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By P. Asaru. Medical College of Wisconsin.

A 78-year-old woman with hypertension presents for a 3-month follow-up visit for her hypertension safe tadora 20 mg erectile dysfunction treatment centers in bangalore. A year ago order tadora 20mg overnight delivery erectile dysfunction drugs non prescription, she moved to a retirement community, where she began to eat meals more regularly; during the past year, she has gained 15 lb. She is a lifelong smoker; she smokes one pack of cigarettes a day and has repeatedly refused to receive coun- seling regarding smoking cessation. She has occasional stiffness on waking in the morning. She reports taking the prescribed antihypertensive therapy almost every day. She is concerned about her weight gain because this is the most she has ever weighed. She has reported that she has stopped eating desserts at most meals and is aware that she needs to reduce the amount of fat she eats. She has never exercised regularly, but her daughter has told her to ask about an aerobic exer- cise program. She has asked for exercise recommendations, although she does not know whether it will make much difference. Which of the following would you recommend for this patient? Attendance at a structured aerobic exercise program at least three times a week ❏ B. Membership in the neighborhood YMCA for swimming ❏ C. Walking three times a week, preferably with a partner ❏ D. Contacting a personal trainer to develop an individualized exercise program ❏ E. No additional exercise because she has symptoms of osteoarthritis Key Concept/Objective: To recognize that even modest levels of physical activity such as walking and gardening are protective even if they are not started until midlife to late in life Changes attributed to aging closely resemble those that result from inactivity. In sedentary patients, cardiac output, red cell mass, glucose tolerance, and muscle mass decrease. Systolic blood pressure, serum cholesterol levels, and body fat increase. Regular exercise appears to retard these age-related changes. In elderly individuals, physical activity is also associated with increased functional status and decreased mortality. Although more stud- ies are needed to clarify the effects of exercise in the elderly, enough evidence exists to war- rant a recommendation of mild exercise for this patient, along with counseling concern- ing the benefits of exercise at her age. Walking programs increase aerobic capacity in indi- viduals in their 70s with few injuries. Although structured exercise is most often recom- mended by physicians, recent studies demonstrate that even modest levels of physical activity such as walking and gardening are beneficial. Such exercise is protective even if it is not started until midlife or late in life. Because this patient is used to a sedentary lifestyle 4 BOARD REVIEW and is not strongly motivated to begin exercising, compliance with exercise recommen- dations may be an issue. Lifestyle interventions appear to be as effective as formal exercise programs of similar intensity in improving cardiopulmonary fitness, blood pressure, and body composition. Exercise does not appear to cause or accelerate osteoarthritis. However, counseling concerning warm-ups, stretches, and a graded increase in exercise intensity can help prevent musculoskeletal problems as a side effect of exercise. A 50-year-old woman presents for a follow-up visit to discuss the laboratory results from her annual physical examination and a treatment plan. Her total serum cholesterol level is 260 mg/dl, which is up from 200 mg/dl the previous year.

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Then cheap tadora 20mg with mastercard impotence juice recipe, we flex the knee while letting go instability is in a lateral direction 20 mg tadora with mastercard erectile dysfunction treatment in lucknow; some patellae the patella, which causes the patella to go into have medial instability and some patients suffer the femoral trochlea. In patients with medial from multidirectional instability. If this test is positive, we should put instability is lateral. This is patellar displacement with 20˚ to 30˚ of knee another way to confirm our diagnosis before flexion), indicates that lateral patellar instability indicating a surgical treatment. It is very important to assess the flexibility of This test may be so positive that the patient quadriceps, hamstring, and gastrocnemius mus- withdraws the leg rapidly when the examiner cles and that of the iliotibial band, as the pathol- approaches the knee with his or her hand, pre- ogy under scrutiny is often associated to a venting thus any contact, or he or she grabs the decrease in flexibility of these structures. Tightness of these structures indicates the need Figure 6. Patellar glide test in a patient with multidirectional instability. Pathological lateral displacement of the patella (a). We have seen an image (a) similar to the sulcus sign observed in patients with multidirectional instability of the shoulder (c). Evaluation of the Patient with Anterior Knee Pain