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  • Field Chair of Ophthalmologic Research, Professor and Head, Department of Ophthalmology and Visual Sciences, University of Illinois Eye and Ear Infirmary, Chicago, IL, USA

However inoar hair treatment cheap copegus 200mg without prescription, the entrance is usually blocked by the N-termini of the -subunits medications valium buy copegus 200mg free shipping, which together form a gate to medications knee order copegus 200 mg overnight delivery control entry and prevent indiscriminate protein degradation medications errors cheap 200mg copegus. Pleurisy pain radiate to right shoulder which part of pleura affected: a- visceral b- mediastina l c- anterior Answer: B Explanation: the visceral pleura does not contain any noci-ceptors or pain receptors. The parietal pleura is innervated by somatic nerves that sense pain when the parietal pleura is inflamed. The parietal pleura subdivided according to the part of the body that it is contact with: Mediastinal pleura (central), Cervical pleura, Costal pleura, and Diaphragmatic pleura. The phrenic nerve supplies innervations to the central part of each hemidiaphragm; when these fibers are activated, the sensation of pain is referred to the ipsilateral neck or shoulder Intercostal nerves supply outer rib cage and lateral aspect of each hemidiaphragm: when these fibers are activated, the sensation of pain is referred to thoraco-abdominal wall. Atypical hyperplasia -What is most common serious chronic infection found in expatriates coming to Saudi Arabia? Aurine catacholamins Bdexamethasone stress test **I think pheochromocytoma -twisted ankle What is the most common ligament Anterior talofibular ligament ** in inversion sprain. A Sickle cell anemia B Thalassmia C Spherocitosi s D B12 **Functional hyposplenism is a condition accompanying many diseases such as 1-sickle celiac disease 2-alcoholic liver disease 3-hepatic cirrhosis 4-lymphomas 5-autoimmune disorders. Pneumonea Mycoplasma pneumonea Others 2- 77 yo male with early onset of dyspnea whin moving 50 meters, has left apical heave and loud audible systolic murmur most intenst to hear in hight sternal border. Sever mitral regurgitate Calcified aortic stenosis 3- Gram -ve lactose non fermenting oxidase +ve. Vancomycin (metronidazole not in the choices) 6- Women with high heels fall in a bizarre way with outward (eversion) of foot. Fentenyl (not sure) 21- Case of rheumatoid arthritis with swilling in the 2nd to 5th fingers bilaterally, what are these? Bouchard nodules Heberden nodules Synovial swilling (my answer) Subcutaneous nodules 22- Case of hematoma under nail after door Closed over finger, management? Observation Evacuation of hematoma 23- Village with high nomber of cretinism, first thing to do is? Levothyroxin (my answe) 24- Psoriasis (silver scale) involving 15% of skin treatment. Give anti tetanus 72 h before delivery Vaccinate the mother during her pregnancy (my answer) 29- 17 yo boy with Audiogram shows conductive hearing loss in the left ear. I tried to write what was confusing but it is a personal effort has the possibility to be wrong. Use in connection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed is forbidden. The use in this publication of trade names, trademarks, service marks, and similar terms, even if they are not identified as such, is not to be taken as an expression of opinion as to whether or not they are subject to proprietary rights. While the advice and information in this book are believed to be true and accurate at the date of going to press, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein. These two very capable, caring young people represent the bright future of health care. In this edition, physical diagnosis is a subsection in each chapter, which we believe gives better continuity. Additionally, at the end of each chapter we have created a number of multiple-choice questions considered appropriate for medical students to be able to answer. Each chapter has been revised to reflect updated material and, as in previous editions, we have kept to a standardized format as much as possible. The topics are presented from a straightforward practical point-ofview, with the material being condensed to its most salient features. Algorithms are at the heart of each chapter, with the decision points being based on practice standards and guidelines. This format allows the student, when confronted with a specific clinical problem, to formulate both a diagnostic plan and a treatment plan.

