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Whereas the Digitalis Investigation Group trial demonstrated the best clinical outcomes in patients with a serum digoxin concentration of 0 500 mg keppra with mastercard medicine 72. Sacubitril/valsartan is a combination pill that consists of a neprilysin inhibitor with angiotensin receptor blocker generic keppra 500 mg on line medicine grapefruit interaction. Inhibition of neprilysin leads to the inhibition of natriuretic peptides and additional vasoactive peptides subsequently augmenting natriuresis and decreasing sympathetic tone purchase keppra 500 mg online medicine under tongue, aldosterone cheap 250mg keppra amex treatment plan for ptsd, and cardiac fibrosis/hypertrophy. This remains a controversial subject and the decision of whether to use aspirin or not should be made on a case-by-case basis. In general, oral potassium supplementation is necessary to maintain serum potassium level in the ideal range of 4. Magnesium, thiamine, and calcium depletion are also common with long- standing diuretic therapy. Sodium restriction (<2,000 mg daily) and medication compliance are crucial to reducing hospitalizations. The Seattle Heart Failure Model is perhaps the most widely used of these and incorporates demographic, clinical, pharmacologic, and laboratory data to provide accurate 1-, 2-, and 3-year survival estimates. The effect of cardiac resynchronization on morbidity and mortality in heart failure. Effect of vasodilator therapy on mortality in chronic congestive heart failure: results of a Veterans Administration Cooperative Study (V- Heft). A randomized trial of the angiotensin-receptor blocker valsartan in chronic heart failure. A trial of the beta-blocker bucindolol in patients with advanced chronic heart failure. The effect of carvedilol on morbidity and mortality in patients with chronic heart failure. Valsartan, captopril, or both in myocardial infarction complicated by heart failure, left ventricular dysfunction, or both. Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. National Academy of Clinical Biochemistry Laboratory Medicine Practice Guidelines: clinical utilization of cardiac biomarker testing in heart failure. This clinical entity historically has also been referred to as diastolic heart failure. Abnormal mitral inflow Doppler pattern suggesting impaired relaxation (E/A < 1), E/A pseudonormalization or restrictive physiology (E/A > 2) 5. These include arterial stiffness, the relationship between arterial and ventricular stiffness, and chronotropic incompetence. Associated comorbidities include hypertension, diabetes, obesity, and chronic kidney disease. Other patients experience overt symptoms of left-sided (dyspnea, orthopnea, and paroxysmal nocturnal dyspnea) and right-sided (edema and abdominal bloating) heart failure. Patients should be evaluated for typical signs of right-sided (elevated jugular venous pressure, hepatic congestion, ascites, and lower extremity edema) and left-sided (pulmonary edema and pleural effusion) congestion. In contrast to patients with dilated cardiomyopathy, the location of the apical impulse is usually close to the midclavicular line, signifying a normal-sized ventricle. In addition, a hypertrophied ventricle will often have a stronger impulse than a ventricle of normal thickness. This may be appreciated on examination in patients who do not have thick chest walls. In patients with exertional symptoms alone, these signs may not be present as the manifestation of their diastolic dysfunction may occur only during exercise. The presence of severe right-sided heart failure features, particularly ascites and hepatic congestion, should raise suspicion for restrictive cardiomyopathy, constrictive pericarditis, or both. In these patients, clinical findings of multiorgan disease may provide additional insights into the etiology of their cardiomyopathy. Kussmaul sign, a paradoxical elevation in the mean jugular venous pressure during inspiration, has been classically described in constrictive pericarditis. However, it can also be present in patients with restrictive cardiomyopathy as well as other pathologies involving the right heart (e. In a posterior– anterior film, a normal-sized heart (lateral heart width less than two-thirds of a hemithorax) may be a clue to a normal-sized left ventricle. In a patient who has an established clinical syndrome of heart failure, the differential diagnosis is typically narrowed following echocardiography. In such patients, myocardial ischemia may play some role in the manifestation of heart failure. This is particularly true for patients presenting with acute heart failure or flash pulmonary edema. In the absence of dynamic valvular regurgitation, ischemia leading to pulmonary edema usually denotes a large amount of myocardium at risk. This type of presentation certainly warrants aggressive investigation for obstructive coronary disease and, when applicable, revascularization. Amyloidosis refers to the deposition of amyloid, or an abnormal protein, in organ tissue. There are several causes, and the following are the most important ones that manifest with cardiac involvement. Monoclonal plasma cells produce a light chain immunoglobulin; deposition into cardiac tissue is variable. Early stages show subclinical diastolic dysfunction (usually seen on echocardiography); later stages show severe restrictive cardiomyopathy. Traditionally, patients presenting with heart failure are felt to have a very poor prognosis with limited treatment options. However, tertiary center experience suggests that achieving remission of the malignancy with chemotherapeutics may positively impact a patient’s heart failure symptoms. Familial amyloidosis involves the inheritance of a gene that produces a mutant form of transthyretin, a serum protein carrier of thyroxine and retinol. The protein is produced in the liver and is deposited in the kidneys, the heart, and the nerves. Senile amyloidosis is similar to familial amyloidosis in that it is related to the deposition of a pathologic variant of transthyretin. Endomyocardial fibrosis is an idiopathic restrictive cardiomyopathy that occurs in areas close to the equator, such as equatorial Africa, South America, and Asia. Histologically, it is characterized by granulation tissue, collagen, and extensive connective tissue lining the endocardium. It affects both ventricles (50%), left ventricle (40%), or isolated right ventricle (10%) and is associated with a 2-year mortality rate of up to 50%.

