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Clifford Raabe Weiss, M.D.

• Medical Director, The Johns Hopkins Center for Bioengineering, Innovation and Design (CBID)
• Associate Professor of Radiology and Radiological Science

https://www.hopkinsmedicine.org/profiles/results/directory/profile/0015953/clifford-weiss

He is the author of Trans Gendered: Theology gastritis diet treatment medications order doxazosin 4mg with mastercard, Ministry gastritis symptoms sore throat order doxazosin 2 mg with amex, and Communities of Faith (Pilgrim Press gastritis diet ���� cheap doxazosin 2 mg free shipping, 2003) uremic gastritis symptoms discount 1mg doxazosin overnight delivery, which was the result of his doctoral research into the experiences of transgender people in communities of faith gastritis diet mayo generic 1 mg doxazosin otc. Among his other writing credits gastritis diet ������� buy doxazosin uk, he and Lisa Mottet collaborated on Opening the Door to the Inclusion of Transgender People:the Nine Keys to Making Lesbian, Gay, Bisexual and Transgender Organizations Fully Transgender-Inclusive. He holds a bachelors degree from Mount Holyoke College, a Masters degree from Harvard University, and a doctorate from San Francisco Theological Seminary. But still I have pressed forward, started a new career, and rebuilt my immediate family. I have walked these streets and been harassed nearly every day, but I will not change. Professor and Chairman Department of Ophthalmology and University Eye Hospital Ulm Germany With contributions by J. English] knowledge, in particular our knowledge of Ophthalmology: a short textbook / proper treatment and drug therapy. Includes biblio cation, readers may rest assured that the graphical references and index. Every user is requested to examine care Student contributors: fully the manufacturers leaflets accom Christopher Dedner, Tubingen panying each drug and to check, if neces Uta Eichler, Karlsruhe sary in consultation with a physician or Heidi Janeczek, Gottingen specialist, whether the dosage schedules Beate Jentzen, Husberg mentioned therein or the contraindications Mathis Kayser, Freiburg stated by the manufacturers differ from the Kerstin Lipka, Kiel statements made in the present book. Such Maren Molkewehrum, Kiel examination is particularly important with Alexandra Ogilvie, Munich drugs that are either rarely used or have Patricia Ogilvie, Wurzburg been newly released on the market. Every Stefan Rose, Oldenburg dosage schedule or every form of applica tion used is entirely at the users own risk Translated by John Grossman, Berlin, and responsibility. The authors and pub Germany lishers request every user to report to the publishers any discrepancies or inaccura Thisbookisanauthorizedtranslationofthe cies noticed. German edition published and copyrighted 1998 by Georg Thieme Verlag, Stuttgart, Some of the product names, patents, and Germany. Thieme New York, 333 Seventh Avenue this book, including all parts thereof, is New York, N. Any use, exploitation, or commercialization outside Typesetting by Druckhaus Gotz GmbH, the narrow limits set by copyright legisla Ludwigsburg tion, without the publishers consent, is Printed in Germany by illegal and liable to prosecution. Definition:the concept behind this book was to organize content and layout according to a uniform structure. This enhances the clarity of the presenta tion and allows the reader to access information quickly. Each chapter has its own header icon, which is shown on every page of the chapter. Figure headings summarize the key information presented in the respective figure, eliminating the need for the reader to read through the entire legend. Epidemiology: In the absence of precise epidemiologic data, the authors state whether the disorder is common or rare wherever possible. Etiology: this section usually combines information about the etiology and pathogenesis of a disorder and in so doing helps to illuminate important rela tionships. Symptoms and diagnostic considerations: these items are usually dis cussed separately. The section on symptoms includes only the phenomena with which the patient presents. How and by which methods the examiner proceeds from these symptoms to a diagnosis is only discussed under diag nostic considerations. These may be facts that one is often required to know for exami nations, or they may be practical tips that are helpful in diagnosing and treating the disorder. Differential diagnosis: Wherever possible, this section discusses not only other possible diagnoses but also important criteria for differentiating the disorder from others. Treatment: this section goes beyond merely documenting all possible ther apeutic options. It also explains which therapeutic measures are advisable and offer a prospect of success. The discussion of medical treatment occa sionally includes dosage information and examples of preparations used. This is done where such information is relevant to cases students will encounter in practice. Prognosis and clinical course:the further development of the book depends in no small measure on your criticism. We are happy to receive any suggestions for improvements as this will help us tailor the next edition to better suit yor needs. Director, Department of Medical Retina and Laser Surgery, University Eye Hospital, Ulm Doris Recker Orthoptist, University Eye Hospital, Ulm C. V Preface When my coworkers and I first took up the task of writing a textbook of ophthalmology that was aimed at medical students but would also be suita ble for interns and ophthalmology residents, we did not know exactly what we were getting ourselves into. We did not merely intend to design a book according to the maxims understand it in medical school, learn it for the examination, and use it during your internship. In an age in which teaching is undergoing evaluation, we felt this was particularly important. In pursuing this admittedly ambitious goal, we were able to draw upon many years of teaching experience. This experience has shaped the educational concept behind this book and manifests itself in details such as the layout, which is characterized by numerous photographs and illustrative drawings. These illustrations make ophthalmology come alive and hopefully will be able to imbue the reader with some of the enthusiasm that the authors themselves have for their specialty. I would like to take this opportunity to offer my heartfelt thanks to my teacher, Prof. Naumann, Erlangen, Germany, for his sugges tions and for the slides from the collection of the Department of Ophthal mology and University Eye Hospital, Erlangen. Peter Wagner for their harmonious cooperation and exceptional initiative in writing this book. Jurgen Luthje and Sabine Bartl of Georg Thieme Verlag, whose professionalism and active and tireless support were a constant source of inspiration to us all. I would again like to thank Markus Voll, Furstenfeldbruck, Germany, for his splendid illustrations. Testing the Potential Resolving Power of the Retina in the Presence of Opacified Optic Media. O Desmarres eyelid