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Jeffrey A Brinker, M.D.

Jeffrey A Brinker, M.D.

  • Professor of Medicine
  • Joint Appointment in Radiology and Radiological Science


You tell her it is (1) a filter placed in the large vein entering her heart that will catch all the clots before they enter her heart and lungs purchase cardizem with a visa heart attack high come over to the darkside feat jimi bench. The inferior vena cava filter is designed to buy 180 mg cardizem amex blood pressure chart based on age trap emboli before they enter the left atrium proven cardizem 120 mg blood pressure juicing. Bananas, orange juice, tomatoes, and potatoes are all high in potassium, which tends to be depleted with diuretic use. The patient is transferred to the unit for management of congestive heart failure. The nurse asks him to describe his symptoms, and the patient replies that he is often short of breath when he tries to walk and has a frequent cough. The nurse knows that these symptoms are characteristic of (1) left-sided heart failure. Left-sided heart failure is characterized by dyspnea on exertion and a moist cough, as well as cyanosis or pallor, fatigue, irritability, and palpitations. The nurse is treating an overweight post-cesarean section patient with varicose veins. It is especially important that she checks for the following when assessing this patient. Although all of these assessments are made on a postpartum C/S patient, an overweight woman with varicose veins is particularly at risk for phlebitis. The bones also store and release vital minerals, and the bone marrow produces erythrocytes (red blood cells) and thrombocytes (platelets). The cells of the bone are called osteocytes, which are embedded in a matrix of a calcified intercellular substance composed of calcium phosphate and other inorganic mineral salts. Each bone is composed of cylindrical layers, and the outside layer is called the periosteum. There are also fine branching canals (the haversian system) through which blood vessels and lymphatics run. Bones develop through the calcification of this cartilage by layers, first cartilage, then calcification, then another layer of cartilage, etc. The epiphysis is a cartilage area on the ends of children’s bones that provides for longitudinal bone growth. The thyroid and parathyroid control the deposition and reabsorption of calcium from blood to bone. Bone Maintenance—formation and reabsorption of bone are controlled by the following: 1. Weight-bearing stress stimulates bone formation and calcium formation on the bone. Immobility, in contrast, allows mobilization of calcium from the bone to the blood. Diarthroses (synovial)—freely movable joints (1) Hinge type—elbows and knees (2) Ball and socket type—hip (3) Saddle type (multidirectional movement)—thumb (4) Pivot type (rotary movement)—radius and ulna (5) Gliding type (sliding)— wrist, ankle, intervertebral joints (6) Condyloid—wrist b. Fibrous connective tissue surrounding and separating muscles and binding blood vessels and nerves together (deep fascia) 1. Function—allows independent muscle action and gliding of one muscle over another 2. Each muscle has a point of origin and a point of insertion (insertion point usually moves). Previous injuries, neuromuscular problems, inflammatory/metabolic/ endocrine disorders affecting the musculoskeletal system b. Don’t allow the patient to bear weight on the cast until instructed by provider to do so 5. A fractured hip should be maintained in an abducted position with neutral rotation (use pillows) 6. A fat embolism is a life-threatening complication that causes shortness of breath, shock, and possibly death. Common types of fractures: Colle’s: Fracture of distal radius (common while protecting with hand in fall) Pelvic: Common in elderly due to falls Hip: Common in women over 60 due to osteoporosis A. Total Hip Replacement—used to alleviate pain and restore movement for patients with arthritis or a fracture 1. Elevate stump for approximately 24 hours, then keep the joint above the stump extended to prevent a flexion contracture 2. Provide analgesics and discuss phantom limb pain (is real to the patient and should be treated) 3. Herniated Disc—stress on the disc causes the cartilage (nucleus pulposus) to herniate inward toward the spinal cord causing pain from compression of the spinal nerve root. Laminectomy (1) Preoperative—practice of logrolling (2) Evaluate bowel and bladder function (3) Postoperative—positioning pillow between the legs when on the side (4) Logroll patient when turning (5) Evaluate pain, extremity sensation, bowel and bladder function (The patient may have difficulty voiding postoperatively due to edema from surgery that may interfere with sensation). Rheumatoid Arthritis—a systemic inflammatory disease, involving synovial (freely moving) bone joints 1. Usually involves weight-bearing joints, may be unilateral and occur as a result of stress b. Gout—arthritis caused by uric acid crystals deposited in the joints and cartilage 1. Rapid onset of pain, swelling, and inflammation of great toe (usually); also ankles and knees c.

