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Which of the following is NOT true for this patient? If this patient continues to smoke cheap 200mcg cytotec overnight delivery treatment jaundice, his FEV1 value will continue to decrease two to three times faster than normal B discount cytotec 100mcg fast delivery medications management. If this patient stops smoking, the rate of decline in expiratory flow reverts to that of nonsmokers, and there may be a slight improve- ment in FEV1 during the first year C. This patient would be expected to have evidence of extensive panacinar emphysema D. This patient would be expected to have increased RV, increased FRC, and normal or increased total lung capacity (TLC) E. This patient is at risk for right-sided heart failure Key Concept/Objective: To understand the progression of chronic bronchitis and emphysema 12 BOARD REVIEW Panacinar emphysema is common in patients with α1-antitrypsin deficiency. Centriacinar emphysema is commonly found in cigarette smokers and is rare in non- smokers. Centriacinar emphysema is usually more extensive and severe in the upper lobes. In most cigarette smokers, a mixture of centriacinar and panacinar emphysema develops. In healthy nonsmokers, FEV1 begins declining at about 20 years of age and continues at an average rate of about 0. In smokers with obstructive lung disease, FEV1 decreases, on average, two to three times faster than normal. When per- sons with mild to moderate airflow obstruction stop smoking, the rate of decline in expiratory flow reverts to that observed in nonsmokers, and there may be a slight improvement in FEV1 during the first year. Measurement of lung volumes uniformly reveals an increased RV and a normal to increased FRC. RV may be two to four times higher than normal because of slowing of expiratory flow and gas trapping behind pre- maturely closed airways. One group of patients (type A) exhibit dyspnea with only mild to moderate hypoxemia (PaO2 levels are usually > 65 mm Hg) and maintain normal or even slightly reduced PACO2 levels. The other clinical group of patients (type B) are some- times called blue bloaters; they typically exhibit cough and sputum production, fre- quent respiratory tract infections, chronic carbon dioxide retention (PACO2 > 45 mm Hg), and recurrent episodes of cor pulmonale. In the type B patient, both alveolar hypoxia and acidosis (secondary to chronic hypercapnia) stimulate pulmonary arterial vasoconstriction, and hypoxemia stimulates erythrocytosis. Increased pulmonary vas- cular resistance, increased pulmonary blood volume, and, possibly, increased blood vis- cosity (resulting from secondary erythrocytosis) all contribute to pulmonary arterial hypertension. In response to long-term pulmonary hypertension, cor pulmonale gen- erally develops: the right ventricle becomes hypertrophic, and cardiac output is increased by means of abnormally high right ventricular filling pressures. A 43-year-old female patient with chronic bronchitis associated with a 40-pack-year history of cigarette smoking presents for a routine appointment. Although she has a productive cough on a daily basis, she denies having any dypsnea and is currently not taking any medication. Smoking cessation Key Concept/Objective: To know key treatment measures for chronic bronchitis and emphysema Of the therapeutic measures available for patients with chronic bronchitis and emphy- sema, only smoking cessation and long-term administration of supplemental oxygen to the chronically hypoxemic patient have been shown to alter the natural history of the disease favorably. Helping a patient to quit smoking is probably the single most impor- tant intervention. Most patients with chronic bronchitis and emphysema who are given a sufficiently strong bronchodilating medication will exhibit at least a 10% increase in maximal expiratory airflow. Dyspneic patients should be given a trial of bronchodilators even if pulmonary function testing shows that they do not manifest significant bronchodilation, because bronchodilator responsiveness may vary over time. Given the underlying pathophysiology of emphysema, corticosteroids would be expected to provide little benefit, because tissue destruction is the basic disease mecha- nism. Only some patients derive significant benefit from corticosteroids. Clinical trials of daily antibiotic use in patients with mild chronic airflow obstruction demonstrated that neither the degree of disability nor the rate of progression of disease was signifi- cantly altered by this intervention. Intermittent antibiotic administration is indicated for acute episodes of clinical worsening marked by increased dyspnea, excessive sputum production, and sputum purulence. Physical-training programs, such as treadmill walk- 14 RESPIRATORY MEDICINE 13 ing, significantly increase the exercise capacity of patients with even far-advanced chronic bronchitis and emphysema.

