lhcqf logo 2016


Jeffrey A Brinker, M.D.

Jeffrey A Brinker, M.D.

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


True glandular enlargement beneath the areola mine whether they are cryptorchid or intra-abdominal order rizatriptan 10mg otc pain treatment center bethesda md. A Hyperthyroidism Haloperidol karyotype (for Klinefelter syndrome) is obtained in men Klinefelter syndrome Hydroxyzine with persistent gynecomastia without obvious cause order 10 mg rizatriptan with visa chest pain treatment guidelines. Male hypogonadism Isoniazid Investigation of unclear cases should include a chest Partial 17-ketosteroid Ketoconazole radiograph to buy rizatriptan 10mg line unifour pain treatment center search for bronchogenic or metastatic car? reductase deficiency Lavender oil (topical) cinoma. Treatment Refeeding after starvation Methyldopa Metoclopramide Pubertal gynecomastia ofen resolves spontaneously within Spinal cord injury Neoplasms Metronidazole l-2 years. Drug-induced gynecomastia resolves after the Adrenal tumors Mirtazapine offending drug is removed (eg, spironolactone stopped, Bronchogenic carcinoma Nucleotide reverse with substitution of eplerenone). Generally, it is prudent to hepatocellular, gastric, renal Omeprazole treat patients for gynecomastia only when it becomes a carcinomas Opioids troubling and continuing problem for them. Raloxi? tumors Progestins Drugs (partial list) Protease inhibitors fene, 60 mg orally daily, may be somewhat more effective Alcohol Proton pump inhibitors than tamoxifen, 10-20 mg orally daily. For example, anastrozole reduces breast volume Anabolic steroids Reserpine significantly over 6 months in adolescents given in a dose Androgens Risperidone of 1 mg orally daily. Serum estradiol levels fall slightly Anti-androgens Somatropin (growth hormone) while serum testosterone levels rise. Cimetidine Tricyclic antidepressants Radiation therapy has been used prophylactically to Verapamil prevent gynecomastia in men with prostate cancer being treated with antiandrogen therapy. Existing gynecomastia improves in 33% with radiation are worrisome for malignancy: asymmetry; location not therapy. However, the long-term breast and other cancer immediately below the areola; unusual frmness; or nipple risks of such radiation are unknown. Surgical correction is reserved for patients with persis? tent or severe gynecomastia. Laboratory Findings In the presence of true glandular gynecomastia, serum Deepinder F et al. Gynaecomastia-pathophysiology, diagnosis familial and transmitted as a modifed autosomal domi? and treatment. Case records of the Massachusetts General Hos? excess, including hirsutism, acne, and male-pattern thin? pital. Obesity and high serum insulin levels (due to insulin resistance) contribute to the syndrome in 70% of? Steroidogenic Enzyme Defects Hirsutism is defined as cosmetically unacceptable terminal hair growth that appears in women in a male pattern. The amount of hair growth enzyme defect is 21-hydroxylase deficiency, with a preva? deemed unacceptable depends on a womans ethnicity and lence of about 1: 18,000. Virilization is defined as the Partial defciency in adrenal 21-hydroxylase can pres? development of male physical characteristics, such as pro? ent in women as hirsutism. About 2% of patients with nounced muscle development, deep voice, male pattern adult-onset hirsutism have been found to have a partial baldness, and more severe hirsutism. The phenotypic expression is delayed until adolescence or adulthood; such patients do not have Hirsutism may be idiopathic or familial or be caused by the salt wasting. Patients ofen have a strong 17-beta-hydroxysteroid dehydrogenase-3 or a deficiency in familial predisposition to hirsutism that may be considered 5-alpha-reductase-2 may present as phenotypic girls in normal in the context of their genetic background. Pure androgen-secreting affecting about 4-6% of premenopausal women in the adrenal tumors occur very rarely; about 50% are malignant. Maternal virilization during ally is due to adrenal hyperplasia and rarely to adrenal pregnancy may occur as a result of a luteoma of pregnancy, carcinoma. In postmeno? No firm guidelines exist as to which patients (if any) pausal women, diffuse stromal Leydig cell hyerplasia is a with hyperandrogenism should be screened for "late? rare cause of hyperandrogenism. The evaluation requires lanuginosa is manifested by the appearance of diffuse fine levels of serum 17-hydroxyprogesterone to be drawn at lanugo hair growth on the face and body along with stoma? baseline and at 30-60 minutes after the intramuscular tologic symptoms; the disorder is usually associated with an injection of 0. Ideally, internal malignancy, especially colorectal cancer, and may this test should be done during the