patient has poliomyelitis, the only treatment is supportive therapy. This includes physical therapy to prevent contractures and joint ankylosis, prosthet- ic devices, and respiratory/swallowing therapy to minimize pulmonary compli- cations like aspiration and atelectasis. Some clinicians recommend that pa- tients with PPS minimize their activity, but studies suggest that exercise is beneficial for PPS, too.
Because disorders in other systems frequently affect the skin purchase apcalis sx 20 mg visa, ask about the history of cardiovascular generic 20mg apcalis sx otc, respiratory, hepatic, immunologic, and endocrine dis- orders. Identify any recent exposures to others who have been ill and/or who have had obvi- ous skin problems that might have been contracted. Many medications affect the skin, and a list of all prescribed and over-the-counter agents should be obtained, including herbal and nutritional supplements. Table 2-1 includes a nonexhaustive list of medications with potential adverse skin effects. Finally, ask the patient how he or she generally tolerates expo- sure to the elements, such as heat, cold, and sun, to determine whether environmental exposure is responsible for or may contribute to the patient’s complaint. Family History The family history should include the occurrence of such skin diseases as eczema, psoria- sis, and skin cancer, as well as other disorders commonly associated with skin problems, such as cardiovascular, respiratory, hepatic, immunologic, and endocrine disorders. Habits Investigate habits related to skin, hair, and nail care. Identify any chemicals used in groom- ing, as well as potential exposures encountered through work and recreational activities. Identify occupational, daily living, and recreational activities that could be responsible for lesions resulting from friction, infestations, environmental extremes (heat/cold/sun), and other variables. Dietary history is helpful for identifying the potential sources of atopic reactions. PHYSICAL EXAMINATION Order of the Exam During the general examination of the skin, compare side to side for symmetry of color, texture, temperature, and so on. There are many situations in which additional equipment, such as a magniﬁer, Copyright © 2006 F. Skin 15 measuring device, ﬂashlight/transilluminator, and Wood’s (ultraviolet) lamp, are helpful. The progression for the skin exam can be completed in a systematic head-to-toe fashion, or by region as other systems are being examined and are uncovered. Regardless of the sequencing or system chosen, the exam of the skin consists of both inspection and palpa- tion. Privacy is an important consideration because any area being examined must be com- pletely bared. As the skin is examined, it is important to keep in mind the structures underlying the skin and the amount of exposure a particular area is likely to receive. This can help to explain any particular “wear and tear” patterns, scars, calluses, stains, and/or bruises. For instance, an eczematous rash on the area of the nipple and/or areola should always trigger consideration of Paget’s disease, a malignant breast condition (see Plate 20). As the history is obtained, a general survey is performed to determine the patient’s gen- eral status. Notice the posture, body habitus, obvious respiratory status, and whether the patient is guarding or protecting any area of the skin. The general survey should provide an indication of the patient’s overall skin condition, including color, visible lesions, mois- ture, and perspiration. As each section of skin is inspected and palpated, there are basic considerations.
