Finast

By J. Surus. American University.

EXAMPLE OF MEDICAL HISTORY City: Arezzo Date: January 2 discount 5 mg finast amex hair loss cure google, 2000 Mr/Mrs: PAOLA ROSSI Address: Florence Tel discount finast 5mg visa hair loss with weight loss. Past medical history: Noncontributory Family history: Positive to vasculopathy Allergies: & Yes &ü No Smoker: &ü Yes & No Hepatitis: & Yes &ü No Diabetes: & Yes &ü No Exercise: & Yes &ü No MEDICAL HISTORY: Deliveries: Two Surgeries: Appendectomy; tonsillitis episodes Diseases: Mild overweight Therapies: Current Medical History: 1. Hormones: Estro-progestagens since 3 years ago 102 & LEIBASCHOFF EXAMINATION ARTERIAL SYSTEM: No lower limb arteriopathy VENOUS SYSTEM: Normal deep veins, with normal valves R (Right): NO Varicosis saphena—small saphenous vein normal L (Left): NO Varicosis saphena—telangiectasia due to knee hyperextension—small saphe- nous vein normal LYMPHOADIPOSE SYSTEM: Mixed adipoedematous hypodermatosis with adiposity in flanks and culotte de cheval. LOCOMOTOR SYSTEM AND FEET: Lower limbs dysmetria þ pes varus valgus to the left with thrust deficit and takeoff alteration. Typical primary lymphedema observed that started unexpectedly in summer, as usual. Adi- poedematous cellulitis with localized adiposity and true bitrochanteric culotte de cheval–knee lymphedema. Cellulitic pathology Localization: Type: Echography Videocapillaroscopy ROM test VEGA expert test CLINICAL INSTRUMENT CLASSIFICATION OF CELLULITE PATHOLOGY: Cellulite pathology code: G1a/S2/V3/A1a-b Clinical instrument examination: Photoplethysmography-podoscopy-videocapillaroscopy DIAGNOSIS & 103 THERAPEUTIC STRATEGY: Suggested: Medical therapy: Phase 1: Cleansing: Cellulase gold 3 per day Phase 2: Maintenance: Cellulase gold 2 tablets/day + SPECIFIC THERAPY: Carboxytherapy Carboxytherapy six sessions one/week Endermologie1 Endermologie1 twice a week during one month Mesotherapy Mesotherapy once a week in calves Control within 30 days Diet Hyperprotein 15 days SURGICAL THERAPY: Liposculpture in culotte de cheval and knees LOCAL THERAPY: Functional plantar þ panty hose 15 mm/Hg LIFESTYLE: Walk frequently Pay attention to stypsis and control weight 6 Cellulite Characterization by High-Frequency Ultrasound and High-Resolution agnetic Resonance Im aging Bernard Querleux Department of Physics, L’Oreal´ Recherche, Aulnay-sous-bois, France & INTRODUCTION Cellulite is an accepted term for describing an aesthetic problem called the ‘‘orange peel effect,’’ which causes some dimpling of the skin. Cellulite, which affects about 90% of women, is usually associated with lipodystrophy, localized on the thigh, buttock, and hip (1,2). Histologically, some authors report modifications of the dermal–hypodermal interface, and describe different patterns of the architecture of fibrous septae in adipose tissue in women with cellulite (3,4). Also an increase in the volume of adipocytes in women with cellulite as well as alterations of the lymph vessels and blood circulation has been reported (5). Few studies have been performed in vivo with noninvasive methods. In this chapter, we will present a comparison of the skin and adipose tissue properties in women with cellulite compared to normal women without visible signs of cellulite. We used in vivo high-frequency US imaging for skin characterization, and high-spatial-resolution MR imaging and spectroscopy for adipose tissue characterization. The subjects were recruited by a medical expert according to the follow- ing main inclusion criteria—age range: 18 to 45 years; body mass index (BMI): 17 to 27; constant weight during the last year; regular menstrual cycle; and between 0 and 10 days postmenstruation at the date of the experiment. The volunteers were divided into two 105 106 & QUERLEUX groups by experienced medical personnel: women with no visible cellulite even after compression at the study sites (n ¼ 21, age ¼ 23. US IMAGING High-frequency US imaging was performed with our home-built scanner equipped with a focused 25 MHz transducer offering an axial resolution of 70 mm and a lateral resolution of 130 mm (12). Series of 64 cross-sectional images [field-of-view (FOV) ¼ 4mm 20 mm  20 mm] were acquired on the upper dorsal thigh (Fig. From these images, the thickness of the skin was measured as well as the topography of the dermal–hypodermal interface. Figure 1 In vivo high-frequency US imaging of skin on the thigh. A resolution of 70 mm in the direction perpendicular to the skin surface allows a clear visualization of hypodermal indentations (! MR IMAGING High-spatial-resolution MR images were obtained by connecting to a standard 1. With an in-depth resolution of 80 mm, CELLULITE