follicular phase of a regress after tumor removal. Patients with congenital adrenal minoxidil, cyclosporine, phenytoin, anabolic steroids, inter? hyperplasia will usually have a baseline 17 -hydroxyproges? feron, cetuximab, diazoxide, and certain progestins. Menstrual irreg? sound, about 25-30% of normal young women have poly? ularities, anovulation, and amenorrhea are common. If cystic ovaries, so the appearance of ovarian cysts on androgen excess is pronounced, defeminization (decrease ultrasound is not helpful. However, tion (frontal balding, muscularity, clitoromegaly, and deep? small virilizing ovarian tumors may not be detectable on ening ofthe voice) occur. Virilization points to the presence imaging studies; selective venous sampling for testosterone of an androgen-producing neoplasm. Treatment body with a maximum possible score of 36; scores 8-15 Any drugs causing hirsutism (see above) should be stopped. A pelvic examination may disclose clitoromegaly or ovarian enlargement that may be cystic or neoplastic. Surgery Hypertension may be present and should prompt consider? ation for the possible diagnosis of Cushing syndrome, Androgenizing tumors of the adrenal or ovary are resected adrenal 11-hydroxylase deficiency, or cortisol resistance laparoscopically. Laboratory Testing and Imaging normal), since small hilar cell tumors of the ovary may not be visible on scans. Women with classic salt-wasting con? Serum androgen testing is mainly useful to screen for rare genital adrenal hyperplasia and infertility or treatment? occult adrenal or ovarian neoplasms. Some general guide? resistant hyperandrogenism may be treated with lines are presented here, though exceptions are common. L) or free testosterone greater than 40 ng/dL (140 pmol/L) indicates the need for pelvic examination and ultra? Laser therapy (photoepilation) can be a very effective sound. In such women, laser removal when serum testosterone levels are less than 300 ng/dL of facial hair significantly improves their appearance and (10.


  • Urinalysis and urine cultures
  • The eardrum bulges out or pulls back inward (collapses)
  • Weakness
  • Fructose (found in fruits)
  • Hyperactivity
  • You think you have been pregnant for several days
  • Wear special stockings on your feet and legs to prevent blood clots

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Lesions of the left angular gyrus basis buy 10 mg rizatriptan with amex pain treatment in shingles, and congenital factors bear on the development of cause Gerstmann syndrome (a combination of alexia buy rizatriptan 10 mg on-line pain treatment in multiple sclerosis, craniopharyngiomas generic rizatriptan 10 mg line swedish edmonds pain treatment center. Tumors may occur at any age, but agraphia, acalculia, right-left confusion, and finger agno? certain gliomas show particular age predilections. Tumor Clinical Features Treatment and Prognosis Glioblastoma Presents commonly with nonspecific complaints and increased Course is rapidly progressive, with poor multiforme intracranial pressure. Astrocytoma Presentation similarto glioblastoma multiforme but course more Prognosis is variable. Cerebellar astrocytoma total excision is usually impossible; tumor may have a more benign course. Generally arises from roof of Treatment consists of surgery combined with fourth ventricle and leads to increased intracranial pressure radiation therapy and chemotherapy. Ependymoma Glioma arising from the ependyma of a ventricle, especially the Tumor is best treated surgically if possible. Brainstem glioma Presents during childhood with cranial nerve palsiesand then Tumor is inoperable; treatment is by irradia? with long tract signs in the limbs. Signs of increased intracra? tion and shuntfor increased intracranial nial pressure occur late. Cerebellar Presents with dysequilibrium, ataxia of trunk or limbs, and signs Treatment is surgical. Pineal tumor Presents with increased intracranial pressure, sometimes associ? Ventricular decompression by shunting is ated with impaired upward gaze (Parinaud syndrome) and followed by surgical approach to tumor; other deficits indicative of midbrain lesion. Craniopharyngioma Originates from remnants of Rathke pouch above the sella, Treatment is surgical, but total removal may depressing the optic chiasm. Radiation may be used for usually in childhood, with endocrine dysfunction and residual tumor. Treatment is excision by translabyrinthine Subsequent symptoms may include tinnitus, headache, surgery, craniectomy, or a combined vertigo, facial weakness or numbness, and long tract signs. Meningioma Originates from the dura mater or arachnoid; compresses rather Treatment is surgical. Symptoms vary with tumor site-eg, unilateral proptosis (sphenoidal ridge); anosmia and optic nerve compression (olfactory groove). Treatment is high-dose methotrexate and lymphoma Presentation may be with focal deficits or with disturbances of corticosteroids followed by radiation cognition and consciousness. In patients with or rejection of a paralyzed limb) is seen in patients with normal hormone levels and an intrasellar mass, angiogra? lesions of the nondominant (right) hemisphere. Construc? phy is sometimes necessary to distinguish with confidence tional apraxia and dressing apraxia may also occur with between a pituitary adenoma and an arterial aneurysm. Occipital lobe lesions-Tumors of the occipital lobe characteristically produce crossed homonymous hemiano? the electroencephalogram provides supporting information pia or a partial feld defect. With left-sided or bilateral concerning cerebral function and may show either a focal lesions, there may be visual agnosia both for objects and for disturbance due to the neoplasm or a more diffuse change colors, while irritative lesions on either side can cause refecting altered mental status. Bilateral occipital lobe necessary; the findings are seldom diagnostic, and the pro? involvement causes cortical blindness in which there is cedure carries the risk of causing a herniation syndrome. Treatment loss of color perception, prosopagnosia (inability to iden? Treatment depends on the type and site of the tumor tif a familiar face), simultagnosia (inability to integrate (Table 24-5) and the condition of the patient. Some benign and interpret a composite scene as opposed to its individ? tumors, especially meningiomas discovered incidentally ual elements), and Balint syndrome (failure to turn the eyes during brain imaging for another purpose, may be moni? to a particular point in space, despite preservation of spon? tored with serial annual imaging. The denial of blind? complete surgical removal may be possible if the tumor is ness or a field defect constitutes Anton syndrome. Brainstem and cerebellar lesions-Brainstem lesions a critical or inaccessible region of the brain (eg, cerebellar lead to cranial nerve palsies, ataxia, incoordination, nystag? hemangioblastoma). Surgery also permits the diagnosis to mus, and pyramidal and sensory deficits in the limbs on be verified and may be benefcial in reducing intracranial one or both sides. Intrinsic brainstem tumors, such as glio? pressure and relieving symptoms even if the neoplasm can? mas, tend to produce an increase in intracranial pressure not be completely removed. Cerebellar tumors produce due in part to obstructive hydrocephalus, in which case marked ataxia of the trunk if the vermis cerebelli is simple surgical shunting procedures often produce dramatic involved and ipsilateral appendicular deficits (ataxia, inco? beneft. In patients with malignant gliomas, survival corre? ordination and hypotonia of the limbs) if the cerebellar lates to the extent of initial resection. Indications for irradiation in the treat? signs other than by direct compression or infltration, ment of patients with other primary intracranial neoplasms thereby leading to errors of clinical localization. These false depend on tumor type and accessibility and the feasibility of localizing signs include third or sixth nerve palsy and bilat? complete surgical removal. Temozolomide is a commonly eral extensor plantar responses produced by herniation used oral and intravenous chemotherapeutic for gliomas, syndromes, and an extensor plantar response occurring and the use of monoclonal antibodies like bevacizumab as a ipsilateral to a hemispheric tumor as a result of compression component oftherapy may be helpful (see Table 39-4). Anticon? shape, and size; the extent to which normal anatomy is vulsants are also commonly administered in standard doses distorted; and the degree of any associated cerebral edema (see Table 24-3) but are not indicated for prophylaxis in or mass effect. Long-term neuro? ment could be performed; however, it is less helpful than cognitive defcits may complicate radiation therapy. When to Refer tron-emission tomography) and high metabolism or cell All patients should be referred. When to Admit as stroke and infammatory or infectious diseases, are sometimes associated with hyperperfusion and hyperme? All patients with increased intracranial pressure. All patients requiring biopsy, surgical treatment, or Arteriography is largely reserved for presurgical shunting procedures. Findings may include elevated cerebrospi? the European Association for Neuro-Oncology. The role logic studies may indicate that malignant cells are present; of targeted therapies in the management of progressive glio? if not, lumbar puncture should be repeated at least twice to blastoma: a systematic review and evidence-based clinical obtain further samples for analysis.