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Lumbar transforaminal injection and use of digital subtraction to identify intra-arterial needle location safe keppra 250 mg treatment 11mm kidney stone. A: Anterior-posterior radiograph of the lumbar spine with the needle in final posi- tion for right L4/L5 transforaminal injection keppra 500mg without a prescription medications quizzes for nurses. B: Lateral radiograph of the lumbar spine with the needle in final position for right L4/L5 transforaminal injection buy keppra 500 mg low price symptoms qt prolongation. C: Anterior-posterior radiograph of the lumbar spine with the needle in final position for right L4/L5 transforami- nal injection acquired during active injection of radiographic contrast demonstrating intra- arterial contrast injection buy 500 mg keppra amex treatment hepatitis c. Needle positioning A firm grasp of the anatomy of adjacent vascular and neu- toward the posterior aspect of the foramen reduces the ral structures is essential to avoid complications during risk of entering the spinal segmental artery. Particular care lumbar selective spinal nerve and transforaminal injection should be taken when performing transforaminal injec- (see Fig. Direct injection of particulate steroid into a tion on the left between T9 and L1 because the artery of spinal segmental artery supplying the spinal cord can lead Adamkiewicz, the largest of the spinal segmental arteries, Chapter 6 Transforaminal and Selective Spinal Nerve Injection 79 lies between these levels in the majority of individuals. Effectiveness of transforaminal The use of radiographic contrast injected during “live” or epidural steroid injection by using a preganglionic approach: a prospective randomized controlled study. Periradicular means to accurately verify that injectate is not injected infiltration for sciatica: a randomized controlled trial. Fluoroscopic transforaminal lumbar cuff as it extends laterally onto the exiting nerve root. Selective nerve root blocks for the treatment of sciatica: evaluation of injection site Botwin K, Gruber R, Bouchlas C, et al. Outcome of cervical radiculopathy treated cohort of 56 patients with low back pain and sciatica. Systematic review of ther- apeutic lumbar transforaminal epidural steroid injections. Is it really possible to do a selective cervical spondylotic radicular pain: a retrospective analy- nerve root block? Their role in the evaluation of son with radiculography, computed tomography, and operative recurrent sciatica. Selective nerve root block in patient selection for lum- Vad V, Bhat A, Lutz G, et al. Paraplegia after lumbosacral nerve root thy: lateral approach periradicular corticosteroid injection. Complications of common selective vulnerable arteries and ischemic neurologic injuries after trans- spinal injections: prevention and management. Chapter 7 Facet Injection: Intra-articular Injection, Medial Branch Block, and Radiofrequency Treatment 81 C1 C1 C2 C2 C3 C3 C4 C4 C5 C5 C6 o 25 – 35 C7 C6 T1 C7 T1 T2 T2 T3 T3 T4 T4 T5 T5 T6 T6 T7 T7 T8 T8 T9 T9 o 60 – 70 T10 T10 T11 T11 T12 T12 L1 L1 L2 L2 L3 L3 o L4 25–35 L4 from o sagittal 0 L5 plane L5 Figure 7-1. The plane of orientation of the facet joints varies significantly among cervical, thoracic, and lumbar levels. The axis of the joints and the plane of entry for intra-articular injection are shown for typical cervical, thoracic, and lumbar facet joints. The most important vertebra forming the superior portion of each thoracic facet historical feature is a predominance of axial spinal pain; joint lies directly posterior to the superior articular process, those patients who report that the predominance of their forming the inferior portion of each joint. This allows for pain is in the extremities are more likely to have acute or some degree of flexion and extension, but limited rotation chronic radicular pain than facet-related pain. The steeply angled ceph- ity of the pain is typically deep and aching, and waxes and alad-to-caudad orientation of the thoracic facets also makes wanes with activity. Burning or stabbing qualities suggest intra-articular injection difficult or impossible. Diagnos- facet joints are angled with a somewhat oblique orientation, tic studies are often unrevealing. Patients with significant allowing for flexion, extension, and rotation that is greater facet-related pain may have unremarkable plain radiographs than that in the thorax but less than in the cervical region. Patient selection for facet needle insertion for intra-articular facet