Damage to medicinenetcom buy 200 mg copegus with amex the spinal accessory nerve results in trapezius dysfunction and lateral scapular winging medicine 319 purchase copegus 200 mg with visa. Long thoracic nerve injury leads to treatment 247 buy cheap copegus 200 mg on-line serratus anterior dysfunction and medial scapular winging symptoms 8 dpo discount 200mg copegus fast delivery. Pain and loss of motion in the glenohumeral joint can lead to overuse and fatigue of the scapular stabilizer muscles, resulting in scapular winging. The Brachial Plexus the brachial plexus is composed of the ventral rami of cervical roots C5, C6, C7, and C8 and ventral thoracic root T1. The brachial plexus includes five nerve roots, three trunks (superior, middle, and inferior), six divisions (three anterior, three posterior), three cords (lateral, medial, and posterior), and six terminal branches (musculocutaneous, ulnar, medial cord branch to median nerve, lateral cord branch to median nerve, axillary, and radial). With the exception of the divisions, nerves originate from each level of the brachial plexus to innervate muscles of the shoulder girdle. Brachial plexus injuries are relatively common with traumatic shoulder girdle injuries such as proximal humerus fractures, glenohumeral dislocations, and fracture-dislocations. Carroll For example, a high-school athlete with activity-related shoulder pain is more likely to have instability or labral pathology than a rotator cuff tear. Conversely, a 65-year-old who has shoulder pain with activities of daily living is more likely to have rotator cuff disease than a labral tear or instability. The physical examination is used to narrow the differential diagnosis and make the definitive diagnosis. Most of the time an accurate diagnosis can be made using only the history and physical examination. Before ordering additional studies, the examiner must have a clear understanding of how the study will contribute to the evaluation and treatment of the patient. History Patients with shoulder pathology most often complain of pain, stiffness, instability, and weakness. When pain is the chief complaint, the examiner must characterize the pain, with particular attention to location. Pain from the glenohumeral joint and its surrounding soft tissues typically is localized to the anterosuperior aspect of the shoulder. Localization of the pain to the deltoid insertion in the arm is common in rotator cuff or subacromial pathology. Pain emanating from the neck or to the posterior scapular region is often due to cervical spine disease. Pain and crepitation in the periscapular region, however, may be related to scapulothoracic bursitis. The timing and frequency of shoulder pain must also be given careful consideration. Pain with overhead activities of daily living is common in rotator cuff pathology. Pain with sporting activities such as swimming, throwing, or serving is often related to the labrum or glenohumeral ligaments. Night pain is often reported with shoulder girdle pathology, especially in the setting of rotator cuff tears. Rest pain is uncommon but may occur with severe arthropathy or radicular pain from the cervical spine. If rest pain is the predominant complaint, the examiner should consider infection or malignancy as a possible source of pain. Pain that begins with a traumatic event such as a fall on an outstretched hand, direct blow to the shoulder, or shoulder dislocation may represent significant damage to the rotator cuff, ligaments, or bony structures. Pain that begins days or weeks after a seemingly innocuous event such as shoveling snow; trimming hedges, or painting may represent tendonitis or early capsulitis. Pain that begins more insidiously or over time is more likely to be related to degenerative lesions of the shoulder girdle such as rotator cuff tears or osteoarthritis. The patient may describe the shoulder "slipping out of place" or "getting stuck" in 8. It is important to establish whether a frank shoulder dislocation was ever documented. True traumatic shoulder dislocations are the result of significant trauma and require a manipulative reduction.

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Indeed medications equivalent to asmanex inhaler buy 200 mg copegus, it is generally believed that if treatment is delayed until after the age of walking treatment gout cheap copegus 200mg on-line, it will not be possible to treatment jaundice copegus 200mg amex produce a normal hip treatment qt prolongation cheap copegus 200 mg online. For the child under 3 months of age with a frank dislocation or with persistent instability (as documented, for example, by a positive Barlow test in a 3-week-old), appropriate application and use of a Pavlik harness assures a normal hip in about 80% of cases. The device, however, is not foolproof, with avascular necrosis, inferior dislocation, and femoral nerve palsy reported as complications, not to mention failure to achieve a reduction. If diagnosis for some reason is delayed and the child presents after 6 months for treatment, more-aggressive modalities are generally required 212 J. Closed reduction under anesthesia, adductor tenotomy, and occasionally prereduction traction are generally employed at this point, with open reduction indicated for those who cannot undergo closed reduction. After 18 months of age, operative approaches are required to reduce the hip and also to reconform the acetabulum. Pelvic osteotomies and proximal femoral osteotomies are utilized in the older age groups. Keep in mind that it is rarely possible to produce a normal hip when treatment is initiated after the age of walking. The complication most dreaded, avascular necrosis, can occur at many points in the treatment algorithm. Unfortunately, all authors interpreted that the observed changes were caused by nontuberculous sepsis. It has more recently been shown that the changes cannot be produced by a single period of avascularity. Rather, multiple episodes are needed to cause the characteristic pathologic changes. The affected children are typically male, from a lower socioeconomic status, aged 4 to 9 years, and slightly delayed in skeletal growth. Clinically, the child usually has restricted hip motion, especially rotational, and some adductor muscle spasm. Because