retractor and glass rod or sterile cotton swab for eyelid eversion. O Antibiotic eyedrops for first aid treatment of injuries, sterile eye compresses, and a 1cm adhesive bandage for protective bandaging. An ophthalmologist should be consulted following any emergency treatment of eye injuries. Many eye disorders are hereditary or of higher incidence in members of the same family. Examples include refractive errors, stra bismus, cataract, glaucoma, retinal detachment, and retinal dystrophy. As ocular changes may be related to systemic disorders, this possibility must be explored. Conditions affecting the eyes include diabetes mellitus, hypertension, infectious diseases, rheumatic disorders, skin diseases, and surgery. Eye disorders such as corticosteroid-induced glaucoma, corticosteroid-induced cataract, and chloroquine-induced maculopathy can occur as a result of treatment with medications such as steroids, chloroquine, Amiodarone, Myambutol, or chlorpromazine (see table in Appendix). The examiner should inquire about corrective lenses, strabismus or amblyopia, posttraumatic conditions, and surgery or eye inflammation. Does the patient have impaired vision, pain, redness of the eye, or double vision One eye is covered with a piece of paper or the palm of the hand placed lightly over the eye. The fingers should not be used to cover the eye because the patient will be able to see between them. The general practitioner or student can perform an approximate test of visual acuity. The patient is first asked to identify certain visual symbols referredtoasoptotypes(see. These visual symbols are designed so that optotypes of a cer tain size can barely be resolved by the normal eye at a specified distance (this standard distance is specified in meters next to the respective symbol). The sharpness of vision measured is expressed as a fraction: Examining visual acuity. A normal-sighted person would be able to discern the 4 at a distance of 50 meters or 200 feet (standard distance). The ophthalmologist tests visual acuity after determining objective refraction using the integral lens system of a Phoroptor, or a box of individual lenses and an image projector that projects the visual symbols at a defined distance in front of the eye. Visual acuity is automatically calculated from the fixed actual distance and is displayed as a decimal value. Plus lenses (convex lenses) are used for farsightedness (hyperopia or hypermetropia), minus lenses (concave lenses) for nearsightedness (myopia), and cylindrical lenses for astigmatism. If the patient cannot discern the symbols on the eye chart at a distance of 5 meters (20 feet), the examiner shows the patient the chart at a distance of 1 meter or 3 feet (both the ophthalmologist and the general practitioner use eye charts for this examination). If the patient is still unable to discern any symbols, the examiner has the patient count fingers, discern the direction of hand motion, and discern the direction of a point light source. This allows the examiner to diagnose strabismus, paralysis of ocular muscles, and gaze paresis. Evaluating the six cardinal directions of gaze (right, left, upper right, lower right, upper left, lower left) is sufficient when examining paralysis of the one of the six extraocular muscles. The motion impairment of the eye resulting from paralysis of an ocular muscle will be most evident in these positions. Only one of the rectus muscles is involved in each of the left and rightpositionsofgaze(lateralormedialrectusmuscle). The examiner holds a point light source beneath his or her own eyes and observes the light reflec tions in the patients corneas in the near field (40cm) and at a distance (5m). If the corneal reflection is not in the center of the pupil in one eye, then a tropia is present in that eye. If tropia is present in a newborn with extremely poor vision, the baby will not tolerate the good eye being covered. Stenosis of the nasolacrimal duct produces a pool of tears in the medial angle of the eye with lacrimation (epiphora). In inflammation of the lacrimal sac, pressure on the nasolacrimal sac frequently causes a reflux of mucus or pus from the inferior punctum. Patency of the nasolacrimal duct is tested by instilling a 10% fluorescein solution in the conjunctival sac of the eye. If the dye is present in nasal mucus expelled into paper tissue after two minutes, the lacrimal duct is open (see also p. Due to the danger of infection, any probing or irrigation of the nasolacrimal duct should be performed only by an ophthalmologist. The bulbar conjunctiva is directly visible between the eyelids; the palpebral conjunctiva can only be examined by everting the upper or lower eyelid. The examiner should be alert to any reddening, secretion, thickening, scars, or foreign bodies. The patient looks up while the examiner pulls the eyelid downward close to the anterior margin. The patient looks up while the ex aminer pulls the eyelid downward close to the ante rior margin. The patient should repeatedly be told to relax and to avoid tightly shutting the opposite eye. The examiner grasps the eyelashes of the upper eyelid between the thumb and forefinger and everts the eyelid against a glass rod or swab used as a fulcrum. Eversion should be performed with a quick levering motion while applying slight traction. The examiner places a swab superior to the tarsal region of the upper eyelid, grasps the eyelashes of the upper eyelid between the thumb and forefinger, and everts the eyelid using the swab as a fulcrum. To expose the superior fornix, the upper eyelid is fully everted around a Desmarres eyelid retractor. This method is used solely by the ophthalmologist and is only discussed here for the sake of completeness. This eversion technique is required to remove for eign bodies or lost contact lenses from the superior fornix or to clean the conjunctiva of lime particles in a chemical injury with lime. Examination of the upper eyelid and superior fornix (full eversion with retractor). In contrast to simple eversion, this procedure allows examination of the superior fornix in addition to the palpebral conjunctiva. In these cases, the spasm should first be eliminated by instilling a topical anesthetic such as oxy buprocaine hydrochloride eyedrops. Epithelial defects, which are also very painful, will take on an intense green color after application of fluorescein dye; corneal infiltrates and scars are grayish white. Sensitivity is evaluated bilaterally to detect possible differences in the reaction of both eyes. The examiner holds the upper eyelid to prevent reflexive closing and touches the cornea anteriorly. Decreased sensitivity can provide information about trigeminal or facial neuropathy, or may be a sign of a viral infection of the cornea. The patient looks straight ahead while the examiner holds the upper eyelid and touches the cornea anteriorly. In a cham ber of normal depth, the iris can be well illuminated by a lateral light source. The pupillary dilation should be avoided in patients with shallow ante rior chambers because of the risk of precipitating a glaucoma attack.