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These her pregnancy generic cardizem 60 mg with mastercard hypertension lifestyle modifications, namely whether there is a risk of moods last for 5-10 minutes cardizem 60 mg overnight delivery heart attack 6 hours, after which the fetal malformations because of received vaccipatient exhausts himself and falls asleep purchase cardizem us arteria pudenda externa. What advice should the doctor give in waking he is depressed, sad, cannot recall his this casefl A 44-year-old woman has undergone consulted subtotal thyroid resection due to diffuse toxic goiter. A 15-year-old girl suffers from systemic patient’s condition deteriorated; she developed lupus erythematosus and has been receiving palpitations, dyspnea, sweating, and diarrhea, prednisolone therapy in the daily dosage of 2 and became fearful the patient is anxious, mg/kg for the last 6 weeks. What should be necessary to develop the immunity against this measured to clarify the patient’s conditionfl Immediately after the prednisolone therapy th a 30-year-old man that complains of severely is complete itching rashes that especially disturb him at niE. A 45-year-old veterinary worker has made on the lateral surfaces of his flngers, hands, an appointment with the doctor for regular wrists, elbows, lower abdomen, genitals, and examination. In his duties he frequently deals thighs there are paired papulovesicles, single with animals, however he denies working wipustules, and scratch marks. What tactics of vaccination agaianimal nst respiratory infections should be chosen to C. Preventive immunization with rabies provide secondary prevention of exacerbations immunoglobulin and to avoid heart failure decompensation in D. A healthy child 1 year and 5 months of otic administration age is being vaccinated against hepatitis B. Vaccination is contraindicated due to severe child did not receive the flrst dose of the vacciheart failure ne previously, while in the maternity hospital. Any vaccination is contraindicated due to the doctor makes an individual vaccination elderly age of the patient schedule for this child and plans the adminiE. Any vaccination is contraindicated due to stration of the next dose of the vaccine. What is mitral valve disease the minimum interval between doses of vaccine in this casefl A 69-year-old woman was diagnosed with the following: ischemic heart disease; stable A. Type of influenza vaccine is not important in the wound on his left foot, insomnia, and B. Vaccination is contraindicated due to severe stepped on a glass shard, while on the beach. Vaccination is contraindicated due to elderly the patient’s general condition is satisfactory, age of the patient pulse is 75/min. What tactics should be are moderately hyperemic, no discharge from chosen regarding the vaccination against the wound is observed. A 45-year-old woman has been suffering patient from rheumatoid arthritis for 10 years and takes 191. He has a closed fracture regarding vaccination against pneumococci of the left forearm and a contused lacerated (23-valent vaccine) would conform to the wound on his left shin. After the patient receirecommendations for the management of ved initial wound management, he presented rheumatoid arthritis issued by the European the documents conflrmingthathehasreceiLeague Against Rheumatism in 2010fl No signs of gynecological pathology I degree of rheumatic activity; combined miKrok 2 Medicine (àíãëîìîâíèé âàðiàíò, iíîçåìíi ñòóäåíòè) 2018 ðiê 24 were detected. Epinephrine pertussis, tetanus) vaccination but the mother is absolutely against this procedure. In autumn a 45-year-old man was and is not contraindicatory to immunobiologirecommended an elective surgery for coronary cal agents. Choose the most rational tactics of artery bypass grafting due to multivessel measles prevention in this schoolboy: coronary artery disease. Measles-Mumps-Rubella vaccine the family doctor offer a scheduled yearly vacciB. Primary prevention of influenza during considered necessary as there was a measles postoperative care outbreak in the city and the patient had not E. After a course of glucocorticoids treatment story, the doctor claimed this procedure to D. Under supervision in the infectious diseases What anamnestic data