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She has a medical required him to take off from work for a few days each history that includes stable coronary disease proven amantadine 100mg, mild em- time discount amantadine 100mg on line. He comes into your office at the outset of his third physema, and multi-infarct dementia. In your office, he has tinnitus and vertigo while following is true regarding head injury and hematomas? Which is the best long-term treatment option mas will experience a lucid interval prior to loss of for the patient at this time? While you are working in the urgent care center, a tracranial pressure and can require arterial ligation. He gives a history of having slipped on the ice and On examination, visual acuity in the right eye is 20/60 and severely contusing his right shoulder approximately 1 in the left eye 20/80. At this time he has sharp knifelike pain in the He has cerebellar ataxia on neurologic examination as well right arm and forearm. His strength is 5 out of 5 in all major right arm that is more moist and hairy than the left arm. When the mother arrives, you find ever, the right arm is clearly more edematous than the out that many relatives on the father’s side of the family, in- left, and the skin appears somewhat atrophic in the af- cluding the father, have been diagnosed with cerebellar fected limb. The patient’s pain most likely is due to ataxia but she does not know more than that. Physical examination demonstrates progressive weak- to find on examination of this patient’s fundi? All the following are associated with a decreased sistance, and the ankle drags for varying distances before sense of smell except being lifted off the bed. The finding is not seen in the other leg nor in the upper extremities when examining the el- A. He has had left a pseudobulbar affect, mildly increased muscle tone, and lower extremity weakness that has been constant for 6 brisk deep tendon reflexes in the right upper extremity and months. The history and ex- pain is intermittent and he uses chronic narcotics on an amination are most consistent with which of the following? All the following are causes of paresthesias in the thumb and the index and middle fin- carpal tunnel syndrome except gers. Delirium often goes unrecognized despite clear evidence that it is often a cognitive manifestation of many medical and neurologic illnesses. Delirium is asso- ciated with a substantial mortality with in-hospital mortality estimates ranging from 25– 33%. Overall estimates of delirium in hospitalized patients range from 15–55% with higher rates in the elderly. Postoperative patients, especially status post hip surgery, have an incidence of delirium that is some- what higher than patients admitted to the medical wards. Because of these associated symptoms, pa- tients may be misdiagnosed as having sinus headache due to allergic rhinitis and treated inappropriately with antihistamine and nasal steroids. A typical presentation of cluster headaches is one of episodic severe headaches that occur at least once daily at about the same time for a period of 8–10 weeks. An attack usually lasts from 15–180 minutes, and 50% of headaches will have nocturnal onset. Men are af- fected three times more commonly with cluster headaches than women, and alcohol in- gestion may trigger cluster headaches. A distinguishing feature between cluster headaches and migraine headaches is that individuals with cluster headaches tend to move about during attacks and frequently rub their head for relief, whereas those with migraines tend to remain motionless during attacks. Interestingly, unilateral phonophobia and photo- phobia can occur with cluster headaches but do not with migraines. Treatment of acute at- tacks of cluster headaches requires a treatment with a fast onset as the headaches reach peak intensity very quickly but are of relatively short duration. High-flow oxygen (10–12 L/min for 15–20 min) has been very effective in relieving the headaches. Alternatively, sub- cutaneous or intranasal delivery of sumatriptan will also halt an attack. The oral-route triptan medications are less effective because of the time to onset of effect is too great. Pre- ventive treatment may be considered in individuals with prolonged bouts of cluster head- aches or chronic cluster headaches that occur without a pain-free interval. Paroxysmal hemicrania is characterized by unilateral severe head- aches lasting only 2–45 min but occurring up to five times daily. In this case, the plan to switch to long-term maintenance with steroid-sparing immunosuppressants should still be pur- sued. There have been no controlled studies comparing mycophenolate to methotrexate for the long-term use in polymyositis, and in the absence of an adverse reaction to myco- phenolate, therapy should not be changed. Dermatomes above and below the level of the destruction are usually spared, cre- ating a “suspended sensory level” on physical examination. As the lesion grows, corticospinal tract or anterior horn involvement can produce weakness in the affected myotome. Common causes include syringomyelia, intramedullary tumor, and hyperex- tension in a patient with cervical spondylosis. A lateral hemisection syndrome (the Brown-Séquard syndrome) is classically due to penetrating trauma from a knife or bullet injury and produces ipsilat- eral weakness and contralateral loss of pain and temperature sensation. Amyotrophic lat- eral sclerosis presents with combined upper and lower motor neuron findings; sensory deficits are uncommon. Hyperventilation causes vasoconstriction, reducing cerebral blood vol- ume and decreasing intracranial pressure. However, this can be used only for a short pe- riod as the decrease in cerebral blood flow is of limited duration. Mannitol, an osmotic diuretic, is recommended in cases of increased intracranial pressure resulting from cyto- toxic edema. Instead, hypertonic saline is given to elevate sodium levels and prevent worsening of edema. Further decreases in mean arterial pressure may worsen the patient’s clinical status. The patient already has had more than a 20% reduction in mean arterial pressure, which is the recommended reduc- tion in cases of hypertensive emergency.