injection are illus- injection or radiofrequency treatment is empiric and relies trated in Figure 7-1. The spinal nerve at facet joints has been established by injecting a mild irritant each level traverses the intervertebral foramen and divides (usually hypertonic saline) into specific facet joints in healthy into anterior and posterior primary rami. The posterior primary ramus, in vical, thoracic, and lumbar regions, respectively. The levels turn, divides into a lateral branch that provides innerva- to be treated are chosen by correlating the patient’s report of tion to the paraspinous musculature and a small, variable pain to these pain diagrams. Occasionally, a patient will pres- sensory branch to the skin overlying the spinous processes; ent with evidence of facet arthropathy and a pattern of pain the medial branch of the posterior primary ramus courses that corresponds to a single level, but this is uncommon. Treatment should be directed along the articular process to supply sensation to the joint. The specific course of C2/3 the medial branch nerves and cannula position for radiofre- quency treatment at specific spinal levels is discussed in the following sections. C3/4 C3/4 C5/6 Patient Selection Patients with facet-related pain are difficult to distinguish from those with other causes of axial spinal pain. Some patients will present with sudden onset of pain follow- ing a significant flexion-extension (whiplash) injury, but more common is an insidious onset over months to years. Patients with myofascial or discogenic pain and, in the low back, those with sacroiliac dysfunction present with simi- lar symptoms. The pain caused by facet arthropathy is most pain patterns produced by specific cervical facet joints are illustrated. Data are derived from intra-articular injection in pronounced over the axis of the spine itself and is typically healthy volunteers. Typical pain patterns produced by specific thoracic facet joints are pain patterns produced by specific lumbar facet joints are illustrated. The overuse of How to select between intra-articular facet injection and facet injections, including intra-articular injections and diagnostic medial branch blocks followed by radiofre- radiofrequency treatment, has been singled out as a sig- quency treatment is still a question that is frequently posed nificant area of concern. Limited outcome studies of intra-articular examined the scientific literature and made evidence- injection, particularly at the cervical level, have demon- based guidelines regarding the use of this treatment. In contrast, in those patients who obtain quency treatment are limited, and we will discuss each significant pain relief from diagnostic blocks of the medial in turn. Based on this improved joint corticosteroid injection…[is] not recommended efficacy and a long track record of safety, many practitioners (strong recommendation, moderate-quality evidence). Intra-articular injection remains of therapeutic medial branch block [and] radiofrequency of some value in those patients who have had recent onset denervation…for nonradicular low back pain. Intra-articular injection is also a because randomized trials consistently found them to be no reasonable alternative when the expertise or equipment for more effective than sham therapies. While A 2010 Practice Guideline, offering the following recom- observational studies have suggested that use of medial mendations: (1) “Intra-articular facet joint injections may branch blocks with local anesthetic alone can provide sus- be used for symptomatic relief of facet-mediated pain. Indeed randomized trials demonstrate C-arm is rotated 25 to 35 degrees caudally from the axial little benefit for use of intra-articular injections, while well- plane without any oblique angulation. This brings the axis conducted observational studies suggest a more significant of the x-rays in line with the axis of the facet joints and effect in treating chronic axial low back pain. Although trials of the use of medial branch blocks with local anesthetic the cervical facet joints can also be entered from a lateral alone, without subsequent radiofrequency treatment, have approach with the patient lying on his or her side, advanc- been encouraging, but randomized trials are lacking. Guidance on the optimal frequency for repeating these inter- The skin and subcutaneous tissues overlying the facet joint ventions as well as the efficacy of using multiple repeated where the block is to be carried out are anesthetized with treatments over time is lacking entirely.