is the absolute contraiinpatient ward ndication to vaccinationfl Adsorbed diphtheria tetanus vaccine (modisevere condition; there are small pale pink fled) non-merging spots on the skin of his back, B. What is the likely etiology of this diKrok 2 Medicine (àíãëîìîâíèé âàðiàíò, iíîçåìíi ñòóäåíòè) 2018 ðiê 25 Laboratory values Complete blood count Laboratory value Normal reference range Male: 4. Ruhf Art Director Elaine Kasmer Design Joseph John Clark Design Assistants Kate Zulak, Karen Kappe Nugent Illustrators Bot Roda, Judy Newhouse, Betty Winnberg Vendor Manager Karyn Crislip Senior Manufacturing Coordinator Beth J. To the best of our knowledge, these procedures reflect currently accepted practice. For individual applications, all recommendations must be considered in light of the patient’s clinical condition and, before administration of new or infrequently used drugs, in light of the latest package-insert information. The authors and publisher disclaim any responsibility for any adverse effects resulting from the suggested procedures, from any undetected errors, or from the reader’s misunderstanding of the text. No part of it may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means—electronic, mechanical, photocopy, recording, or otherwise—without prior written permission of the publisher, except for brief quotations embodied in critical articles and reviews, and testing and evaluation materials provided by the publisher to instructors whose schools have adopted its accompanying textbook. Here’s why this book is so terrific: It will teach you all the important things you need to know about pathophysiology.

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Symptomatic dystonia • Athetoid cerebral palsy Dystonias (Putamen) • Cerebral anoxia Idiopathic (or primary) torsion dystonia is a disorder • Post-encephalitic dystonia characterised by involuntary sustained muscle contracDrug induced dystonia tions frequently causing twisting and repetitive move• Neuroleptics ments (along the long axis of the arm—axial rotation) • Mn poisoning or abnormal postures without other associated • Levodopa neurological features safe 120 mg cardizem blood pressure of 100/60. Dystonia affecting adjacent parts of the body such • Encephalitis—Post-thalamotoms as an arm and neck (segmental dystonia) order cardizem mastercard blood pressure healthy numbers. Dystonia restricted to order cardizem 60 mg mastercard blood pressure zones a single body part (focal dys• Paroxysmal exercise induced dystonia tonia) is common in adults. Focal dystonias include • Paroxysmal kinesigenic choreo-athetosis spasmodic torticollis, blepharospasm, oromandi• Paroxysmal dystonic choreo-athetosis. Tremors Causes of Dystonia Tremor is defined as a rhythmical and oscillatory movement of a body part caused by regular, rhythmical, Primary generalised dystonia (Autosomal dominantcontractions of the agonist and antagonist muscles. Chromosome 9) Tremors may be fine (thyrotoxicosis) or coarse (alcoFocal adult-onset dystonia (Autosomal dominantholism). A fine tremor is one that is visible only on close Chromosomes 8 and 18) inspection and best brought out by balancing a piece of • Blepharospasm paper on the patient’s outstretched fingers. A coarse • Oromandibular dystonia tremor is one which is very obvious and needs no special • Cranial dystonia measures to see it. Benedict’s syndrome (due to involvement of the red • Benign essential (familial) tremor nucleus) i. Hepatic failure, renal failure, respiratory failure (flapIntentional tremor ping tremor or asterixis). Primary writing/task specific tremor Myoclonic jerks may be a normal phenomenon occurring Dystonic tremor. It can be present throughout the Generalised Myoclonus range of voluntary movements or when the limbs Progressive myoclonic encephalopathies are maintained in a particular position when it is Hereditary myoclonus known as postural tremor. Postural tremor occurs when the limb maintains a Metabolic cause—Tay-Sachs and Batten’s disease posture such as holding the arms and hands outEncephalitis lethargica stretched. Perioral tremor is a constant coarse tremor of the • Hyponatraemia orbicularis oris and chin, usually seen in general • Hypocalcaemia paresis of insane. Nervous System 489 Tics