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Image contrast to distinguish a lesion depends on its size relative to system resolution and its surrounding background generic amantadine 100mg line. Unless a minimum size of a lesion larger than system resolution develops order 100 mg amantadine overnight delivery, contrast may not be suf- ficient to appreciate the lesion, even at higher count density. The lesion size factor depends on the background activity surrounding it and on whether it is a “cold” or “hot” lesion. A relatively small-size “hot” lesion can be well contrasted against a lower background, whereas a small “cold” lesion may be missed against surrounding tissues of increased activities. This primar- ily results from the overlapping of normal and abnormal areas by the move- ment of the organ. It is somewhat alleviated by restraining the patients or by having them in a comfortable position. Quality Control Tests for Gamma Cameras To ensure high quality of images produced by imaging devices, several quality control tests must be performed routinely on gamma cameras. The frequency of tests is daily, weekly, and, for some tests, monthly or even quarterly. Performance Parameters of Gamma Cameras (peaking), uniformity, and spatial resolution of the camera. These tests can be carried out with the collimator attached to the camera (extrinsic) or without the collimator (intrinsic), and should be performed for each radionuclide used in a specific clinical study. In the intrinsic method, the source of a particular radionuclide contain- ing approximately 100 to 200mCi (3. Because the collimator is removed, the integrity of the collimator cannot be assessed by this method. In the extrinsic method, a sheet source is used made of plastic contain- 99m ing the radionuclide of interest. Because Tc is most commonly used in 99m nuclear medicine studies, a Tc sheet source is prepared by adding several millicuries of 99mTc activity to a water-filled plastic sheet container. Due to the inconvenience of daily preparation of the 99mTc sheet source and radiation exposure to the technologist during preparation, an alternative solid 57Co sheet source is used, which is commercially available in rectangular or 57 circular forms. Co has a longer half-life (~270d) and emits photons of 122keV and 136keV, which are equivalent to the 140keV photons of 99m 57 Tc. Because Co activity decays over time, counting time increases with time to accumulate sufficient counts for the image. Peaking for 111In, 67Ga, 123I, 201Tl, and so on must be done separately, as needed. In modern cameras, peaking is performed automatically by menu-driven protocol-based software provided by the manufacturer. Initially at the time of the camera set-up, the photopeak window is set with a 99mTc source using the intrinsic method. Subsequently the daily check of the position of the photopeak is performed with a 57Co flood source by the extrinsic method Quality Control Tests for Gamma Cameras 135 using a low-energy high-resolution collimator. Tuning is performed by the computer program by repeaking of the camera with a 99mTc source placed at least 30cm away from the detector and without a collimator (intrinsic method). Uniformity 57 The uniformity of the detector response is checked daily by using a Co flood source. The flood source is placed on the detector with a low-energy high-resolution collimator attached (extrinsic) and an energy window of 20% is used. C max − min integral uniformity = × 100 C max + min where Cmax and Cmin are the maximum and minimum count rates across the field of view in a nine-point smoothed image. Images of a 57Co flood source showing the uniformity (a) and nonunifor- mity (b) of the response of a gamma camera. Performance Parameters of Gamma Cameras high − low differential uniformity = × 100 high + low where “high” and “low” are the maximum and minimum differences in counts over five contiguous pixels in all rows and columns of the matrix. These values should be in the range of 1 to 2%, otherwise, the camera needs to be tuned. Weekly Checks Spatial Resolution and Linearity The spatial resolution and linearity of the gamma camera is checked weekly by using a bar phantom (Fig. An image is taken with approximately 10 million counts and visually inspected to check the linearity and separation of the smallest bars. Although extrinsic tests are done for convenience, intrinsic tests are prefer- able for better accuracy. Annual or As-Needed Checks Tuning of the camera is performed monthly or quarterly by the protocols described earlier. Other essential parameters such as energy resolution, high count rate response, multiwindow registration (e. In addition, tests on accessories such as computers, multiformat cameras, scanning