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History: Exposure to drugs quality 250mg keppra treatment of diabetes, infections order genuine keppra on line 7 medications that can cause incontinence, cancer discount keppra 500 mg overnight delivery medicine of the wolf, inflammatory The disorder is self-limiting although recurrent bowel disease discount 250mg keppra with amex symptoms juvenile rheumatoid arthritis, connective tissue disease disease may require treatment with oral corti- Clinical examination/Laboratory assessment costeroids cytotoxic agents or plasmapharesis. Rarely the syndrome may progress to life threatening renal or Pathological examination • Of involved organs such as skin muscle, nerve lung or pulmonary disease. Treatment previously consisted of immuno- Immunohistologic evaluation suppression and plasmapheresis with temporary • For presence of IgA dominant vascular deposits indicative of Henoch-Schönlein purpura IgG and IgM immune efficacy. Trials with interferon alpha-2 have been complexes that are consistent with cryoglobulinemic successful. Corticosteroids together with cytotoxic agents presence of skin and peripheral nerve involvement. Polyarteritis nodosa, microscopic the diagnostic possibility of vasculitis should be polyangitis and Churg Strauss syndrome. The spectrum of manifestations are seen in most vasculitides and may pulmonary vasculitis. Pulmonary Congestive cardiac failure/cor pulmonale embolism implies clinically significant obstruction of Prior venous thrombus a part or the whole of the pulmonary artery tree, Hypercoagulability Malignancy usually by a thrombus that becomes detached from Anticardiolipin antibody its site of formation outside the lung, being swept Nephrotic syndrome downstream until it is arrested at points of intra- Estrogen therapy Heparin induced thrombocytopenia pulmonary vascular narrowing. Pulmonary embolism Vessel wall injury Trauma is a disease of recurrence and the mortality for each Surgery subsequent embolism approaches 30%. Other surgeries included are • Age—Incidence increases exponentially with age coronary bypass and neurosurgery. Reduced venous alveolar collapse resulting from loss of alveolar return and resultant stasis may result from surfactant contributing to fluid accumulation. Further fibrinolytic activity may be blood flow through these hypoventilated edematous reduced and the level of certain clotting factors areas of the lung. Sub-massive embolism with pulmonary infarction: Emboli that are small and few usually cause no Patients complain of pleuritic chest pain, hemo- hemodynamic upset as long as pre-existing pulmo- ptysis and dyspnea. Conversely large embolism is difficult to distinguish from pleuritis emboli to major pulmonary artery or a large shower or pneumonia. Sub-massive embolism without infarction: Patient bradycardia, pulmonary hypertension and decrease presents with acute unexplained dyspnea, which in cardiac output. Resembles congestive heart failure, Respiratory Effects asthma or primary hyperventi-lation. This type usually goes unrecognized and multiple such Pulmonary embolism produces mismatching of episodes lead to pulmonary hyper-tension, which ventilation and perfusion by increase in alveolar is clinically indistinguishable from primary dead space and increasing intrapulmonary shunts. This shunting results from bronchoconstriction due Acute Massive Embolism to hypocapnia secondary to increase in alveolar ventilation and release of vasoconstrictor substances This is defined as blockage of flow from a volume from platelet aggregates within the clot and possibly of lung greater than that served by two lobar Pulmonary Thromboembolic Disease 311 pulmonary arteries. The classical triad of chest provided by a large number of studies that the pain, dyspnea and hemoptysis is seen in only 20% clinical diagnosis of venous thrombosis is both patients The percentage of symptoms and signs are insensitive and nonspecific. Dyspnea 84% Hence noninvasive testing for the diagnosis of deep Pleuritic chest pain 74% Cough 53% venous thrombosis and pulmonary embolism Hemoptysis 30% became popular. Autopsy studies have shown residua of chronic partially recanalized thrombi in virtually all patients who have had prior pulmonary embolism. In most cases obstruction occurs in small and peripheral vessels, however persons with hypercoagulability or with poor intrinsic thrombolytic activity may have signi- ficant narrowing of large and central pulmonary vessels. Other abnormalities which may be seen are Wedge shaped pleural based opacity, Hampton’s hump—due to pulmonary infarction, elevation