Fibrillation these are repetitive irregular stereotyped movements these are contraction of individual muscle fibres occuror vocalisations which can be imitated. They relaxed and not consciously suppressing them, in can however be perceived over the tongue, where they contrast to most other dyskinesias which are more can be easily seen under the thin mucous membrane. Myokymia these are the most common involuntary movements of the muscles seen as a fine or coarse very rapid rippling Causes of Tics movement of muscle fibres, persisting in the same group of fibres for minutes at a time. Symptomatic tics • Encephalitis lethargica Minipolymyoclonus • Drug induced tics In cases where there is chronic denervation of muscles • Post-traumatic (motor neuron disease) and renervation, involving many • Neuroacanthocytosis fascicles, an involuntary tremor like movement of the • Focal brain lesions. Fasciculation this term is applied to an irregular, non-rhythmical Titubation contraction of muscle fascicles. They are best seen in It is the involuntary nodding of the head seen in lesions large muscles such as deltoid or calf muscles. It is a sign of lower motor neuron lesion, Gait and especially a sign of active degeneration of the the gait of the patient may give a clue to the neurological anterior horn cells or irritative lesions of the nerve roots condition. Fasciculation, if not seen at rest, the patient may be asked to walk in a straight line may be brought about by contracting the muscle, for atleast 9 metres and then turn and walk back to the hyperventilation or by cooling the muscle with ethyl starting point. Note is made of the posture of the body while Conditions causing fasciculation walking, the position and movement of the arms, the a. Primary muscular atrophy to maintain a straight course, the ease of turning and. Administration of edrophonium or neostigmine this type of gait is seen in hemiparesis. A reflex is a consistent involuntary adaptive response to the stimulation of a sense organ. The components of Spastic Gait (Bipyramidal Lesion) the reflex arc are: this type of gait is seen in lesions of the upper motor i. The the reflexes to be tested are the superficial reflexes, steps are short with the feet scraping the floor. The deep tendon reflexes are monosynaptic reflexes High Stepping Gait (Foot Drop) and the superficial and visceral reflexes are polysynapthis type of gait is seen in patients with foot drop. High Stepping and Stamping Gait Sherrington’s law of reciprocal innervation: (Posterior Column Lesion) Activation of agonist muscle group is accompanied this type of gait is seen in patients with posterior column by inhibition of antagonist muscle group. The the patient must be appraised of the procedure to patient does not know where his foot is and so, on be adopted in eliciting the various reflexes, as these walking raises his foot high up in the air and brings it reflexes can be easily and correctly elicited only in a down on the ground forcefully (stamping), the heel of completely relaxed patient. This the reflexes may be present, lost or exaggerated abnormal gait is more prominent in the dark or when and thereby give a clue to the underlying neurological the patient walks with his eyes closed. Ataxic Gait (Cerebellar Lesion) Abdominal Reflexes this type of gait is seen in patients with cerebellar lesion. The patient is ataxic and reels in any direction, including Abnormal Responses backwards and walks on a broad base. The patient finds Exaggerated abdominal reflexes may be seen in psychodifficulty in executing tandem walking. Shuffling Gait (Extrapyramidal Lesion) Absent abdominal reflexes may be seen in this type of gait is seen in patients with lesions of the 1. Defects of technique, relaxation, or observation extrapyramidal system, associated with rigidity. A breach of the appropriate reflex arc, due to lesions patient makes a series of small, flat footed shuffles. This such as herpes-zoster, or scar due to surgical operagait is typically seen in parkinsonism, where the patient tions which have damaged the peripheral nerves or has a stooped posture (universal flexion) and walks the muscle itself. The automatic associated upper limb patients with flaccid abdominal muscles, distention movements are absent.