and Patellar Instability 99 Figure 6. We hold the patella slightly in a medial direction with the knee extended (a). It is important to assess quadriceps con- hand to prevent compensatory hip flexion tracture as this can increase in a direct way the (Figure 6. We can measure the quadriceps contact pressure between patella and femur. To test hamstring flexibility the patient lies Suggestions of quadriceps retraction are:34 (1) supine with the hip at 90˚ of flexion. Evaluation of the Patient with Anterior Knee Pain and Patellar Instability 101 is then asked to straighten his or her knee (Figure 6. If complete extension is not possi- ble, there is a hamstring contracture, and its amount is measured by the popliteal angle. Most young athletic individuals have popliteal angles between 160 and 180 degrees. Hamstring tightness could also be associated with spondylolisthesis. We evaluate gastrocnemius tightness per- forming a passive ankle dorsiflexion with the knee extended and the foot in slight inversion (Figure 6. Normally this should reach 15˚ from the neutral position. Tightness of the gastrocnemius, in the same way as ham- strings tightness, increases the PFJR force, pro- ducing a maintained flexed position of the knee. Moreover, limited ankle dorsiflexion results in increased subtalar joint pronation that causes an increment of tibial internal rotation that has deleterious effects on patellofemoral biome- chanics. We use the Ober’s test to assess ITB flexibility Figure 6. To perform this test, the patient lies which places the ITB on maximal stretch. Then, the examiner cause severe pain in patients who have excessive flexes the involved knee and hip 90˚ each. At this position, we ask the patient that, he abducts passively the involved hip as far to relax, and then the thigh is adducted passively. If the thigh drops Evaluation of the Patient with Anterior Knee Pain and Patellar Instability 103 into an adducted position, the test is negative producing the reflex inhibition and subsequent (normal ITB). They found that As we have seen, patients suffering from VMO inhibition is produced with approximately patellofemoral problems usually show a flexibil- 20–30 ml of intra-articular fluid. Thus, patellar dislocation is six times more fre- Thus, control of effusion is essential for ade- quent in hypermobile patients in comparison quate rehabilitation. With the patient less frequent in hypermobile patients.

There is rarely an acute indication for biopsy order tadora 20 mg mastercard bpa causes erectile dysfunction, except in the suspicion of peripheral nerve vasculitis or florid polymyositis safe 20 mg tadora erectile dysfunction prevalence age. According to our own experience, the number of nerve biopsies seems to be decreasing due to the increased power of genetic testing, or the sufficiency of clinical and immunological criteria for some diseases like CIDP. Imaging studies are becoming increasingly important as a precursor to biopsy. Particularly in muscle disease, imaging allows estimation of the pattern of distribution of the disease in various muscles. In patients with considerable muscle atrophy and fatty replacement, imaging helps in the selection of the muscle to be biopsied. Nerve biopsy The sural nerve is the most frequently biopsied nerve. Some schools prefer the superficial peroneal nerve, and biopsies from other nerves such as the superfi- 29 cial radial or pectoral nerves can be obtained. The nerve should be fixed in formalin, prepared for electron microscopy, and a special segment should be kept ready if nerve teasing is indicated. Immunologic studies can be best obtained on a frozen section. More material for serial sections may be necessary in cases of vasculitis. The histologic examination includes hematoxilyn eosin (HE) sections, stain- ing for myelin, and special stainings depending on the case. A morphometric analysis can be used to define the population of myelinated fibers, which is bimodal in the normal nerve. Plastic embedded sections and preparations for teased fibers should be available. The analysis of the biopsy can distinguish between axonal pathology, demyelination, regeneration, inflammation, and rare conditions such as neoplastic involvement or deposition of amyloid. Muscle tissue can be examined by several histologic techniques, including light Muscle biopsy microscopy, electron microscopy, and histochemistry. Immunohistochemistry uses available antibodies to detect immunologic alterations or defined struc- tures. Molecular diagnosis, studying the cytoskeleton and its interaction with the sarcolemma, extracellular matrix, and transmembrane proteins, has been applied in the diagnosis of dystrophies. There is a long list of myopathies that warrant a biopsy, either for morpholog- ical, molecular, or biochemical analysis. In clinical practice, a biopsy is often performed to discover or confirm inflammatory conditions (dermato-, polymyositis), structural abnormalities, and finding additional morphologic indication of neuromuscular disease. Simultaneous muscle and nerve biopsies are recommended in cases of suspect- ed vasculitic