CHARACTERIZATION BY US AND MRI & 107 epidermis, dermis, hypodermis, and fibrous septae within the hypodermis were clearly differentiated. A series of 60 contiguous images at high spatial resolutions were acquired on the upper dorsal thigh (FOV ¼ 18 mm  50 mm  30 mm). Firstly, with an in-depth resolution of the skin of 80 mm, the Camper’s fascia was clearly visible and allowed differ- entiation of the superficial adipose layer from the deep adipose layer (Fig. Figure 2 In vivo MR imaging of skin and adipose tissue. An in-depth resolution of 80 mm of the skin and a slice thickness of 0. STATISTICS Data were analyzed with SPSS software (SPSS, Chicago, Illinois, U. All results were expressed as mean Æ standard deviation. Water resonance as well as eight different lipid resonances are clearly resolved. The volume of interest is intentionally selected within a fat lobule to avoid water-rich structures such as fibrous septae.

Abdominal aortic aneurysmal rupture Key Concept/Objective: To be able to recognize atheromatous emboli syndrome This patient experienced the onset of abdominal pain order finast 5mg online hair loss medication over the counter, purple toes discount finast 5 mg mastercard hair loss 3 months after pregnancy, and livedo reticularis shortly after undergoing cardiac catheterization. These symptoms are consistent with atheromatous emboli syndrome. The patient also has renal insufficiency, a common fea- ture of the syndrome. Contrast nephropathy is common in patients with diabetes, but that condition would not account for the cutaneous findings. Aortic dissection and rupture could cause abdominal pain and renal insufficiency, but that should not cause livedo retic- ularis or purple toes. The abdominal pain this patient experienced was most likely the result of pancreatitis caused by atheromatous emboli. A 24-year-old man presents to the emergency department complaining of chest pain. He reports having substernal chest pain of 2 days’ duration. The pain is worse with inspiration and is alleviated by main- taining an upright position. His medical history and physi- cal examination are unremarkable. An ECG shows 2 mm elevation of the ST segment in precordial leads, without reciprocal changes and with concomitant PR segment depression. What is the most likely diagnosis and the most appropriate treatment approach for this patient? Acute pericarditis; start a nonsteroidal anti-inflammatory drug (NSAID) ❏ B. Acute pericarditis; start prednisone 36 BOARD REVIEW ❏ C. Acute pericarditis; repeat echocardiogram in 1 week to confirm diagnosis ❏ D. ST elevation myocardial infarction; start thrombolytics Key Concept/Objective: To understand the diagnosis and treatment of acute pericarditis The clinical diagnosis of acute pericarditis rests primarily on the findings of chest pain, pericardial friction rub, and electrocardiographic changes. The chest pain of acute peri- carditis typically develops suddenly and is severe and constant over the anterior chest. In acute pericarditis, the pain worsens with inspiration—a response that helps distinguish acute pericarditis from myocardial infarction. Low-grade fever and sinus tachycardia also are usually present. A pericardial friction rub can be detected in most patients when symp- toms are acute. Electrocardiographic changes are common in most forms of acute peri- carditis, particularly those of an infectious etiology in which the associated inflammation in the superficial layer of myocardium is prominent. The characteristic change is an ele- vation in the ST segment in diffuse leads. The diffuse distribution and the absence of recip- rocal ST segment depression distinguish the characteristic pattern of acute pericarditis from acute myocardial infarction. Depression of the PR segment, which reflects superficial injury of the atrial myocardium, is as frequent and specific as ST segment elevation and is often the earliest electrocardiographic manifestation. Analgesic agents, salicylates, or NSAIDs are often effective in reducing pericardial inflammation. Corticosteroids should be reserved for severe cases that are unresponsive to other therapy, because symptoms may recur after steroid withdrawal. The absence of a significant effusion on echocardiography is not evidence against acute pericarditis. Other symptoms include an erythematous rash, fatigue, and weight loss. Her medical history is significant for hyperten- sion. On physical examination, the patient’s temperature is found to be 100. A complete blood count shows anemia; the patient’s erythrocyte sedimentation rate (ESR) is ele- vated at 80 mm/hr. A transthoracic echocardiogram shows a 2 cm pedunculated mass in the left atrium.