A 75-year-old female patient is brought to the clinic information gastritis diet ����� buy doxazosin 1 mg otc, which of the following diagnoses is 93 gastritis symptoms for dogs generic 2 mg doxazosin mastercard. A 35-year-old male patient arrives at the clinic (C) A 15-year old Asian woman on birth by her daughter gastritis diet �� generic doxazosin 1 mg mastercard, who believes she may be suffering most likely to be correct She also frequently displays (D) Kyphosis Based on this information gastritis diet for gastritis generic doxazosin 1mg line, which of the following 97 gastritis diet ����� purchase doxazosin line. A 19-year-old female presents with a complaint several primitive reflexes like the palmomental (E) Scoliosis diagnoses is most likely to be correct A 68-year-old male patient who was recently treated She reports that the itching is intense at night and of strokes gastritis diet ��� cheap 4 mg doxazosin otc. Based on her condition, what is the (B) Spermatocele for pneumonia comes to the clinic complaining of that she is often awakened by her dorm roommate, patients most likely diagnosis He also who tells her that she is scratching her hands in her (A) Alzheimers disease (D) Phimosis presents with pain and pressure. Upon examination of the rash, red bumps, (B) Vascular dementia (E) Testicular torsion in the ear. Based on his symptoms, what type of small blisters, and thin red lines are discovered. A 20-year-old female college student walks into Laboratory results reveal the presence ofSarcoptes (D) Frontotemporal dementia (A) Otis externa the clinic complaining of vaginal itching, a thin scabiei and mite eggs. Which of the following (E) Pseudodementia (B) Menieres disease white discharge, and a fishy vaginal odor. A 53-year-old patient is brought to the emergency (C) Otis media also reports burning on urination. Microscopic examination of her vaginal (B) Salicylic acid plasters, applied at night and 91. A 60-year-old male patient arrives at the clinic fever and his stool contains some blood and mucus fluid shows clue cells, a pH of >4. Which of the following diagnoses is most (A) Bacterial vaginosis area says that the pain started very suddenly overnight. Of the fol (A) Diphtheria (C) Gonorrhea area lowing diagnoses, which is the most likely to be (B) Gastroenteritis (D) Syphilis correct Which of the following individuals would be most (C) Shigellosis (E) Candidiasis (A) Calcium pyrophosphate dehydrate disease likely to develop berryliosis A 25-year-old female presents with pale skin, (A) A demolition crewmember (E) Pertussis (C) Polymyositis fatigue, and numbness in her hands and feet. A 16-year-old girl comes to the clinic asking for (D) Psoriatic arthritis reports that she exercises three times a week and (C) A construction worker the cancer vaccine. Before you give her the vaccine, what do diet is depriving her of essential nutrients, which clinic complaining of pain and tenderness on the 99. A 42-year-old female presents with a persistent you tell the patient that Gardisil protects against She is a right-handed bladder infection, which has been treated (A) Breast cancer sible nerve damage. Which nutrient is most likely pitcher and reports increased pain that radiates with fluoroquinolone for 5 days. The patients (B) Most strains of genital human papilloma missing from this patients diet She has not fallen or suffered any direct trauma accompanied by fever, flank pain, and vomiting. What (D) Syphilis (C) Vitamin B6 which of the following diagnoses is most likely additional findings would you expect to see in this (E) Ovarian cancer (D) Vitamin B12 to be correct A 58-year-old male is seen at the clinic and (A) Lateral epicondylitis (A) Androgen excess complains of back and leg pain. Which of the following women would be most at (B) High concentrations of protein in the urine burning back pain that spreads down his legs as (C) Olecranon bursitis risk for developing uterine fibroids He also reports that he can frequently (D) Radial head fracture (A) A 32-year-old white woman with familial (D) Heavy growth of Escherichia coli in the alleviate the pain by leaning forward. Radiographic imaging tests reveal (B) A 25-year-old black woman without (E) Low red blood cell count indicating anemia soft-tissue and thecal narrowing. A 16-year-old boy presents with a cough, which (A) Caloric intake should break down as 112. A 19-year-old woman comes to the clinic com with less than 7 percent saturated fat. Which of the following individuals is most at-risk plaining of localized, dull pain along the 2nd (E) Caloric intake should break down as for developing multiple myeloma An 18-year-old male awoke early and experienced edematous, and when the 2nd metatarsal area isthe woman has no family history of thalassemia. By evening, the pain had become constant difficulty lifting her toes on the affected foot. Which of the following results of a spirometry and is centered toward the right lower quadrant patient is limping slightly. Movement increases track for 4 years, and is on the womens track (B) Vitamin B12 deficiency persistent asthma Which of the following is the most common eti and hypercholesterolemia comes to your office vaccine ology of mesothelioma Which of the following is the most likely (C) Exposure to coal dust series of laboratory tests including a lipid profile. A 12-year-old girl has been diagnosed with type 1 (C) Myocardial infarction (B) Risk of atherosclerosis diabetes mellitus. To maintain her health, the girl (D) Acute gastritis (C) Decreased hemoglobin levels will have to make certain lifestyle modifications. He says withdrawn at times, but can also become agitated (C) Hyperthyroidism stated she found him holding his nose, screaming, he has to sit on the toilet to urinate to prevent urine for no apparent reason, shouting obscenities and (D) Electrolyte imbalance Ow! A 17-year-old high school student comes to the happened, the boy would not answer her. What has heard there is a type of surgery to correct his diagnosis in this patient He said the pustule will not go away, and it (D) Nasal irrigation (D) Balanitis burning on urination, hematuria, and low-grade seems to be getting bigger and redder every day. A 70-year-old female patient comes to the office a weekend vacation with her husband, and she suspect is the cause of the boys condition She (A) Brown recluse spider bite been placed on oral contraceptives for the first time had heartburn for several weeks, but it is usually has pain when palpated in the lower abdomen, (B) Foliculitis 5 weeks previously by her gynecologist in order relieved with chewable antacid tablets. What is the most likely (C) Poison ivy to provide