tables, rotation of gantry, and so on should be performed period- ically. Furthermore, all tests must be documented in a record book with per- tinent information, such as the date, time, total counts, window settings, the type of radioactive source, the type of camera, and initials of the technolo- gist performing the tests. Questions 137 (c) A system with a spatial resolution of 5mm is better than a system with a spatial resolution of 8mm. The intrinsic resolution of a gamma camera depends on: (a) The thickness of the NaI(Tl) detector. For a gamma camera with a parallel-hole collimator, (a) The spatial resolution increases with decreasing detector thickness. What are the effects of the following factors on the spatial resolution and sensitivity of a gamma camera? Single-photon emission computed tomography in the year 2001: Instrumentation and quality control. In imaging modalities, the computers are used to quantitate the distribution of radiopharmaceuticals in an object both spatially and temporally. Both data acquisition and image processing in scintigraphy are accomplished by digital computers. In nonimaging appli- cations, patient scheduling, archiving, inventory of supplies, management of budget, record keeping, and health physics are just a few examples of what is accomplished with the help of digital computers. Computational capabil- ities have advanced tremendously over the years and are still evolving, and the utility of a computer is limited only by the limitations of hardware and software. I/O devices include peripherals such as keyboards, mouse, video monitors, and printers, whose functions are to communicate with the computer for input of the acquired data and output of the processed data.

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A 29-year-old woman presents to your clinic com- tion and treatment of this patient? On physical examination discount amantadine 100mg line, she is noted to have a and potassium levels small goiter that is painful to the touch amantadine 100 mg discount. Laboratory studies are sent, and reveal a white blood cell count of 14,100 cells/µL with a normal differ- X-19. What is the most likely copious watery diarrhea that has not abated with the use diagnosis? What is the most appropriate treatment for the pa- ical examination is notable for blood pressure of 100/70, tient described above? All the following would be important Na 146 meq/L + initial steps in the clinical assessment of this patient except K 3. A patient visited a local emergency room 1 week ago stool osmolality is 170 mosmol/L. Diagnose her with subclinical pan-hypopituitarism, sion, she is found to have a calcium level of 19. A 16-year-old previously healthy teenage boy pre- sents to the local emergency room with a headache that A. Continue therapy with large-volume fluid adminis- has been worsening over the course of 2 months. Continue therapy with large-volume fluid adminis- over the past 2 weeks has been complaining of double vi- tration, but stop furosemide and treat with hydro- sion. Differentiating primary dysmenorrhea from other causes of the following is the most likely cause? Which of the following is the most common site for a treatment of the hypertensive crisis. Postmenopausal estrogen therapy has been shown to lowing physiologic alterations will cause an increase in re- increase a female’s risk of all the following clinical out- nin secretion except comes except A. All the following therapies have been shown to re- finding a pituitary microadenoma at autopsy in the gen- duce the risk of hip fractures in postmenopausal women eral population? A 33-year-old woman presents to the emergency room complaining of headache, palpitations, sweating, and anxi- X-29. These feelings began abruptly about 30 min ago, and she cytoma after presentation with confusion, marked hyper- reports intermittent symptoms similar to these that occur tension to 250/140 mmHg, tachycardia, headaches, and perhaps once per month. His fractionated plasma metanephrines show a with panic attacks and has been prescribed paroxetine 20 normetanephrine level of 560 pg/mL and a metaneph- mg daily. Her symptoms have not improved since initiation rine level of 198 pg/mL (normal values: normetaneph- of this drug, and she believes that her episodes of palpita- rine: 18–111 pg/mL; metanephrine: 12–60 pg/mL). Which of the following statements past year for which she has been prescribed ibuprofen, 600 is true regarding management of pheochromocytoma is mg as needed. Her blood pressure while lying cardia even after adequate alpha-blockade has been down is 170/100 mmHg with a heart rate of 90 beats/min. Immediate surgical removal of the mass is indicated, with a heart rate of 112 beats/min. Her respiratory rate is 22 because the patient