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In part due to discount cardizem 60 mg amex 5 fu arrhythmia portal hypertension buy cheap cardizem 60 mg on-line hypertension new guidelines, but may be due to cardizem 180mg fast delivery heart attack get me going extended version associated liver dysfunction. Pathological features Cirrhosis is characterized by flbrosis of the liver parenchyma, nodular regeneration, and hepatocellular necrosis. Small and uniform nodules (<4mm in diameter), separated by thin flbrous septa uniformly throughout the liver. Larger nodules separated by wider scars and irregularly distributed throughout the liver. Clinical features Carcinoma of the head of pancreas (65%) • Obstructive jaundice (90%). Presents as emboli; splenic vein thrombosis may lead to splenomegaly in 10% of patients. Carcinoma of the body (25%) and tail (10%) • Usually asymptomatic in the early stages. Treatment Palliative treatment the majority of tumours (95%) are not suitable for surgical resection due to presence of metastases, local invasion, involved lymph glands, age, or comorbidity of patient. Relief of jaundice Obstructive jaundice is associated with pruritus, coagulopathy, immunological and nutritional derangement, deterioration in liver function, risk of acute renal failure (hepatorenal syndrome), and increased susceptibility to infection. Curative treatment Radical surgical resection is the only hope of cure if patient is suitable. Cholangiocarcinoma • Usually arises in the extrahepatic biliary tree, but may be intrahepatic. Ampullary carcinoma • Typically small and presents relatively early due to the early onset of painless obstructive jaundice. Diagnosis of ampullary and bile duct carcinoma; allows biopsy or brush cytology of distal tumours; allows therapeutic stenting. Diagnosis of intrahepatic biliary tumours, therapeutic stenting, or external drainage of proximal biliary tumours. Treatment Curative • Surgery offers the only cure for primary liver or biliary cancers. Palliative • Endoscopic or percutaneous stenting for unresectable cholangiocarcinoma or ampullary carcinoma. Typical variceal bleeding is: • Rapid onset, copious dark red venous blood with little mixing with food. Only use O –ve blood if the patient is in extremis; otherwise wait for cross-matched blood if transfusion needed. Usually only inserted without a prior gastroscopy if the patient is known to have varices and has lifethreatening bleeding. Deflnitive management Considered for failed endoscopic treatment and ongoing bleeding. May be performed to rapidly reduce the portal pressure, but has the risk of inducing portal encephalopathy. In portacaval shunts, encephalopathy occurs in 50% of survivors and the procedure is now seldom performed. May be simple or associated with phlegmon formation; transient fluid collections common. Persistent large peripancreatic fluid collections may form (‘pseudocyst’), which may become infected. Diagnostic, but may be normal even in severe cases; elevated amylase may occur in a wide range of other acute abdominal events (intestinal ischaemia, leaking aneurysm, perforated ulcer, cholecystitis). Absent psoas shadows, ‘sentinel loop sign’ (dilated proximal jejunal loop adjacent to pancreas because of local ileus’), ‘colon cut-off sign’ (distended colon to mid-transverse colon with no air distally); may show gallstone, pancreatic calciflcation. Shows pancreatic oedema, swelling, loss of fat planes; may show haemorrhagic or necrotic complications. Sir Astley Paston Cooper (1804) Deflnition of a hernia the abnormal protrusion of a viscus or part of a viscus through a weakness in its containing wall. Associated with a developmental disorder, such as persistent processus vaginalis (infantile inguinal hernia) or failure of complete obliteration of umbilical opening (infantile umbilical hernia). Weakness of the abdominal wall due to ageing or previous surgery; risk increases in conditions where there is i intra-abdominal pressure, such as heavy lifting, chronic cough, straining on urination or defecation, abdominal distension, ascites, pregnancy, etc. Peritoneal lining of a hernia; may be complete or incomplete as in sliding hernia (b p. Contents can be fully restored to the abdominal cavity, spontaneously or with manipulation. Part or all of the contents cannot be reduced due to a narrow neck and/or adhesions; there is a risk of strangulation. Contains an obstructed bowel loop due to kinking; usually goes on to strangulation. Groin hernias rank third, after adhesive obstruction and cancer, as the most common cause of bowel obstruction in the west. In tropical Africa, strangulated external hernia is the commonest cause of intestinal obstruction. Blood supply to the contents of the sac is cut off; the tight neck of the peritoneal sac is the usual site of strangulation. Pathological sequence Venous and lymphatic occlusion l oedema and i venous pressure l impeding arterial flow l bowel necrosis and perforation.


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