contraception and to help regulate her appears to be worse when she is hungry or at diagnosis When asked about the color of her stools, (A) Pyelonephritis (E) Methicilin-resistant Staphylococcus aureus is taking is 20 mg atorvastatin (Lipitor) daily for the patient said sometimes they are dark. A 78-year-old woman is brought to the clinic by the calf pain three days previously, and thought she no vomiting, but some nausea. She also complains (C) Cystitis her daughter with shortness of breath, fatigue, had pulled a muscle. Her medications are lisinopril for high (D) Interstitial cystitis edema of the lower extremities, irregular heartbeat, the third day, she noticed her lower leg appeared blood pressure and Cosopt eye drops for glaucoma. She also reported throbbing pain She has osteoarthritis, for which she takes over 121. When asked how much He complains of skin flushing, dizziness, itching, states her mothers symptoms started about two causing the symptoms in her leg He has been prescribed niacin (vitamin patient is on no medications and states that she (D) Fracture last few weeks. What diagnosis do you suspect in B3) for hypercholesterolemia and hypertriglyceri has no known history of heart disease. The patient is unsure of his dose, but he she sometimes has chest pain that radiates down (A) Cholelithiasis 116. Her (B) Peptic ulcer disease with obesity, high blood pressure, and hypercholes changed the type of over-the-counter niacin blood pressure is 160/90, and her pulse is 100 and (C) Gastroesophageal reflux disease terolemia is at risk of type 2 diabetes. An 18-year-old male is brought into the office by would make his current dose 8,000 mg daily, or 8 the most likely diagnosis A 38-year-old woman comes to the office with she is not on any form of birth control, and that 131. A 20-year-old woman is brought into the clinic by (A) Endometriosis red to brownish-gray colored patches on her inner her partner does not use condoms. She reports severe itching, especially at you most likely perform first on this patient Her mother says she is very (D) Alopecia areata fluid and crust over when scratched. The baby has edema of the (A) Poison ivy (E) Culture for Chlamydia trachomatis picks up men for sex. His temperature is (D) Psoriasis daughter became very angry and screamed at her has hypertension, hypercholesterolemia, and a 101. At other times, her daughter is withdrawn strong family history for cardiac disease. A 25-year-old woman comes to the office com is the first test you would order to detect possible (A) Sickle cell anemia to hold down a job or keep friends. She is (D) Cardiac catheterization the daughter will not take her medications as 135. A 51-year-old man comes to the office for his experiencing nausea, vomiting, and sensitivity to (E) Chest X-ray prescribed. An 80-year-old male comes to the office com (A) Major depression arthritic-type pain in his left knee. He also complains of difficulty starting (C) Schizophrenia cardiovascular disease He fell in the bathroom, and could not (A) Ultrasound with biopsy other medications are 20 mg of atorvastatin daily last Pap smear was a year ago, and it was normal. He has weakness of the left arm and leg, (B) Ultrasound without biopsy and 60 mg of raloxiphene daily. What is likely to Prior to that, she had yearly Pap smears starting left facial drooping, confusion, difficulty speaking, (C) Cystoscopy be causing the patients syncope What is the most (D) Bone scan (A) Prazosin you if she can have Pap smears less frequently. A 32-year-old obese woman comes to the office nervousness, tremor, irregular menstruation, and (B) Every two years complaining of hirsuitism of the face, alopecia, 127. She has had (C) Every three years irregular menstruation, acne, and inability to con vaginal bleeding, breast tenderness, mild cramping one period in the last three months and has lost 10 (D) Every five years ceive. She has not had a period in four months, and and worsening pain in the lower right abdomen, pounds. She states she is only sleeping about three (E) Only if she has symptoms of human papil thought she was pregnant several times. When asked about menstruation, the (B) Paroxysmal supraventricular tachycardia mainly on the forehead and cheeks. What is the patient states she is about a week past due for her (C) Cardiomyopathy most likely diagnosis The patient takes simvastatin, probe (A) Chronic bronchitis back and flank pain, frequent urination, pain on 20 mg daily; metoprolol, 50 mg daily; and a daily (E) Fluoroscopy (B) Chronic obstructive pulmonary disease urination, and hematuria. She has vaginal bleeding, pain and (B) Ulcerative colitis (D) Transudative pleural effusion of urinary tract infections. You explain both medical She says she previously enjoyed intercourse with the office complaining of numbness of the skin and surgical treatment options to the patient. A 53-year-old male comes to the clinic with chest on his arms, back, and buttocks; tremors in his chooses surgery. The patient is postmenopausal pain, diaphoresis, nausea, lightheadedness, and hands; double vision; and cognitive problems, prescribe for her The patient (A) Colposcopy topical estrogen vaginal creams, but she did not the patient is having an acute myocardial infarction reports no other medical problems and states he is (B) Hysteroscopy like the messiness of them. When (E) Suction dilation and curettage (D&C) (A) Oral estrogen and progesterone (B) Streptokinase questioned further, the patient states that he eats (B) An estrogen vaginal ring (C) Morphine 141. On a June afternoon, a 65-year-old man comes some type of fish daily, including salmon, tuna, (C) Over-the-counter vaginal lubrication (D) Beta blockers to the office for an annual physical exam. He and swordfish, and some freshwater fish such as products (E) Aspirin states he does not remember the last time he had mackerel. Based on this information, what is the (D) Estrogen vaginal suppositories a vaccination, but it was probably when he was 148. The only surgery he has ever had was an plaining of fatigue, dizziness, cognitive problems, (A) Diabetes appendectomy as a child. On further ques (D) Hypothyroidism (B) Meningococcal polysaccharide or conjugate upright and improves when he is reclining. He tioning, she tells you she has been having heavy (E) Dementia (C) Pneumococcal pneumonia also complains of halitosis. A 10-year-old boy is brought to the clinic by his (D) Haemophilus influenzae type b (Hib) con discharge, and a fever of 100. You suspect she has mother after sustaining a head injury during soccer jugate vaccine likely diagnosis