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Another illness that can cause confusion is a very rare disease of unknown cause purchase 100 mcg cytotec visa symptoms internal bleeding, known as SAPHO syndrome (because of its salient features: synovitis order cytotec 100mcg amex medications in mothers milk, acne, palmoplantar pustulosis, hyperostosis, and aseptic osteomyelitis). This disease causes bone damage that sometimes affects the sacroiliac joints or the spine. As explained in Chapter 3, the disease usually begins as an inflammation in the sacroiliac joints. When these joints become inflamed they cause pain that you can feel not just over the joints but diffusely over the buttock (gluteal) area. The sacro- iliac joints usually become tender on direct firm pressure in the early stages, but the pain and ten- derness gradually get less over the years as the sacroiliac joints become fused and replaced by bone. When the inflammation spreads to involve the lumbar spine, you will be aware of low back pain and stiffness. The inflammation and pain can result in muscle spasm and tenderness, as well as stiffness of the back. There is a natural tendency to stoop forward to mini- mize the symptoms, because backward stretching is uncomfortable. This can gradually lead to irreversible bad posture, because if the inflammation is not resolved the body begins a gradual repair process that results in further limitation of back motion due to thefacts 101 AS-15(101-110) 5/29/02 5:52 PM Page 102 Ankylosing spondylitis: the facts (a) (b) (c) Figure 17 The effects of AS on posture: (a) A healthy person standing erect: Note the hollow lower (lumbar) back and the inclination of the pelvis. Also shown, in a schematic drawing (slightly exaggerated), the transmission of body weight vertically downward (arrow) through the hip joints (black), oblique to the plane of the pelvis. The center of gravity is vertically in line with the hip, knee and ankle joints. Note the upright position of the pelvis and elimination of the lumbar hollow (i. The whole static equilibrium is changed; there is some forward stooping of the neck, and the beginnings of upper thoracic kyphosis. Note the flexion contracture of the hip joints and the flexed knees, to keep the gaze horizontal. Chest expansion is limited, so the diaphragm must be used for breathing, which makes the abdomen look more prominent (‘rubber ball belly’). The name enthesis is given to these sites, and the inflammatory lesion is called enthe- sitis or sometimes enthesopathy. The doctor should check for pain and tenderness along the back, pelvic bones, sacroiliac joints, and the chest, looking for the presence of enthesitis. There may be heel swelling and tenderness either at the site of insertion of the Achilles tendon to the calcaneus (heel bone), or at the site of the attach- ment of the plantar fascia to the same bone at the bottom of the heel (see Figure 18). The medical names for these conditions are Achilles tendinitis, and plantar fasciitis respectively. A process of healing and repair, which follows the enthesitis phase, results in gradual limitation of back motion due to scarring and subsequent bone thefacts 103 AS-15(101-110) 5/29/02 5:52 PM Page 104 Ankylosing spondylitis: the facts Figure 19 formation. This process may, after many years, lead ultimately to complete spinal fusion. Any clinical examination to look for the presence of AS must therefore include a thorough examination of spinal mobility in all directions (Figure 5), Chapter 3. The inflammatory changes affect the superficial layers of the ligament (annulus fibrosus) that surrounds the disc, especially at its attachment to the corners of the vertebral bodies, resulting in increased bone density (sclerosis) of these corners, seen on X-ray as shiny corners (Figure 19). The bone at these corners may subsequently disappear, and this may ultimately result in squaring of the vertebral bodies. Gradually a thin layer of vertical bony outgrowths at the edges of the vertebrae bridges the gap between the two adjacent vertebral bodies, replacing the superficial layer of the annulus fibrosus of the disc. This intervertebral bony bridging that surrounds the disc is called a syndesmophyte (Figure 19). At the same time, inflammatory changes and slowly progressive bony fusion may be going on in spinal joints called the apophyseal or facet joints (Figure 19). Thus in someone with severe disease the inflammatory process of the spine may gradually, after many years, result in complete fusion (also 104 thefacts AS-15(101-110) 5/29/02 5:52 PM Page 105 The disease process called bony ankylosis) of the whole spine. The X-ray of the spine may ultimately look like a bamboo and is sometimes called bamboo spine. Spinal osteoporosis (discussed earlier) is also fre- quently observed among such patients, partly as a result of the lack of spinal mobility and aging. The inflammation of the joints between the ribs and the spine (the costovertebral and costotrans- verse joints), and at the junction of the ribs to the breastbone in front of the chest (the costochondral areas), can result in chest pain and tenderness. This pain can be accentuated by coughing or sneezing.