standard laboratory studies are usually normal, imaging studies are paramount in the diagnosis and treatment of the disease. Initially, the stage of synovitis, which lasts 2 to 3 weeks, produces an irritable hip syndrome easily confused with toxic synovitis. Subsequently, the stage of avascularity onsets, lasting 2 to 3 months, during which time the femoral head necrosis occurs. Once the avascular event has occurred, the femoral head revascularizes and the process will "heal," resulting in the stage of revascularization. The critical issue is the degree of deformation of the normally spherical femoral head before complete healing occurs. Eccentric mechanical loads applied to the softened, diseased head frequently alter its sphericity. Ultimately, the process burns itself out, leaving the hip in the stage of residua. The healing phase lasts approximately 2 years, at which time only the residual deformity remains as the permanent marker of the disease. The treatment principles for this disease are really no more advanced than they were 30 years ago. Children under age 5 will do well left untreated, which is the current recommendation. Obviously, the head that is completely necrotic is more likely to sustain permanent deformation than a head only partially involved. Note the smaller ossific nucleus caused by cessation of bone growth as a result of avascular necrosis. Note in (E) the dent in the lateral part of the femoral head that is blocking concentric reduction of the hip. On abduction of the hip (F), the femoral head is displaced further laterally, with increase in the medial joint space. Lauerman children of intermediate age, 5 to 8 years, the principle of "containment" continues to be accepted. Conceptually, the thought is to place the softened femoral head concentrically into the acetabulum, which will in turn act as a mold or template as the head revascularizes. This alteration can be accomplished in the smaller child by using an abduction orthosis. The treatment for the older child with an already deformed hip is highly controversial.

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The majority of patients with neck pain will respond to symptoms xeroderma pigmentosum buy copegus 200 mg amex therapy and return to medications vs grapefruit buy copegus 200mg line a normal life pattern within 2 months of the beginning of their problem treatment concussion cheap copegus 200 mg with amex. If the initial conservative treatment regimen fails medicine 369 cheap copegus 200mg line, symptomatic patients are divided into two groups. The first is composed of people who have neck pain as a predominant complaint, with or without interscapular radiation. In the lower cervical spine (C3 through C7), instability is identified by horizontal translation of one vertebra on another of more than 3. The majority of patients with instability will respond well to further nonoperative measures, including a thorough explanation of the problem and some type of bracing. In some cases, these measures fail and a surgical fusion of the involved spinal segments will be necessary. Another group of patients complaining mainly of neck pain will be found to have degenerative disease on their plain X-ray films. The roentgenographic signs include loss of height of the intervertebral disk space, osteophyte formation, secondary encroachment of the intervertebral foramina, and osteoarthritic changes in the apophyseal joint. The difficulty is not in identifying these abnormalities on the roentgenogram but in determining their significance. In a study of matched pairs of asymptomatic and symptomatic patients, it was concluded that large numbers of asymptomatic patients show roentgenographic evidence of advanced degenerative disease. There was no difference between the two groups insofar as changes at the apophyseal joints, intervertebral foramina, or posterior articular process. These patients should be treated symptomatically with antiinflammatory medication, support, and trigger-point injections as required. Finally, they should be reexamined periodically because some will develop significant pressure on the neurologic elements (myelopathy). The bone scan is an excellent tool, often identifying early spinal tumors or infections not seen on routine roentgenographic examinations. A thorough medical search may also reveal problems missed in the early stages of neck pain evaluation. The Spine 297 pain and his stability in relationship to his sociologic environment. Drug habituation, alcoholism, depression, and other psychiatric problems are frequently seen in association with neck pain. If the evaluation reveals this type of pathology, proper measures should be instituted to overcome the disability. Should the outcome of the psychosocial evaluation prove to be normal, the patient can be considered to have chronic neck pain. Patients with chronic neck pain need encouragement, patience, and education from their physicians. All these patients need periodic reevaluation to avoid missing any new or underlying pathology. Arm Pain Predominant (Brachialgia) Patients who have pain radiating into their arm may be experiencing their symptoms secondary to mechanical pressure and inflammation of the involved nerve roots. This mechanical pressure may arise from a ruptured disk or from bone secondary to degenerative changes. Extrinsic pressure on the vascular structures or on the peripheral nerves are most likely imitators of brachialgia. If any of these are positive for peripheral pressure on the nerves or other pathology, the appropriate therapy should be administered. It has been repeatedly documented that for surgery to be effective, unequivocal evidence of nerve root compression must be found at surgery. One must have a strong confirmation of mechanical root compression from the neurologic examination and a confirming study before proceeding with any surgery. If the patient does not have these, there is inadequate clinical evidence to proceed with surgery. For patients who have met these criteria for cervical decompression, the results will usually be satisfactory: 95% of them can expect good or excellent outcomes. Conservative Treatment Modalities Most patients with neck pain will achieve relief from a conscientious program of conservative care.