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She specifically denies any history of hematuria gastritis diet ������ order doxazosin 1 mg with mastercard, hematochezia gastritis diet ��������� 1mg doxazosin with visa, epistaxis gastritis symptoms in cats discount doxazosin uk, or unusual bruising diffuse gastritis definition buy doxazosin 1mg line. Folate deficiency is most often dietary chronic gastritis x ray order doxazosin without prescription, typically in children whose diets rely heavily on goat milk gastritis diet ������� buy doxazosin 1 mg lowest price. When vitamin B12 (also called cobalamin) is consumed, it attaches to haptocorrin and travels to the duodenum, where it is hydrolyzed and released from the haptocorrin. The free vitamin B12 then binds to gastric intrinsic factor and travels to the ileum. It is then absorbed in the ileum, enters the blood stream, and binds to transcobalamin. Vitamin B12 deficiency in pediatrics most often occurs either because of an absence of the terminal ileum (where B12 is absorbed), or because of a deficiency of intrinsic factor. The deficiency of intrinsic factor and subsequent vitamin B12 deficiency is called pernicious anemia. Congenital pernicious anemia occurs when there is a genetic defect resulting in hypofunctional or absent intrinsic factor. Pernicious anemia in adolescents typically results from gastric atrophy and achlorhydria caused by antibodies to the parietal cell and intrinsic factor. Left untreated, vitamin B12 deficiency results in a macrocytic anemia, in addition to neurologic symptoms including paresthesias, ataxia, and gait abnormalities, as a result of posterior and lateral spinal column degeneration. Vitamin B12 deficiency can be treated with the parenteral administration of vitamin B12. The patient in the vignette has a medical history remarkable for autoimmunity, suggesting that her macrocytic anemia also has an autoimmune origin. Thus, it is likely that her macrocytic anemia is caused by autoimmune damage to the gastric parietal cells. Autoimmune damage to the adrenal cortex results in Addison disease, a deficiency of cortisol (glucocorticoids) and often aldosterone (mineralocorticoids). It can be damaged and underproduce catecholamines or have a tumor such as a pheochromocytoma and overproduce catecholamines. Hepatic injury in the form of alcoholic cirrhosis can coexist with vitamin B12 deficiency, but it is not, by itself, a cause of macrocytic anemia. Injury to the pancreatic islet cells results in an insulin deficiency and diabetes, but not macrocytic anemia. He says he feels sleepy throughout most of the school day and occasionally falls asleep in class. On most days, he takes a nap right after getting home from school, sleeping for more than 1 hour. He has dysfunction at school because of feeling sleepy and not paying attention in class. His family members are all reported to be "evening people," therefore it would be worth asking further if there are family distractions happening for this patient at night. Adolescents tend to have phase advanced sleep, meaning that there is a natural tendency while progressing into adolescence of falling asleep later in the evening, followed by waking up later in the morning. Some schools now try to match their schedules to that pattern, by scheduling high school classes to start later in the morning than classes for younger children. The total number of hours a day of sleep that humans need is fairly consistent, so when there is chronically short duration sleep at night, a sleep deficit is created that requires payback to be able to maintain normal level functioning. This experienced sleep deficit is what is most likely leading this adolescent to take a nap every afternoon. A downside of taking naps lasting beyond about 15 min in duration is that "sleep inertia" is created in which it is harder for someone to feel fully awake for the subsequent hours after waking. Even after taking his afternoon nap of approximately 1-hour duration, he is likely to experience sleep inertia rather than feeling truly refreshed upon awakening. More importantly in this situation, the use of afternoon naps decreases the need for sleep later that evening, and impairs the ability to easily fall asleep at night. The most immediate need for the adolescent in this vignette is sleep hygiene management. It may be hard for him to make himself stay awake after school at first, given the routine that has been established, but doing so should lead to a rapid resolution of the problem. Extra catch-up sleep on the weekends can help to restore an accumulated sleep deficit and restore clear cognition. Maintaining a relatively consistent sleep pattern every day of the week is another key way to help maintain an appropriate-for-circumstances biological clock. However, performing significant physical exercise within an hour of the intended bedtime typically impairs being able to settle the mind and body down and be able to fall asleep. Exercise should happen earlier in the day to be able to obtain sleep benefits at night. Referring the patient to a surgeon to consider a tonsillectomy may be appropriate in the setting of significant problems with snoring, nocturnal enuresis, or gasping respirations. If these symptoms are present, a polysomnogram should be considered before a referral to a surgeon. Polysomnography would be the appropriate next step to document apneic pauses if sleep apnea is suspected. In this vignette, the patients history suggests that he is having sleep hygiene problems and referral for a sleep study is not necessary, presuming an uncomplicated course with sleep hygiene interventions. Sometimes sleep can be disrupted because of nightmares, particularly for individuals with post traumatic stress disorder for whom repeated nightmares may decrease sleep quality and cause sleep avoidance behaviors. Nightmares occur during rapid eye movement sleep when muscle tone and movement is inhibited, and generally in the latter part of the morning. Nightmares are different than sleep terrors in that children between 4 and 12 years of age may experience them. Sleep terrors usually occur during the first third of sleep at night, cause abrupt apparent awakening (though typically not full consciousness) with a loud scream, and physical agitation that is unresponsive to parental calming. Television viewing, bedroom television, and sleep duration from infancy to mid childhood. By history, she was unresponsive on arrival with a heart rate of 190 beats/min, blood pressure of 65/45 mm Hg, and respiratory rate was 15 breaths/min. While she was being evaluated, she regained consciousness, her heart rate dropped to 90 beats/min, and her blood pressure normalized to 105/70 mm Hg. In the case