The optic nerve leaves the orbit through the optic canal (lesser wing of the sphenoid bone) proven 100 mcg cytotec asthma medications 7 letters, in close proximity to the ophthalmic artery and the cavernous sinus buy generic cytotec 100 mcg on-line medicine used to treat bv. The optic nerve enters the middle cranial fossa and joins the optic nerve from the other eye to form the optic chiasm. Signs While direct pupillary reaction to light is absent, the pupillary reaction can be evoked indirectly. Toxic optic neuropathy: Alcohol Anilin dye Amoproxan Ara C (high dose) Arsenic Aspidium (antihelmintic drug) Cafergot Carbon disulfide Carbon tetrarchloride Chinin Chinolin derivates Chlorambucil (edema of the retina) Chloramphenicol Digitalis Disulfiram Docetaxel: may cause visual sensations (“visual field flash”) Ethambutol Isoniazid Lead Mercury (Hg) Nitrosurea and radiation Nitrous oxide (N2O) Thallium Vincristine Vascular: Ischemic optic neuropathy due to: Amyloidosis Arteritis cranialis Herpes zoster Retrobulbar optic neuropathy Systemic lupus erythematosis (SLE) 37 Infectious: Meningitis Sarcoid Syphilis Tuberculosis Focal infection: Granulomatous disease Sinusitis Inflammatory: Optic neuritis due to demyelinating diseases (MS, neuromyelitis optica) Nutritive: Alcohol ingestion B12 anemia Cuban neuropathy Methylol toxicity Strachan’s syndrome Tobacco alcohol amblyopia Compression: Apoplexy of the pituitary Carotid aneurysm Endocrine orbitopathy Orbital tumors Inflammatory causes of compression: syphilis, tuberculosis, arachnitis opto- chiasmatica Tumors: Metastases Melanocytoma Meningeal carcinomatosis (see Fig. Compression occurs in 50% of pituitary adenomas; other potential causes include craniopharyngeoma (in childhood), meningeoma of the tuberculum sellae, aneurysm, tumors of the chiasm itself (spongioblastoma, meningioma, neuronoma, or retinoblastoma). Paraneoplastic: Rarely involved in paraneoplastic dysfunction: CAR (carcinomatous retino- pathy) Hereditary: Charcot-Marie-Tooth (CMT) Leber’s disease Lysosomal disease Storage disease (Tay Sachs) Spinocerebellar disease 38 Ataxias: Friedreich’s ataxia Mitochondrial – NARP Syndrome: (Neuropathy; Ataxia; Retinitis Pigmentosa) Posterior column ataxia + Retinitis pigmentosa Iatrogenic: Pressure on the eye bulb caused by anesthesia (ischemic optic nerve neuro- pathy), blepharoplasty, fractures of the orbit, or surgery of the nasal sinus. Radiation: Radiation therapy of brain tumors, pituitary tumors, metastases, or ENT tumors can cause uni- or bilateral loss of vision with long latencies. Progressive optic nerve atrophy is seen within 6 weeks of exposure to 70 Gy (units of gray). Trauma: “Blow out” fractures Gunshot wounds Penetrating trauma Trauma of the orbit Traumatic optic neuropathy Diagnosis Diagnosis is based on X-ray, CT, or MRI imaging, visual function and color discrimination tests, ophthalmoscopic exam, visual evoked potentials (VEP), and electroretinogram (ERG). Differential diagnosis Other causes of papilledema should be considered, including increased intra- cranial pressure (ICP) and pseudotumor cerebri. Therapy Treatment depends upon the cause of the lesion. References Acheson J (2000) Optic nerve and chiasmal disease. J Neurol 247: 587–596 Lee AG, Brazis PW (2000) Neuro-ophthalmology. In: Evans RW, Baskin DS, Yatsu FM (eds) Prognosis of neurological disorders. Oxford University Press, New York Oxford, pp 97–108 Lowitsch K (1986) Nervus opticus. In: Schmidt D, Malin JC (eds) Erkrankungen der Hirnnerven. Thieme, Stuttgart, pp 11–53 Wilson-Pauwels L, Akesson EJ, Stewart PA (1988) Cranial nerves. Decker, Toronto Philadelphia 39 Oculomotor nerve Genetic testing NCV/EMG Laboratory Imaging Biopsy Lee screen (PNP: NCV) + (Diabetes) ++ + Fig. Oculomotor nerve pare- sis: A Complete ptosis; B Upon lifting of the lid lateral deviation of left bulbus. Pupillary dilata- tion (mydriasis) signals the parasympathetic fibers for the sphincter pupillae are affected 40 Qualities Extraocular eye muscles except superior oblique muscle and lateral rectus Somatic motor muscle. Visceral motor Parasympathetic to the constrictor pupillae and ciliary muscles. Anatomy The nucleus of the oculomotor nerve is located in the midbrain, ventral to the cerebral aqueduct. The nerve fibers course ventrally in the tegmentum, through the red nucleus and the medial aspect of the peduncles, emerging in the fossa interpeduncularis. The nerve passes the posterior cerebral and superior cerebel- lar arteries as it courses anteriori. It pierces through the dura and enters the cavernous sinus, where it runs along the lateral wall superior to the trochlear nerve. The nerve then passes the superior orbital fossa and through the tendinous ring. In the orbit, it divides into a superior portion (innervating the superior rectus and levator palpebrae superioris) and inferior portion (innervating the inferior rectus, inferior oblique, and medial rectus). The visceral fibers (originating in the Edinger-Westphal nucleus of the oculomotor nucleus complex) are also found in the inferior portion and terminate in the ciliary ganglion (see Fig.