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Differential diagnosis includes aphthous stomatitis purchase rizatriptan with mastercard treatment of cancer pain guidelines, erythema multi? forme cheap 10 mg rizatriptan with mastercard treatment for post shingles nerve pain, syphilitic chancre purchase rizatriptan on line amex pain treatment center regency road lexington ky, and carcinoma. Coxsackievirus? caused lesions (grayish-white tonsillar plaques and palatal ulcers of herpangina or buccal and lip ulcers in hand-foot? and-mouth disease) are seen more commonly in children under age 6. A l-week tapering course ofprednisone (40-60 mg/day) coccus infection to prevent rheumatic sequelae. Pharyngitis andtonsillitis account for over 10% of all office Large or persistent areas of ulcerative stomatitis may be visits to primary care clinicians and 50% of outpatient anti? secondary to erythema multiforme or drug allergies, acute biotic use. When the diagno? public health policy concern is reducing the extraordinary sis is not clear, incisional biopsy is indicated. Effect ofbedtime on recurrent aphthous stomatitis in alone a sufficient basis for decisions about which patients college students. Herpes Stomatitis Numerous well-done studies and experience with rapid Herpes gingivostomatitis is common, mild, andshort-lived laboratory tests for detection of streptococci (eliminating and requires no intervention in most adults. In immuno? the delay caused by culturing) informed a consensus compromised persons, however, reactivation of herpes experience. However, about one-third of patients with infectious mononucleosis have secondary streptococcal tonsillitis, requiring treatment. Ampicillin should routinely be avoided if mononucleosis is suspected because it induces a rash that might be misinterpreted by the patient as a penicillin allergy. Diphtheria (extremely rare but described in the alcoholic population) presents with low-grade fever and an illpatient with a graytonsillar pseudomembrane. The ColorAtlas of Rhinorrhea and lack of exudate would suggest a virus, but Family Medicine. Clinical Findings anaerobic streptococci, and Corynebacterium haemolyticum (which responds better to erythromycin than penicillin) may A. Laboratory Findings nopathy, lack of a cough, and a pharyngotonsillar exudate (Figures 8-8 and 8-9). Sore throat may be severe, with odyno? phagia, tender adenopathy, and a scarlatiniform rash. Hoarseness, cough, and coryza are not suggestive of this Given the availability of many well-documented studies in disease. Evidence-based evaluation and management once, was the standard antibiotic treatment. Peri? lin V potassium (250 mg orally three times daily or 500 mg tonsillar abscess (quinsy) and cellulitis present with severe twice daily for 10 days) or cefuroxime axetil (250 mg orally sore throat, odynophagia, trismus, medial deviation of the twice daily for 5-10 days) are both effective. The efcacy of soft palate and peritonsillar fold, and an abnormal mufed a 5-day regimen of penicillin V potassium appears to be ("hot potato") voice. Following therapy, peritonsillar celluli? similar to that of a 10-day course, with a 94% clinical this usually either resolves over several days or evolves into response rate and an 84% streptococcal eradication rate. The existence of an abscess may be Erythromycin (also active against My coplasma and confrmed by aspirating pus from the peritonsillar fold just Chlamydia) is a reasonable alternative to penicillin in aller? superior and medial to the upper pole of the tonsil. Cephalosporins are somewhat more effective 19-gauge or 21-gauge needle should be passed medial to the than penicillin in producing bacteriologic cures; 5-day molar and no deeper than 1 em, because the internal carotid administration has been successful for cefpodoxime and artery may lie more medially than its usual location and cefuroxime. The macrolide antibiotics have also been pass posterior and deep to the tonsillar fossa. Less severe cases and patients who are tococcal complications of scarlet fever, glomerulonephritis, able to tolerate oral intake may be treated for 7-10days with rheumatic myocarditis, and local abscess formation. Surprisingly, penicillin-tolerant strains are clindamycin, 300 mg four times daily. Although antibiotic not isolated more frequently in those who fail treatment treatment is generally undisputed, there is controversy than in those treated successfully with penicillin. Some clinicians incise and drain the area Alternatives to penicillin include cefuroxime and other and continue