This nucleus course in CN III discount 5 mg finast with amex hair loss cure jm, synapsing in the ciliary gan- serves as an important center for visual reflex behavior finast 5mg low price hair loss cure in 5 years, glion (parasympathetic) in the orbit before particularly involving eye movements. Fibers project to innervating the smooth muscle of the iris, which nuclei of the extra-ocular muscles (see Figure 8A and controls the diameter of the pupil. Figure 51A) and neck muscles via a small pathway, the tecto-spinal tract, which is found incorporated with the CLINICAL ASPECT MLF, the medial longitudinal fasciculus (see Figure 51B). The pupillary light reflex is a critically important clinical Reflex adjustments of the visual system are also sign, particularly in patients who are in a coma, or fol- required for seeing nearby objects, known as the accom- lowing a head injury. It is essential to ascertain the status modation reflex. A small but extremely important group of the reaction of the pupil to light, ipsilaterally and on of fibers from the optic tract (not shown) project to the the opposite side. The learner is encouraged to draw out pretectal area for the pupillary light reflex. Three events occur simul- of the retina, there can be a reduced sensory input via the taneously — convergence of both eyes (involv- optic nerve, and this can cause a condition called a “rel- ing both medial recti muscles), a change ative afferent pupillary defect. Both pupils will constrict when the light is shone visual information to be processed at the corti- on the normal side. The descending cortico-bulbar fibers eye, because of the diminished afferent input from the (see Figure 46 and Figure 48) go to the oculo- retina to the pretectal nucleus, the pupil of this eye will motor nucleus and influence both the motor dilate in a paradoxical manner. This results in a fixed dilated pupil, via the ciliary ganglion) to effect the pupil on one side, a critical sign when one is concerned reflex. The • Pupillary light reflex Some of the visual infor- significance and urgency of this situation must be under- mation (from certain ganglion cells in the ret- stood by anyone involved in critical care. A nucleus located in the area in front © 2006 by Taylor & Francis Group, LLC Functional Systems 113 Lateral ventricle (occipital horn) Pulvinar Optic radiation Optic radiation Calcarine fissure Primary visual area (17) Md Optic tract Red n. Aqueduct of midbrain Superior colliculus Pretectal area Brachium of superior colliculus Medial geniculate n. Optic radiation Optic tract Md = Midbrain FIGURE 41C: Visual System 3 — Visual Reflexes © 2006 by Taylor & Francis Group, LLC 114 Atlas of Functional Neutoanatomy PART II: RETICULAR included in discussions of the reticular forma- tion. FORMATION It is also possible to describe the reticular formation FIGURE 42A topographically. The neurons appear to be arranged in RETICULAR FORMATION 1 three longitudinal sets; these are shown in the left-hand side of this illustration: RETICULAR FORMATION: ORGANIZATION • The lateral group consists of neurons that are small in size. These are the neurons that receive The reticular formation, RF, is the name for a group of the various inputs to the reticular formation, neurons found throughout the brainstem. Using the ventral including those from the anterolateral system view of the brainstem, the reticular formation occupies (pain and temperature, see Figure 34), the the central portion or core area of the brainstem from trigeminal pathway (see Figure 35), as well as midbrain to medulla (see also brainstem cross-sections in auditory and visual input. These This collection of neurons is a phylogenetically old neurons are larger in size and project their set of neurons that functions like a network or reticulum, axons upward and downward. The RF receives afferents projection from the midbrain area is particularly from most of the sensory systems (see next illustration) involved with the consciousness system. Nuclei and projects to virtually all parts of the nervous system. The importance of which use the catecholamine serotonin for neu- this knowledge was discussed in reference to rotransmission. The best-known nucleus of this the clinical emergency, tonsillar herniation group is the nucleus raphe magnus, which plays (with Figure 9B). In summary, the reticular formation is connected with • Ascending projection system: Fibers from the almost all parts of the CNS. Although it has a generalized reticular formation ascend to the thalamus and influence