neuropathies. The likelihood of detecting inflammatory changes is higher by using both techniques together. Skin biopsy allows an estimation of epidermal innervation. It has been advocat- Skin biopsy ed in diabetic polyneuropathy by several studies. Collins MP, Mendell JR, Periquet MI, et al (2000) Superficial peroneal nerve/peroneus References brevis muscle biopsy in vasculitic neuropathy. Neurology 55: 636–643 Gabriel CM, Howard R, Kinsella N, et al (2000) Prospective study of the usefulness of sural nerve biopsy. J Neurol Neurosurg Psychiatry 69: 442–446 Smith GA, Ramachandran P, Tripp S, et al (2001) Epidermal nerve innervation in impaired glucose tolerance and diabetes associated neuropathy. Neurology 57: 1701–1704 Said G (2002) Indications and usefulness of nerve biopsy. Arch Neurol 59: 1532–1535 Sander S, Ouvrier RA, McLeod JG (2000) Clinical syndromes associated with tomacula or myelin swellings in sural nerve biopsies. J Neurol Neurosurg Psychiatry 68: 483–488 Quantification of function, impairment, disability, treatment outcome, and Assessment and quality of life are some of the parameters which need thorough, statistically treatment of neuro- valid, efficient, sensitive, and specific methods.

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She has a history of rheumatoid arthritis and has been on hydroxy- chloroquine buy tadora 20mg cheap erectile dysfunction medication new zealand, 400 mg/day cheap tadora 20mg otc erectile dysfunction treatment testosterone, and prednisone, 5 mg/day, for several years. On examination, the eye is very red, with a violaceous hue to the sclera. Gentle finger pressure over the eyelid onto the globe is painful. Which of the following should be the next step in the care of this patient? Call for an ophthalmology appointment Key Concept/Objective: To be able to recognize serious eye disease in rheumatoid arthritis Patients with rheumatoid arthritis may have a variety of eye problems, including dry eye, episcleritis, and scleritis. Dry eye is rarely serious and is treated with eyedrops and lubri- cants. Episcleritis is inflammation of superficial vessels and is generally not a threat to vision; scleritis is caused by inflammation of the deeper vessels and can lead to loss of vision. Differentiation of the two is based on the more violaceous hue of the sclera in scle- ritis—caused by inflammation around the sclera vessels—and pain on pressure over the closed lid onto the globe, which is not seen in episcleritis. Confirmation can be done by 8 BOARD REVIEW slit-lamp examination. Scleritis comes in different forms, and treatment decisions are best made in conjunction with an ophthalmologist. The most serious form of scleritis can lead to scleromalacia perforans, which usually leads to blindness in the affected eye. Hydroxychloroquine can cause eye disease, notably retinopathy, but there are no superfi- cial manifestations. A 55-year-old man comes to your clinic with a persistent cough. He had a viral syndrome 3 weeks ago that has cleared, but he continues to have a nonproductive cough. Past medical history is significant for seropositive rheumatoid arthritis and a 25-pack-year history of smoking. Current medications include leflunomide, 10 mg/day, and prednisone, 5 mg/day. Physical examination is significant for mild ulnar deviation of the fingers and fibular deviation of the toes, but little active synovitis. Rheumatoid nodules are present over the extensor surface of both forearms near the elbows. Chest x-ray reveals a 2 cm × 2 cm pulmonary nodule in the right upper lobe but is otherwise normal. Which of the following should be the next step in the care of this patient? Perform a CT scan to evaluate the lesion further E. Schedule a transbronchial biopsy Key Concept/Objective: To understand the evaluation of pulmonary nodules in patients with rheumatoid arthritis Patients with rheumatoid arthritis, particularly men with subcutaneous nodules who are smokers, are prone to developing rheumatoid nodules in the lung. They can be of various sizes, may be single or multiple, and tend to be peripheral in location. Unfortunately, those patients who are at risk for rheumatoid lung nodules are also at risk for lung cancer, and pulmonary nodules in patients with rheumatoid arthritis should be considered potentially malignant. A CT scan of the chest is the most reasonable first step to evaluate location and the presence of adenopathy. In most cases, a biopsy will be necessary for histologic evaluation. A 35-year-old woman comes to clinic for follow-up of rheumatoid arthritis and to evaluate a new rash on the lower extremities. She was diagnosed with rheumatoid arthritis 5 years ago on the basis of joint pain and a positive rheumatoid factor, but the rheumatoid factor has been intermittently positive since then. Physical examina- tion is significant for the lack of synovitis in the small joints of the hands and feet and the presence of palpable purpura on both lower extremities. Biopsy of the purpura reveals leukocytoclastic vasculitis. Which of the following would be the most useful serologic test to clarify this patient’s illness?