presented with hypertensive cri- beats/min, and her temperature is 37. Salt and fluid intake should be restricted to prevent following is most likely to correctly diagnose this patient? No testing is necessary; the patient is suffering from seek medical attention at that time. The mineralocorticoid receptor in the renal tubule is though his appetite has increased lately. His wife adds that responsible for the sodium retention and potassium wast- he has recently taken some time off work due to fatigue; ing that is seen in mineralocorticoid excess states such as despite his time off he has not been able to relax and has aldosterone-secreting tumors. He is admitted to the hospital and screen- characteristic of the mineralocorticoid-glucocorticoid ing tests reveal an undetectable thyroid-stimulating hor- pathways explain this finding? Hyperthyroidism leads to a high-output state for the cently started on methimazole. The patient described above is started on atenolol some low-grade fevers, arthralgias, and general malaise. Which of the fol- Laboratories are notable for a mild transaminitis and a lowing additional therapies is indicated? A patient presents to his primary care physician com- plaining of fatigue and hair loss. A 60-year-old woman is referred to your office for since his last clinic visit 6 months ago but notes markedly evaluation of hypercalcemia of 12. On review of systems, he reports that found incidentally on a chemistry panel that was drawn he is not sleeping well and feels cold all the time. Despite still able to enjoy his hobbies and spending time with his fluid administration in the hospital, her serum calcium at family, and does not believe that he is depressed. Which of the statements re- constipation or bone pain and is now 8 weeks out from garding that diagnosis is correct? Absence of a goiter makes autoimmune hypothy- for Stage 1 hypertension and body mass index of 30 kg/ roidism unlikely. Viral thyroiditis does not induce subsequent au- mia due to the clinical and laboratory findings. Congo red staining of xanthoma biopsy able to extracellular molecules of all size and charge. The parents of a 14-year-old boy want your opinion about treatment of their child’s lipid disorder. A patient is asked to undergo a testing protocol to as- emigrated from South Africa to the United States recently. After 5 days of severe so- The child has had cutaneous xanthomas on the hands, el- dium restriction (10 mmol/day), blood is drawn for bows, heels, and buttocks since childhood. Which hormone abnormality may be detected rica, he underwent thoracotomy for a problem with his using this protocol? Mineralocorticoid excess lipid profile shows a total cholesterol of 734 mg/dL and a E. Genetic test for familial defective apoB100 doctor complaining of fatigue and irritability.

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The metabolic disease in the baby’s liver deformation A change from the normal size or apparently causes the fatty liver disease in the shape of a structure produced by mechanical forces mother proven 100 mg amantadine. See also acute Deformations occur most often late in pregnancy fatty liver of pregnancy amantadine 100 mg visa. For example, a twin pregnancy can cause deformations due to crowding of the twins deficiency, long-chain-3-hydroxyacyl-CoA late in pregnancy. An example is the cri du chat (cat cry) syndrome, which is due to loss of part of chromo- degeneration, macular See macular degener- some 5. Symptoms include uncontrol- may partially or completely dehisce after surgery, lable trembling, hallucinations, severe anxiety, depending upon whether some or all of the layers of sweating, and sudden feelings of terror. Diseases of the gastrointestinal tract that cause vom- iting or diarrhea may lead to dehydration. Symptoms include increasing thirst, dry mouth, weakness or lightheadedness delta cell, pancreatic A type of cell located in (particularly when it worsens on standing), and a tissue that is called the islets of Langerhans in the darkening of or decrease in urination. Delta cells make somatostatin, a hor- dration can lead to changes in the body’s chemistry, mone that inhibits the release of numerous hor- kidney failure, and death. It contracts to move the arm up from out a prescription as a “nutritional supplement. Although most people have ment, language, motor and spatial skills, and func- experienced this feeling at one time or another, in tion. By definition, dementia is not due to major some people sensations of déjà vu are part of a depression or schizophrenia. Alzheimer’s disease is seizure or migraine aura; in others, the sensations the most common cause of dementia. Toothache can be caused by a problem that does not originate demulcent An agent that forms