In patients with symptoms associated with hypocalcemia (e buy apcalis sx 20mg online. In most patients buy cheap apcalis sx 20mg, vita- min D should also be provided. If dietary deficiency is suspected, plain cholecalciferol is adequate. In cases of hypoparathyroidism, however, calcitriol will be required. A 55-year-old woman comes to your office with the results of a screening DEXA scan. She has not had any symptoms and denies having any previous fractures. Six months ago, she underwent mammography and had a Pap smear, both of which were neg- ative. Her physical examination, including examination of the breasts, is normal. Her laboratory workup shows no evidence of conditions that are secondary caus- es of osteoporosis. Start bisphosphonate therapy, start calcium and vitamin D therapy, and recommend exercise B. Start hormone replacement therapy, start calcium and vitamin D ther- apy, and recommend exercise C. Start calcitonin, calcium, and vitamin D therapy, and recommend exercise D. Do not start therapy until the osteoporosis becomes symptomatic Key Concept/Objective: To understand the appropriate management of osteoporosis Osteoporosis is defined as decreased bone mass (or density) with abnormal skeletal microarchitecture that increases the risk of fracture. The diagnostic criteria of the World 8 BOARD REVIEW Health Organization are based on the results of standardized bone mass measurements: osteoporosis is present when the bone mineral density (BMD) is decreased to more than 2. Osteopenia is present when the BMD falls between –1. In patients with osteoporosis, an adequate amount of calcium should be provided. This patient should take 1,000 to 1,500 mg of calcium a day. Also, the patient should receive 400 to 800 IU of vitamin D. Osteoporosis is most often treated with antiresorptive agents; these drugs include bisphosphonates, estrogen, selective estrogen receptor modulators (e. All of these agents reduce fracture rates substantially, but estrogen and bisphosphonates appear to produce the greatest improvement in bone den- sity. Until recently, estrogen replacement therapy was widely recommended as first-line therapy for both prevention and treatment of osteoporosis. Advocates argued that estro- gen directly corrected the chief pathophysiologic defect of the menopause-estrogen defi- ciency. They also cited other benefits, such as relief from vasomotor disturbances, mood swings, sleep disturbance, and urogenital atrophy. Estrogen therapy was also thought to offer cardiovascular benefits, possibly related to its positive effects on plasma lipid levels. As a result of these findings, estrogen should no longer be considered the optimal first-line preventive or therapeutic agent for osteoporosis. Bisphosphonates should be considered the optimal choice for the initial therapy for osteo- porosis. Raloxifene can be used for osteoporosis prevention and treatment; it appears to have a less potent effect on bone density than either estrogens or bisphospho- nates.
Acute pericarditis buy apcalis sx 20 mg line; start prednisone 36 BOARD REVIEW ❏ C apcalis sx 20 mg discount. Acute pericarditis; repeat echocardiogram in 1 week to confirm diagnosis ❏ D. ST elevation myocardial infarction; start thrombolytics Key Concept/Objective: To understand the diagnosis and treatment of acute pericarditis The clinical diagnosis of acute pericarditis rests primarily on the findings of chest pain, pericardial friction rub, and electrocardiographic changes. The chest pain of acute peri- carditis typically develops suddenly and is severe and constant over the anterior chest. In acute pericarditis, the pain worsens with inspiration—a response that helps distinguish acute pericarditis from myocardial infarction. Low-grade fever and sinus tachycardia also are usually present. A pericardial friction rub can be detected in most patients when symp- toms are acute. Electrocardiographic changes are common in most forms of acute peri- carditis, particularly those of an infectious etiology in which the associated inflammation in the superficial layer of myocardium is prominent. The characteristic change is an ele- vation in the ST segment in diffuse leads. The diffuse distribution and the absence of recip- rocal ST segment depression distinguish the characteristic pattern of acute pericarditis from acute myocardial infarction. Depression of the PR segment, which reflects superficial injury of the atrial myocardium, is as frequent and specific as ST segment elevation and is often the earliest electrocardiographic manifestation. Analgesic agents, salicylates, or NSAIDs are often effective in reducing pericardial inflammation. Corticosteroids should be reserved for severe cases that are unresponsive to other therapy, because symptoms may recur after steroid withdrawal. The absence of a significant effusion on echocardiography is not evidence against acute pericarditis. Other symptoms include an erythematous rash, fatigue, and weight loss. Her medical history is significant for hyperten- sion. On physical examination, the patient’s temperature is found to be 100. A complete blood count shows anemia; the patient’s erythrocyte sedimentation rate (ESR) is ele- vated at 80 mm/hr. A transthoracic echocardiogram shows a 2 cm pedunculated mass in the left atrium. Which of the following is the most likely diagnosis for this patient? Cardiac myxoma Key Concept/Objective: To be able to recognize cardiac myxomas Cardiac tumors may be either primary or secondary and either benign or malignant. Metastatic cardiac involvement occurs 20 to 40 times more frequently than primary tumors. Eighty percent of all primary cardiac tumors are benign; myxomas account for more than half of these in adults.