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Because he does not have nasal polyps cheap tadora 20 mg otc erectile dysfunction from smoking, it is unlikely that he has aspirin hypersensitivity B order tadora 20 mg with mastercard for erectile dysfunction which doctor to consult. He is likely to have similar reactions to all NSAIDs C. This reaction was the result of salicylate sensitivity, so ibuprofen should be safe for him to use D. This reaction suggests that he would not benefit from a leukotriene modifier E. A COX-2 inhibitor, such as celecoxib, is likely to be safe for him to use 14 RESPIRATORY MEDICINE 5 Key Concept/Objective: To understand the relationship between asthma and aspirin hypersensitivity Aspirin hypersensitivity can initially present with bronchoconstriction or other allergic symptoms. Cross-reactivity with other NSAIDs is almost universal, because the causal mechanism is likely mediated by COX. Therefore, all NSAIDs, including COX-2 inhibitors, are likely to cause a reaction. Despite the classic triad, asthma and aspirin hypersensitivity often coexist in the absence of nasal polyps. Leukotriene modifiers are likely to be more effective in patients with aspirin hypersensitivity because of their effect on the COX pathway. A 28-year-old woman seeks a second opinion for asthma that has been recently worsening. She has had asthma for the past 14 years, but over the past 6 months her symptoms have been more severe. In addi- tion to wheezing, shortness of breath, and chest tightness, she has had intermittent fevers and flulike symptoms. She has been treated with multiple courses of antibiotics as well as increasing doses of inhaled steroids with no significant improvement. A chest x-ray shows patchy bilobar infiltrates, which are in different locations from those seen on a chest x-ray that she had 3 months ago. Which of the following statements about this patient is false? Her serum eosinophil count is probably elevated B. A sputum culture for Aspergillus is likely to be positive C. Any bronchial involvement is likely to be on the surface only, with- out tissue invasion D. She may need to be treated with systemic corticosteroids E. A trial of antifungal therapy will not be helpful Key Concept/Objective: To understand the pathophysiology, diagnosis, and treatment of aller- gic bronchopulmonary aspergillosis Allergic bronchopulmonary aspergillosis is a hypersensitivity reaction to colonization of the airways by Aspergillus. Recent studies have shown that the combination of the antifungal itraconazole and inhaled steroids may be effective treatment. If they fail, sys- temic corticosteroids may be necessary. Allergic bronchopulmonary aspergillosis typi- cally causes an elevated serum eosinophil count, and sputum cultures will test positive. It is very unlikely that there will be fungal tissue invasion. A 57-year-old patient who smokes cigarettes presents with chronic productive cough and persistent pro- gressive exercise limitation that is a result of breathlessness. For this patient, which of the following statements is true? Significant airway obstruction occurs in only 10% to 15% of people who smoke B. The best tool for assessing the severity of obstruction is the ratio of forced expiratory volume in 1 second to forced vital capacity (FEV1/FVC) C. Chronic bronchitis is a clinical diagnosis defined as the presence of cough and sputum production on most days for at least 3 consecu- tive months in a year 6 BOARD REVIEW D. Measurement of lung volumes in patients with chronic airway obstruction (CAO) uniformly reveals an increased residual volume and a decreased functional residual capacity (FRC) Key Concept/Objective: To understand the pathogenesis and pathophysiology of chronic obstructive pulmonary disease (COPD) Chronic bronchitis and emphysema are by far the most common causes of chronic air- flow obstruction. Chronic bronchitis is defined as the presence of cough and sputum on most days for at least 3 months of the year for a minimum of 2 years in succession.

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