of hemidiaphragm, Pleural effusion, Enlarged proximal pulmonary artery with distal pulmonary oligemia, Rat tail lung, Plate atelectasis, Melting ice sign—to differentiate embolism from infarction. Electrocardiographic findings are frequently abnormal but are nonspecific and transient. Atleast 2% of patients with pulmonary embolism will have this pattern, 96% of patients with this pattern will not have pulmonary embolism. High probability: > 2 large (> 75% of a segment) segmental perfusion defects either without any abnormality on the chest radiograph or with abnormality that are considerably larger than corresponding defects in the ventilation scan or the chest radiographs. Intermediate probability: Not falling into high or gradient in a patient who is not wheezing and has low probability categories. Studies have shown or hypotension is present where it should be good sensitivity and specificity for central or available urgently and when other investigations segmental thrombus but not in subsegmental or in have failed to give a diagnosis. Intermediate 66% 28% 16% Low 40% 16% 4% Echocardiography In patients with major central pulmonary embolism, Echocardiography can establish the diagnosis as well as exclude other diagnosis. Echocardiography shows right ventricular dilatation, tricuspid regurgi- tation, abnormal septal movement and lack of inferior vena cava collapse during inspiration. Leg Imaging (to rule out deep vein thrombosis) Ascending Contrast Venography This is the “gold standard“ for the diagnosis of the various thrombosis in the lower extremity. Radiolabelled Antibody Imaging Depends upon radioactive I125 labelled fibrin being incorporated into actively forming thrombus so that it can be detected using a surface counter. Prompt effective anticoagulation medical conditions and after most surgical pro- with heparin has been shown to reduce mortality cedures lasting longer than 30 minutes. Hence heparin should be started means for prophylaxis are directed primarily immediately when diagnosis of pulmonary embo- towards limiting venous stasis. Intermittent external pneumatic com- initial bolus dose of 10000-20000U followed by a drip pression of calf and thigh is also effective. After full anti- thromboembolic complications is 5000U adminis- coagulation has been established with heparin oral tered subcutaneously 2 hours before surgery and warfarin may be initiated. Heparin The aims of anticoagulation are to prevent formation warfarin treatment should be overlapped by 4 to 5 of new thrombus, to prevent further embolisation days because anticoagulation effect of the vitamin of preformed thrombus and to reduce or prevent K antagonists is delayed until all normal clotting long term complications such as cor pulmonale. The factors are cleared from circulation which takes 36- drugs used are: 72 hours. The dose is10 mg/day for first 2 days and Pulmonary Thromboembolic Disease 315 Flow Chart 15. A total both the deep vein system and the pulmonary treatment of atleast 12 weeks is advised for circulation. It is not tration, early ambulation, no routine laboratory approved for use in deep vein thrombosis. It is generally accepted that intestinal bleed, uncontrolled hypertension The dose in life threatening pulmonary embolism, hemo- given is 5000U once daily for Dalteparin, 4000U once dynamic instability or respiratory compromise, daily for Enoxaparin and 60 μ/kg once daily for thrombolytic agents should be used. After a course Nadroparin to be given for a total duration of 3 of thrombolytic agents, standard anticoagulation months. Thrombolytic Therapy Vena Caval Filters The use of thrombolytic agents should be consi- dered in all patients with pulmonary embolism Such as stainless steel Greenfield filter, Bird’s nest Thrombolytic agents can dissolve existing clots in filter, Simon filter, the indications are presence of 316 Textbook of Pulmonary Medicine contraindications to anticoagulation therapy, dosing and eliminate the need for routine laboratory recurrent thromboembolism inspite of anticoa- monitoring. They Surgical Embolectomy include anti-Xa inhibitors, such as pentasaccharide, and antithrombin inhibitors, such as ximelagatran. Survey on the use of pulmonary scintigraphy and angiography for pulmonary embolism. Spiral computed tomographic scanning and magnetic resonance angiography for the Prognosis diagnosis of pulmonary embolism Thorax 1998;53(Suppl 2):S25-31. Changing measures are taken, death from embolism is practice patterns in the workup of pulmonary embolism. A new noninvasive management strategy for patients with suspected are more likely to have recurrences.