with parenteral antibiotics, whereas others cephalosporins, dicloxacillin (which is beta-lactamase? aspirate only and monitor as an outpatient. When there abscess and avoid recurrence, it may be appropriate to con? is a history of penicillin allergy, alternatives should be sider immediate tonsillectomy (quinsy tonsillectomy). Erythromycin resistance? About 10% of patients with peritonsillar abscess exhibit with failure rates ofabout 25%-is an increasing problem relative indications for tonsillectomy. In cases of severe penicillin allergy, cepha? are effective and have support in the literature. Regardless of losporins should be avoided as the cross-reaction is com? the method used, one must be sure the abscess is adequately mon (8% or more). There is controversy about whether increased the likelihood of complete pain resolution at a single abscess is a sufcient indication for tonsillectomy; 24 hours by threefold without an increase in recurrence or about 30% ofpatients aged 17-30 who do not undergo early adverse events. Some patients fnd that salt water gargling planned tonsillectomy following peritonsillar abscess ulti? is soothing. In severe cases, anesthetic gargles and lozenges mately undergo surgery, and only about 13% of those over (eg, benzocaine) may provide additional symptomatic 30 have their tonsils removed. External drainage via bilateral submental incisions is required if the airway is threat? ened or when medical therapy has not reversed the? When the infection involves the foor ofthe mouth, base of the tongue, or the supraglottic or paraglottic space, the airway may be secured either by intubation or tracheot. Tracheotomy is preferable in the patients with sub? stantial pharyngeal edema, since attempts at intubation Ludwig angina is the most commonly encountered neck may precipitate acute airway obstruction. It is a cellulitis of the sublingual and sub? association with a deep neck abscess is very rare but sug? maxillary spaces, often arising from infection of the man? gests carotid artery or internal jugular vein involvement dibular dentition. Deep neck abscesses most commonly and requires prompt neck exploration both for drainage of originate from odontogenic infections. Suppurative lymphadenopathy in middle-aged persons who smoke and drink alcohol regularly should be consid? Horvath T et a!. Severe neck infections that require wide external ered a manifestation of malignancy (tyically metastatic drainage: clinical analysis of 17 consecutive cases.


  • Rhabdomyosarcoma 2
  • Cardiac conduction defect, familial
  • Toxoplasmosis, congenital
  • Dysostosis Stanescu type
  • Tachycardia
  • Cold agglutination syndrome
  • Situs inversus totalis with cystic dysplasia of kidneys and pancreas
  • Chromosome 11p, partial deletion

Prognosis activity commonly are prescribed discount rizatriptan online master card pain treatment winnipeg, large clinical trials con? frm that antibiotics are not benefcial in uncomplicated Diverticulitis recurs in 10-30% of patients treated with disease generic 10mg rizatriptan with visa home treatment for uti pain. A 2015 American Gastroenterological Association medical management over 10-20 years purchase rizatriptan overnight delivery swedish edmonds pain treatment center. However, less than guideline suggests that antibiotics should be used selectively 5% have more than two recurrences. Reasonable regimens include warrant elective surgical resection in selected patients. Nonetheless, colorectal cancer may cause plus either ciprofoxacin, 500 mg twice daily, or trime? symptoms that may be confused with diverticulitis. There? thoprim-sulfamethoxazole, 160/800 mg twice daily orally, fore, colonoscopy is recommended in patients over age 50 for 7-10 days or until the patient is afebrile for 3-5 days. Once the acute epi? with suspicious radiologic imaging, diverticulitis with sode has resolved, a high-fber diet is often recommended. Patients with severe diverticulitis (high fevers, leukocytosis, or peritoneal signs). When to Refer and patients who are elderly or immunosuppressed or who Failure to improve within 72 hours of medical have serious comorbid disease require hospitalization management. If ileus is present, a nasa? Presence of significant peridiverticular abscesses (4 em gastric tube should be placed. Intravenous antibiotics or larger) requiring possible percutaneous or surgical should be given to cover anaerobic and gram-negative drainage. Single-agent therapy with either a second-generation Generalized peritonitis or sepsis. When to Admit should be continued for 5-7 