of the child in this vignette who is unconscious, one would not want to delay electrical cardioversion. A normal saline bolus would help to raise the patients blood pressure, but would not convert the abnormal cardiac rhythm. This form of ventricular tachycardia will have an inferior axis (negative in V1) because it comes from the superior aspect of the heart. There will also be left bundle branch morphology because the activation arrives in the left ventricle after the right ventricle (Item C152A). It often is seen on stress tests during the recovery phase when the heart rate is decreasing. In each of these syndromes, the first presentation may be collapse or sudden cardiac arrest. During your review of systems, she describes bilateral wrist pain that started 5 months ago. She also reports pain in her hands that interferes with writing and school work, which started at the same time as her wrist pain. You are concerned that the patient may have juvenile idiopathic (rheumatoid) arthritis. The signs and symptoms associated with arthritis are decreased range of motion with either passive or active movement, joint swelling, and pain with range of motion. Although joints may be erythematous and warm, these signs are not always present and can be difficult to assess if the examiner has warm or cold hands. Fatigue can occur with any autoimmune condition, but is not specific to this diagnosis. Patients with leukemia will often present with bone pain that is severe, and occasionally arthralgia or even arthritis. Arthritis or arthralgia associated with a facial rash should raise concerns for infection or a systemic autoimmune condition. Several common infections, such as mononucleosis or parvovirus, can present with arthritis and a rash. Arthritis and rash can also be the initial presentation of systemic lupus erythematosus. Arthritis may be a presenting symptom for reactive processes such as poststreptococcal arthritis, rheumatic fever, serum sickness, and postinfectious arthritis (these illnesses tend to be self-limiting or have other symptoms); infections that can present with symptoms of arthritis include septic arthritis, discitis, or osteomyelitis; mononucleosis, parvovirus, and Lyme disease. Joint enlargement caused by conditions other than arthritis can include trauma; benign tumors such as osteoid osteoma or osteoblastoma; malignancies such as leukemia, neuroblastoma, osteosarcoma, Ewing sarcoma, and rhabdomyosarcoma. Juvenile idiopathic arthritis consists of 6 types of arthritis with different presenting features (Item C153A). The severity of uveitis does not correlate well with arthritis activity; therefore the status of joint disease should not affect the frequency of screening. Some of these patients may have increased acute phase reactants, such as erythrocyte sedimentation rate, C-reactive protein, or thrombocytosis. In patients with 4 or fewer joints involved, intra-articular steroid injection may be used alone to control the arthritis. If the patient fails these regimens, then abatacept (a T-cell modulator) is recommended. If there is still failure to control the arthritis then methotrexate is used in patients without fever and rash. A 14 year-old adolescent presents to the medical tent for evaluation of her left eye after being hit by a pitch during a game. Examination of the cornea with a cobalt blue light following fluorescein staining does not reveal any defects. An athlete who sustains a hyphema should be evaluated urgently by an ophthalmologist. Hyphema carries the risk of additional bleeding, and a large collection of blood can result in staining of the cornea or glaucoma, conditions that can affect visual acuity. Nonsteroidal anti-inflammatory drugs should be avoided because they may increase the risk of bleeding. Secondary hemorrhage occurs in up to one-third of patients with hyphema, with the risk being highest 2 to 7 days after injury. Evidence suggesting that rest prevents rebleeding is limited, but most ophthalmologists recommend restricting physical activity until the hyphema resolves and the risk of rebleeding has passed. Hyphema is more common in children than adults, with the highest incidence seen between 10 and 20 years of age. Surgery may be indicated for large hyphemas that could potentially cause optic nerve damage, but vision loss after hyphema is rare. There are no published return-to-play guidelines following eye injuries; an ophthalmologist should provide clearance before the child returns to sports. Severe pain, lack of normal extraocular motion, disruption of the sclera or cornea, and decreased visual acuity are signs and symptoms of globe rupture. Globe rupture is an emergency; these patients should have an eye shield placed and be referred to the emergency department for ophthalmologic evaluation. Sports and recreational activities account for about one-quarter of the eye injuries seen in the emergency department. Basketball, baseball, softball, and football are the sports with the highest risk of eye injury. Common sports-related eye injuries include corneal abrasions and corneal foreign body. Approximately 80% of eye injuries occur in individuals not wearing eye protection; appropriate sports eyewear can reduce the risk of eye injury. The 7-year old has had recurrent itching of the scalp and physical examination findings shown in Item Q155. Permethrin, a topical insecticide, is the treatment of choice for the 4-month old infant in the vignette. Permethrin 1% lotion is available without a prescription; it is applied to the scalp and hair for 10 minutes, and then washed out. A repeat application is recommended in 9 to 10 days to kill newly hatched lice, because the medication does not affect unhatched eggs. The female louse lives approximately 1 month and lays up to 10 eggs (nits) each day at the base of a hosts hair shaft. After approximately 8 days, the egg capsules hatch nymphs that mature over the next 8 days into adult lice. They move about by crawling and are transmitted by close person-to-person contact. Clinical manifestations of head, body (pediculosis corporis), and pubic (pediculosis pubis) lice include intense itching and small, erythematous maculopapular lesions with excoriations at the site of bites. Pubic lice typically survive for up to 36 hours away from a host, but may live for 10 days under ideal conditions. For the 4-month-old infant in the vignette, the best option for treating head lice is over-the counter permethrin because none of the other topical agents are recommended for young infants (Item C155). Lindane shampoo no longer is recommended for treating children because of neurologic adverse effects and widespread resistance.