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An amputation may entail a marginal medications zanx generic 200mg copegus with mastercard, wide medications not to mix purchase copegus 200mg amex, or radical excision medicine 3d printing copegus 200mg line, depending upon the plane through which it passes in relationship to treatment 5cm ovarian cyst cheap copegus 200mg line the tumor. Therefore, an amputation is not automatically an adequate cancer operation; careful consideration to the desired final margin is required before selection of the amputation level. The local anatomy dictates how a specific margin can be obtained surgically, and proper preoperative staging (as already discussed) is necessary to assess both local tumor extent and relevant local anatomy. In general, benign bone tumors can be adequately treated with either an intralesional procedure (curettage) or a marginal excision. This type of reconstruction is frequently utilized following curettage and cryosurgery to permit early mobilization, and it can be used in all anatomic locations. Tumors of the Musculoskeletal System 119 strates reconstruction of a tumor cavity following curettage and cryosurgery. Malignant tumors require a minimum of wide (intracompartmental) excision or radical (extracompartmental) resection, which can be accomplished by amputation or by an en bloc procedure (limb salvage). Similarly, benign soft tissue tumors are treated by marginal excision, aggressive tumors by wide excision, and malignant tumors by wide or radical resection. Malignant Bone Tumors Primary malignancies of bone arise from mesenchymal cells (sarcoma) and bone marrow cells (myeloma and lymphoma). Multiple myeloma and metastatic carcinoma typically increase in frequency with increasing patient age and are usually seen in patients over 40 years of age. This section describes the clinical, radiographic, and pathologic characteristics and treatment of the primary bone sarcomas. Osteosarcoma provides the model on which treatment of all other sarcomas is based. The effectiveness of multiagent chemotherapy regimens has been proved by increasing overall survival rates from the bleak picture of 15% to 20% with surgery alone in the 1970s to 55% to 80% by the 1980s. In parallel with improved survival, dramatic advances in reconstructive surgery have made it possible for limb salvage to supplant amputation as the standard method of treatment. Its distinguishing characteristic is the production of "tumor" osteoid, or immature bone, directly from a malignant spindle cell stroma. The most common sites are bones of the knee joint (50%) and the proximal humerus (25%). With the exception of the level of serum alkaline phosphatase, which is elevated in 45% to 50% of patients, laboratory findings are usually not helpful. Pain is the most common complaint on presentation, with a firm, soft tissue mass fixed to the underlying bone found on physical examination. Although there is no statistically significant difference among overall survival rates of these types, it is important to recognize the patterns. Between these cells is a delicate, lacelike eosinophilic matrix, assumed to be malignant osteoid. The term osteoblastic osteosarcoma is used for those tumors in which the production of malignant osteoid prevails. Some tumors reveal a predominance of malignant cartilage production; hence, the term chondroblastic osteosarcoma. Yet another variant is characterized by large areas of proliferating fibroblasts, arranged in intersecting fascicles. Such areas are indistinguishable from fibrosarcoma, and thorough sampling may be necessary to identify the malignant osteoid component. Natural History, Prognosis, and Chemotherapy Before the development of adjuvant chemotherapy, effective treatment was limited to radical margin amputation. Tumors of the Musculoskeletal System 121 bones generally occurred within 24 months. No significant correlation between overall survival and histologic subtypes, tumor size, patient age, or degree of malignancy was seen. The most significant clinical variable was anatomic site: pelvic and axial lesions had a lower survival rate than extremity tumors, whereas tibial lesions had a better survival rate than femoral lesions. The dismal outcome associated with osteosarcoma has been dramatically altered by adjuvant chemotherapy as well as by aggressive thoracotomy for pulmonary disease. A recent update of 227 patients showed that 48% remained alive at an average 11 years after surgery. Of critical importance was that no difference in local recurrence or overall survival was seen between patients undergoing amputation versus limb-sparing surgery.

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