a soothing, pro- from a tooth or the jaw. For example, mucilage and oils dentin The hard tissue of the tooth that sur- are demulcents that can relieve irritation of the rounds the central core of nerves and blood vessels bowel lining. Demyelination exposes these fibers and appears to cause problems in nerve impulse Depo-Provera A contraceptive that is injected conduction. It contains the hormonal dendrite A short, arm-like protuberance from a compound medroxyprogesterone acetate. Depression is not the same as a ervation include disease, chemical toxicity, physical passing blue mood. It is not a sign of personal injury, or intentional surgical interruption of a weakness or a condition that can be wished away. Without treatment, dengue fever An acute mosquito-borne viral ill- symptoms can last for weeks, months, or years. The presence of depression include loss of interest in activities that fever, rash, and headache (the “dengue triad”) is were once interesting or enjoyable, including sex; characteristic. Dengue fever is endemic throughout loss of appetite, with weight loss, or overeating, with the tropics and subtropics. Also called breakbone weight gain; loss of emotional expression (flat fever, dandy fever, and dengue. Victims of dengue affect); a persistently sad, anxious, or empty mood; fever often suffer temporary contortions due to the feelings of hopelessness, pessimism, guilt, worth- intense joint and muscle pain. Other cal problems such as headaches, digestive disor- symptoms are bleeding with easy bruising, blood ders, or chronic pain that do not respond to spots in the skin, vomiting of blood, blood in the treatment, and thoughts of death or suicide or sui- stool, bleeding gums, and nosebleeds. Most called major depression, dysthymia, and bipolar deaths occur in children and infants are at particu- disease (manic-depressive disease). The disease tends to be associated with obesity and is dermatome 1 A localized area of skin that about five times more frequent in females than in receives its sensations via a single nerve from a sin- males. The fatty tumors are most often located on zoster) typically affects one or several isolated der- the trunk and limbs. The purpose of dermabrasion is with patches of slightly raised reddish or scaly rash. Chemical skin peels are an alterna- When inflammation of the muscle (myositis) occurs tive to dermabrasion. Dermatitis most common symptom is muscle weakness, usu- has many causes, including direct contact with an ally affecting the muscles that are closest to the irritating substance; allergic reaction to an inhaled, trunk of the body (proximal). Trouble with swal- ingested, or injected allergen; eczema; or underly- lowing may occur. Some patients develop include redness, itching, and in some cases, blister- hardened bumps of calcium deposits under the ing. Other treatments include detergents, especially those with perfumes; including immunosuppressing drugs, such as aza- chemicals used in photo development; ammonia thioprine and methotrexate, may be prescribed. Physical therapy is usually Treatment involves identifying and avoiding sub- recommended to preserve muscle function and stances that cause attacks and, during attacks, using avoid muscle atrophy. Dermatitis herpetiformis is asso- ciated with a disorder of the small intestine called dermatophytic onychomycosis See ony- celiac sprue. For example, when the rash of measles descending aorta starts after the arch of the aorta fades, desquamation occurs. The most important stage of human devel- opment occurs before birth, as tissues and organs designer drug A drug, typically a psychoactive arise from differentiation of cells in the embryo. An brain-based abilities such as speech and hand–eye example of a designer drug is the street drug coordination, and learns. Interruptions in any of “ecstasy,” which is an analogue of methampheta- these processes can result in developmental delay. Also known as selective estrogen-receptor modula- development, fetal See prenatal development. For example, raloxifene (brand name: Evista) is classified as a designer estrogen because, developmental delay A condition in which a like estrogen, it prevents bone loss and lowers child is behind schedule in reaching milestones of serum cholesterol; however, it does not stimulate early childhood development. Desmoid tumors occur most often in young adults, and they developmental disorder One of several disor- usually involve the limbs or trunk, but they can also ders that interrupt normal development in child- arise in the abdomen or thorax. A developmental disorder may affect a single are very difficult to remove because they adhere area of development (specific developmental disor- tenaciously to surrounding structures and organs.