The frequency and dosage of injections may need to be titrated by clinical response gastritis symptoms in infants cheap doxazosin 4mg line, i gastritis diet 2012 doxazosin 4 mg on-line. Discuss use of ocular lubricants and occlusive (moisture chamber) eyewear or goggles after injection if eyelid closure may be impaired B gastritis que no comer 2mg doxazosin otc. Oral medications demonstrate limited success and may have significant side effects D gastritis diet blog order doxazosin canada. Address any causes of secondary blepharospasm which may accompany essential blepharospasm gastritis ulcer disease order doxazosin with a visa. Benign essential blepharospasm among residents of Olmsted County gastritis symptoms reflux cheap 4 mg doxazosin mastercard, Minnesota, 1976 to 1995: an epidemiologic study. Surgery of the Eyelids, Lacrimal System, and Orbit, Oxford University Press, Volume 2, 2011. Iatrogenic (botulinum toxin injection, acoustic neuroma resection, parotid gland surgery, face/brow lifting, temporal artery biopsy) 2. Diminished taste may be present the facial nerve provides taste to the anterior 2/3 of tongue 6. Dysacusis may be noted the facial nerve innervates the stapedius muscle of the inner ear 7. External auditory canal may show a vesicular dermatitis in patients with herpes zoster (Ramsey Hunt syndrome) 8. Axons to the lower face synapse only within the contralateral nucleus i) Significance is upper motor neuron 7th nerve palsy causes isolated contralateral lower facial droop whereas lower motor neuron 7th nerve palsy produces both upper and lower ipsilateral facial paresis 2. Crosses the over the zygomatic arch and is at risk of injury with some periocular surgery b. Upper motor neuron does not involve the forehead due to bilateral (crossed and uncrossed) innervation b. This distinction is helpful in defining etiology and planning evaluation/management 2. If facial weakness continues to progress after three weeks or failure to improve after 4-6 months b. Facial twitch or spasm preceding paralysis which may be indicative of nerve irritation by tumor 3. Most patients with isolated idiopathic palsy experience a satisfactory spontaneous recovery B. Paroxysmal painless synchronous contraction of muscles innervated by facial nerve 2. Often starts with contractions around the eye and spreads to involve the lower facial musculature 3. Complications may involve levator muscle, extraocular muscles, and muscles innervated by the facial nerve where botulinum toxin is injected a. Injections should be superficial and remote from the extraocular muscles, the central portion of the levator palpebrae, and the orbicularis oris 3. Respiratory suppression and other complications may be seen with the use of non-approved forms of botulinum toxin, especially in young patients B. Feedback on effectiveness of botulinum toxin injections (either re-evaluate 2-4 weeks after initial injection or inquire at follow-up visit) B. Microvascular decompression to treat hemifacial spasm; long-term results for a consecutive series of 143 patients. Local manifestation of a widespread systemic disease, also presently of unknown etiology. Sclerosing orbital pseudotumor a subtype distinguished histologically by degree of fibrosis and may be refractory to treatment with prednisone or irradiation, and aggressive requiring additional immunosuppressive agents b. Acute disease typically shows dramatic improvement of symptoms to corticosteroid therapy 5. Selected cases warrant hematologic/oncologic consultation for lymphoproliferative disease or other malignancy c. Selected cases warrant rheumatologic/immunologic consultation, or rare parasitic evaluation d. Bilaterality in adults makes one think of systemic disease; whereas children can have bilateral disease in the absence of an underlying systemic disorder B. Orbital vasculitis (Wegener granulomatosis, polyarteritis nodosa, giant cell arteritis) D. Adjuvant immunosuppression with evolving role of biologic therapies and other steroid sparing agents 3. Biopsy for histology, assess for lymphoproliferative disease or findings characteristic of known inflammatory disease 2. Corticosteroid-induced side effects (See Systemic corticosteroids in neuro-ophthalmology) B. Idiopathic orbital inflammation with extraorbital extension: case series and review. Variable relation to thyroid status, euthyroid or dysthyroid concurrent disease 2. Primary disease of the immune system causing autoimmune disease with potential target cells within orbit as well as the thyroid gland, skin B. Associated with other systemic autoimmune disorders, notably myasthenia gravis in roughly 1% of patients 2. Orbital inflammatory signs including injection specifically worse over muscle insertions and chemosis (may be diffuse or inferior) 2. Treatment with radioactive iodine for hyperthyroidism may exacerbate orbital disease 1. Unless medical necessity requires otherwise, surgery should be performed in the following order i. Unless medical necessity requires otherwise, surgery should be postponed until patients are clinically stable. Bony decompression i) Decompression of orbital apex for compressive optic neuropathy ii) Decompression of the medial, inferior and lateral walls may be performed in isolation or in any combination. Complications i) Visual loss (i) Hemorrhage (ii) Direct injury to optic nerve ii) Diplopia (i) Rates vary, but have been reported to range from 5 to 20% (ii) May be less apt if decompression of the orbital floor is avoided 3. Lower eyelid retraction i) Posterior lamellar spacer ii) Correction of laxity (tarsal strip) if present iii) Midface elevation iv) Orbital rim augmentation iii. Tarsorrhaphy (consider as a last resort) but can effectively manage exposure secondary to both upper and lower retraction C. May have a role in patients with optic neuropathy or active inflammation in the orbit V. Transient