days, before changing to oral Severe pain or inability to tolerate oral intake. Temporal trends in the incidence and natural percutaneous catheter drain placed by an interventional history of diverticulitis: a population-based study. Routine colonoscopy after left-sided acute resolution of the immediate infectious infammatory pro? uncomplicated diverticulitis: a systematic review. Association between colonic diverticular dis? in which the diseased segment of colon is removed and ease and colorectal cancer: a nationwide population-based primary colonic anastomosis performed. Hyperplastic polyps located in the proximal colon (ie, proximal to the splenic fexure) may be associ? Polyps are discrete mass lesions that protrude into the ated with an increased prevalence of advanced neoplasia, intestinal lumen. Clinical Findings mucosal adenomatous polyps (tubular, tubulovillous, and villous), mucosal serrated polyps (hyperplastic, sessile ser? A. Symptoms and Signs rated polyps, and traditional serrated adenoma), mucosal Most patients with adenomatous and serrated polyps are nonneoplastic polyps (juvenile polyps, hamartomas, completely asymptomatic. Chronic occult blood loss may infammatory polyps), and submucosal lesions (lipomas, lead to iron deficiency anemia. Large polyps may ulcerate, lymphoid aggregates, carcinoids, pneumatosis cystoides resulting in intermittent hematochezia. Ofpolyps removed at colonoscopy, over 70% are adenomatous; most of the remainder are serrated. Their significance is that over 95% of comparative trial conducted in persons at average risk for cases of adenocarcinoma of the colon are believed to arise colorectal cancer undergoing colonoscopy, the sensitivity from these lesions. Adenomas and serrated polyps are classified as 90% or more for the detection of polyps larger than 10 mm "advanced" if they are 1 em or larger, or contain villous in size. A believed to have a higher risk of harboring or progressing small proportion of these small polyps harbor advanced his? to malignancy. The prevalence of Multisociety Task Force as an acceptable option for screening advanced adenomas is 6% and colorectal cancer 0. Barium enema is no longer recom? adenomas are believed to arise from hyperplastic polyps. Many pathologists cannot reliably distinguish between hyer? Colonoscopy allows evaluation of the entire colon and is plastic polyps and sessile serrated polyps. Hyperplastic the best means of detecting and removing adenomatous polyps smaller than 5 mm located in the rectosigmoid and serrated polyps. Uptake of colon capsule endoscopy vs adenomas detected on fexible sigmoidoscopy to remove colonoscopy for screening relatives ofpatients with colorectal these polyps and to fully evaluate the entire colon. Guidelines for colonoscopy surveillance preparation or failure to excrete the capsule. Endoscopic detection of proximal serrated lesions and pathologic identification of sessile serrated adeno? mas/polyps vary on the basis of center. Accuracy of capsule colonoscopy in detecting colorectal polyps in a screening population. Serrated polyps of the large intestine: current understanding of diagnosis, pathogenesis, and clinical man? Sessile polyps larger than 2-3 em may be removed by snare agement. Patients with large sessile polys removed in prevention of colorectal-cancer deaths. Postpolypectomy Surveillance Up to 4% ofall colorectal cancers are caused by germline Adenomas and serrated polyps can be found in 30-40% of genetic mutations that impose on carriers a high lifetime risk patients when another colonoscopy is performed within of developing colorectal cancer (see Chapter 39). Most of these polyps are small, without affected more than one family member, those with a personal high-risk features and of little immediate clinical signif? or family history of colorectal cancer developing at an early cance. The probability of detecting advanced neoplasms at age (50 years or younger), those with a personal or family surveillance colonoscopy depends on the number, size, and history of multiple polyps (more than 20), and those with a histologic features of the polyps removed on initial (index) personal or family history of multiple extracolonic colonoscopy. Familial Adenomatous Polyposis Patients with 3-10 adenomas, an adenoma larger than 1 em, or an adenoma with villous features or high-grade dysplasia should have their next colonoscopy at 3 years. Patients with more than 10 adenomas should have a repeat colonoscopy at 1-2 years and may be considered for evalu.


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