within the CNS, it also contains subsystems that project to various nonspecific thalamic nuclei. The most clin- From these nuclei, there is a diffuse distribution ically significant aspects are: of connections to all parts of the cerebral cortex. This whole system is concerned with con- • Cardiac and respiratory centers in the medulla sciousness and is known as the ascending retic- • Descending systems in the pons and medulla ular activating system (ARAS). These are not always tem © 2006 by Taylor & Francis Group, LLC Functional Systems 115 Ascending reticular activating system (ARAS) Locus ceruleus Lateral group Medial group Raphe nuclei Reticulo-spinal tracts FIGURE 42A: Reticular Formation 1 — Organization © 2006 by Taylor & Francis Group, LLC 116 Atlas of Functional Neutoanatomy FIGURE 42B located within the core region. These include the periaq- ueductal gray and the locus ceruleus. RETICULAR FORMATION 2 The periaqueductal gray of the midbrain (for its location see Figure 65 and Figure 65A) includes neurons that are found around the aqueduct of the midbrain (see RETICULAR FORMATION: NUCLEI also Figure 20B).

Other findings on physical exami- nation are as follows: blood pressure generic finast 5mg without prescription hair loss cure bbc, 120/70 mm Hg cheap finast 5mg without prescription hair loss cure dec 2013; pulse, 94 beats/min; respiratory rate, 12 breaths/min; temperature, 100. Cardiovascular examination shows tachycardia, but otherwise the results are normal. Which of the following should be the appropriate step to take next in this patient’s workup? None of the above Key Concept/Objective: To be able to recognize the presentation of acute benign viral pericarditis This patient’s presentation is classic for acute viral pericarditis: constant anterior chest pain that is worse with inspiration, tachycardia, and a low-grade fever. A pericardial fric- 38 BOARD REVIEW tion rub is often heard when patients are symptomatic but may be missed on examina- tion. The differential diagnosis includes pneumonia, spontaneous pneumothorax, and musculoskeletal pain; an electrocardiogram would be the appropriate first step in the evaluation. A finding of diffuse ST segment elevations without reciprocal changes or PR depressions would confirm the diagnosis of viral pericarditis. The patient in Question 65 is found to have PR depressions on electrocardiography. What should be the next step in this patient’s management? Treatment with codeine Key Concept/Objective: To understand the management of acute pericarditis This patient has acute benign pericarditis. Anti-inflammatory medications, including aspirin, are usually effective for reducing pericardial inflammation and decreasing pain. Codeine or another narcotic may be added for pain relief if needed. Although prednisone is effective as well, steroids are generally reserved for patients who are unresponsive to other treatments, because symptoms may recur after steroid withdrawal. Patients do not require hospitalization unless they have other complications such as arrhythmia or tamponade. A 44-year-old man on long-term dialysis for lupus nephritis presents with progressive dyspnea on exer- tion. He has no chest pain or lower extremity edema, nor does he have any other symptoms. Other results of his physical examination are as follows: blood pressure, 130/70 mm Hg; pulse, 84 beats/min; respiratory rate, 14 breaths/min. His neck veins are elevated, and the elevation increases upon inspiration. His cardiovascular examination is remarkable for an extra sound in early diastole, and he has no paradoxical pulse. His hematocrit is normal, and the results of pulmonary function studies and electrocardiography are unremarkable. What would be the definitive diagnostic workup for this patient? A and C Key Concept/Objective: To be able to recognize constrictive pericarditis Given this patient’s symptoms and his history of dialysis, he most likely has constrictive pericarditis. Definitive diagnosis requires demonstration of a thickened pericardium and equalization of right and left heart pressures. Findings of elevated central pressures in the absence of other signs of congestive heart failure are very helpful. In contrast to cardiac tamponade, paradoxical pulse is present, and the Kussmaul sign can occasionally be seen. A 26-year-old woman is being evaluated for dyspnea, which she experiences when she engages in phys- ical activity. She has been having these symptoms for the past 4 months. She denies having chest pain, orthopnea, or paroxysmal nocturnal dyspnea.