complaints (transient visual obscurations) versus slowly progressive visual loss gaze-evoked complaints. Typical course of progression over 7 to 10 days with recovery over following weeks to months 2. Describe the etiology and epidemiology of this disease (only the most common/relevant neoplasms are listed) 1. May have a nonaggressive course with stable level of vision loss and do not always require intervention 4. Squamous cell carcinoma is most common via perineural invasion or direct invasion b. Basal cell usually invades orbit directly but may also spread along sensory nerves c. Intervention is usually indicated with visual compromise but medical treatment often highly successful 10. Composed primarily of lymphatics but may have venous vascular components to varying degree c. Usually presents with several years history of proptosis or infra-medial globe displacement c. Optic nerve compression (abnormal acuity, afferent pupillary defect, visual field loss) 2. Direction of globe displacement affects differential diagnosis as it often determines anatomic region of tumor origin 5. Chronic eyelid abnormalities or proptosis may lead to cornea exposure and scarring 7. Posterior segment abnormality (choroidal folds, optic nerve swelling and/or pallor) 8. Loculated infection (abscess, tuberculosis, parasitic, acute fungal, chronic fungal) G. Treatment may require consultation from neurosurgical, ear, nose and throat, facial plastic surgeons as well as oncologist and internists 3. Observation may be indicated for presumed benign tumor with low likelihood of causing compressive or other damage 4. Some tumors are managed surgically: needle biopsy, excisional biopsy, incisional biopsy, limited orbital approach, craniofacial approach 5. Surgical removal of an asymptomatic benign lesion, while small, may be preferential to waiting until the lesion is symptomatic, when larger and likely more difficult to excise b. May result from muscle displacement, compression of innervation, or direct involvement of muscle d. Reduce functional consequences of tumor which parallel those outlined for benign lesions D. Displacement of muscles, through bony defects or into space previously occupied by neoplasm c. Secondary tumor, cataract, dry eye or retinopathy (chemotherapy or radiotherapy) J. Report progressive loss of function, new visual symptoms, and new systemic symptoms C. Reinforce the necessity of adequate high quality radiographic imaging Additional Resources 1. Emergent reconsultation for worsening pain, proptosis, ecchymosis, motility, or visual loss Additional Resources 1. Recognition of concurrent skull base fractures, trimalar fractures, jaw malocclusions 5. The length of the optic nerve allows for ocular motility and explains why optic nerve stretch is not encountered with small degrees of proptosis 2. Landmarks i) Lacrimal gland fossa ii) Superior oblique tendon iii) Supraorbital notch or foramen ii. Injury may occur in conjunction with injury of the following structures and their contents i. Urgent repair is indicated for abnormal motility in the setting of a trapdoor fracture c. The best time to repair of comminuted fractures is controversial immediate vs observation for 7-14 days 2. Emergent reconsultation for worsening motility, visual loss, or pain Additional Resources 1. Parasympathetic dysfunction in or distal to the ciliary ganglion causing diminished pupillary constriction c. Other neurologic symptoms to suggest brainstem localization in central first order disease d. If associated with amaurosis fugax, assess for an ipsilateral carotid artery dissection. Exposure to systemic medications, drops or other agents that may cause a dilated pupil b. The amount of anisocoria and laterality of anisocoria can be variable, but is usually not greater than 1 mm c. Microvascular ischemia in patients with vasculopathic risk factors, although typically these are not pupil involving d. Step 2 Perform a slit lamp biomicroscopic examination to determine the presence of local structural factors as possible cause of the anisocoria a. Step 3 If a local structural factor is not identified then, examine the patient in bright and dim illumination a. If relative anisocoria remains the same in bright and dim lighting then, it represents physiologic or essential anisocoria i. Benign condition characterized by inequality in the diameter size of the 2 pupils (usually less than 1 mm) b. Step 4 If the anisocoria is greater in dim illumination, then the miotic pupil is the abnormal pupil; and, work up for Horner syndrome is necessary (See Horner syndrome) a. Efferent, sympathetic mediated usually very mild paralytic reverse ptosis of lower eyelid, causing eyelid position to be higher than other side c. Step 5 If the anisocoria is greater in bright illumination then the mydriatic or larger pupil is abnormal, and the clinician must consider: a. Pupillary dilation almost always accompanied by ptosis and limited ocular motility ii. Decreased accommodation and subsequent difficulty with near vision (symptomatic if pre-presbyopic) vii. Pharmacologic testing with cocaine (4% or 10%), hydroxyamphetamine (1%), and apraclonidine (0. Acquired childhood Horner needs evaluation for neuroblastoma (abdominal imaging and urine catecholamines) 2. Pupil will not constrict or show signs of denervation supersensitivity to dilute pilocarpine 4. Benign episodic pupillary mydriasis (may occur in patients with history of headaches) F. All patients need a comprehensive eye examination with measurement of pupillary light responses in dim and bright illumination as discussed above 3. Instillation of dilute pilocarpine to help symptomatic photosensitivity and accommodative difficulties f. Failure to resolve or development of aberrant regeneration findings requires further evaluation b. Instillation of pilocarpine to help symptomatic photosensitivity and accommodative difficulties.