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Patellar tilt: An MRI ment of stress fracture of the patella in athletes order cytotec 200mcg visa treatment west nile virus. Tenth Congress European Society of Sports Surg Sports Traumatol Arthrosc 1996 cytotec 200 mcg for sale red carpet treatment; 4: 206–211. Traumatology, Knee Surgery and Arthroscopy, Book of 39. Localized nodular syn- lar neuroma: An unusual cause of anterior knee pain. New York: Churchill hemangioma of the knee with meniscal and bony attach- Livingstone, 1984. Patellofemoral not the x-ray”: Advances in diagnostic imaging do not problems after anterior cruciate ligament reconstruc- replace the need for clinical interpretation [lead edito- tion. Tenosynovial giant-cell Hemangioma intramuscular (Aportación de 6 casos y tumor in the knee joint. Sanchis-Alfonso, V, E Roselló-Sastre, V Martinez- nosis of medial patellar plica syndrome. Occult localized osteonecrosis of the 2004; 20: 1101–1103. Femoral subtalar joint position on patellar glide position in sub- interference screw divergence after anterior cruciate lig- jects with excessive rearfoot pronation. J Sports Phys ament reconstruction provoking severe anterior knee Ther 1997; 25: 185–191. A ganglion of the ovial plica syndrome: A case report. Am J Sports Med anterior horn of the medial meniscus invading the infra- 1992; 20:92–94. Treatment of deep cartilage defects of the patella with 49. Knee Surg Sports Traumatol knee pain after anterior cruciate ligament reconstruc- Arthrosc 1998; 6:202–208. Late results after menis- coma of the retropatellar fat pad. Fat pad irritation: A mistaken patellar ten- Arthroscopy 1997; 13: 515–516. Conservative management of patellofemoral that developed from the infrapatellar fat pad of the knee. In contrast, intrinsic risk fac- knee pain need conservative treatment to be tors relate to the individual physical and psy- able to return to sport or their daily activities. One ning and carrying out prevention and treatment such model is described by Meeuwisse. This understanding refers this model that numerous intrinsic factors theo- to information on why a particular individual retically may predispose an individual to ante- develops anterior knee pain and another indi- rior knee pain. This model also shows very well vidual, exposed to more or less the same exer- the interaction of both intrinsic and extrinsic cise load, does not. In addition, it seems factors, in the way that the extrinsic risk factors important to understand why some patients act on the predisposed athlete from outside. To answer these impor- and extrinsic risk factors of anterior knee pain tant issues risk factors for the development of seems essential in our understanding of the eti- anterior knee pain need to be identified. Anterior knee pain The Role of Extrinsic Risk Factors can be considered as a multi-risk phenomenon in the Development of Anterior with various risk factors interacting at a given time. The extrinsic (external risk factors) and the development of risk factors relate to environmental variables, anterior knee pain is well known. A dynamic, multifactorial model of sports injury etiology. If excessive focusing on the relationship between the intrin- loading is placed across the joint, loss of tissue sic risk factors and anterior knee pain. However, homeostasis can occur, resulting in pain and the majority of these studies are retrospective other dysfunctions.

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