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T—Trauma discount keppra online master card treatment viral pneumonia, particularly penetrating wounds of the chest causing pneumothorax and hemopneumothorax order 500 mg keppra with mastercard medicine effects, is often associated with hiccoughs generic 500 mg keppra visa medicine tramadol. M—Malformations include hiatal hernia discount keppra 250 mg line treatment yellow tongue, pyloric obstruction, and Barrett esophagitis. I—Inflammation suggests reflux or bile esophagitis, gastritis, hepatitis, cholecystitis, peritonitis, and subphrenic abscess. N—Neoplasms include esophageal carcinoma, carcinoma of the stomach, retroperitoneal Hodgkin lymphoma, and sarcoma. T—Trauma includes hemoperitoneum from ruptured spleen or liver, ruptured viscus, or ruptured ectopic pregnancy. One other group of 447 causes is the reflex stimulation of the phrenic nerve from organs far beneath the diaphragm. For example, carcinoma of the uterus or colon without metastasis may occasionally cause hiccoughs. Approach to the Diagnosis The usual reaction to a patient with hiccoughs is “They’ll get over them regardless of what we do so why worry about them? Relief with Pepto-Bismol or Xylocaine viscus suggests the cause is reflux esophagitis. In the otherwise healthy patient, esophagoscopy and gastroscopy often reveal a reflux esophagitis or gastritis. Cholecystograms, liver and pancreatic function studies, spinal tap, and brain and total body scan have their place in individual cases. Ambulatory pH monitoring (reflux esophagitis) Case Presentation #45 A 44-year-old white male street cleaner presented with recurrent hiccoughs and weight loss. Utilizing the methods discussed above, what would be your differential diagnosis at this point? After hospitalization, he was observed to have intermittent fever and chills and a white blood cell count of 18,900; a chest x-ray revealed an elevated right diaphragm. Looking at each of these structures in terms of etiology, skin should prompt the recall of herpes zoster, and muscle should prompt the recall of contusion or sprain. The bursa should allow one to recall greater trochanter bursitis—a common and easily treated form of hip pain. Visualizing the bone should prompt recall of fracture and primary and metastatic tumors. Visualizing the nerves, one should think of the sciatic nerve and consider a herniated lumbar disc, cauda equina tumor, or sciatic neuritis (which is rare). Approach to the Diagnosis The history and physical examination will allow differentiation of many of the conditions listed above. Remember that fractures of the hip can occur in elderly persons without a history of trauma. If x-rays and laboratory examinations are negative, a trial of lidocaine injections into the greater trochanter bursa or other trigger points may be diagnostic. Table 38 Hip Pain 452 Case Presentation #46 A 56-year-old white woman complained of increasing left hip pain which began 3 months ago and had gradually gotten worse. There is no history of trauma, fever or chills, and no numbness or tingling of the extremities. Physical examination is unremarkable except for tenderness of the greater trochanter bursa and a positive Patrick sign. Simply by visualizing the endocrine glands and proceeding from the head caudally, one may come up with the most significant pathologic causes of hirsutism. If these are ruled out, the patient most likely has idiopathic hirsutism and nothing needs to be done. Pituitary: Acromegaly and a basophilic adenoma of the pituitary may cause hirsutism. Thyroid: Congenital and juvenile hypothyroidism are associated with 453 hirsutism but not virilism. Adrenal gland: Adrenal carcinomas, adenomas, and hyperplasia may all be associated with hirsutism. Congenital adrenal hyperplasia may become manifest at puberty, in which case there will be both hirsutism and virilism. Ovary: Polycystic ovary syndrome (Stein–Leventhal syndrome) will be recalled by visualizing this endocrine gland. The ovary is also the site of arrhenoblastomas, hilus cell tumors, and luteomas that may cause hirsutism. Ovarian failure (menopause) may also be associated with hirsutism, but there is no associated virilism. Anatomy will not be useful in recalling the many drugs that may produce hirsutism. These include phenytoin, diazoxide, minoxidil, anabolic steroids, androgens, and glucocorticoids. Hirsutism may also be found in porphyria, anorexia nervosa, and the Cornelia de Lange syndrome (Amsterdam dwarfism). Approach to the Diagnosis Clinically it is most important to look for obesity and virilism. The workup initially should include serum cortisol or 24-hour urine 17-hydroxycorticoids or 17-ketosteroids, serum prolactin, and a thyroid profile. Serum testosterone Case Presentation #47 A 19-year-old, 6-month-pregnant Hispanic woman complained of increasing hair growth on her face. Physical examination revealed a male escutcheon, enlarged clitoris, and purple striae of the abdomen. Hoarseness may occur from involvement of the larynx, myoneural junction of the vocal cord muscles, vagus nerve, or the brainstem. It may also be involved with allergy, neoplasms, and chronic trauma from overuse of the voice. The myoneural junctions prompt the recall of myasthenia gravis, whereas the peripheral portion of the vagus nerve prompts the recall of the greatest number of disorders; thyroid tumors and surgery to the thyroid, mediastinal tumors, and aortic aneurysms are only a few. The intracranial portions of the vagus nerve may be involved by basilar artery aneurysms, basilar meningitis, platybasia, and foramen magnum tumors. In the brainstem, the nucleus ambiguus is involved in poliomyelitis, ependymomas, Wallenberg syndrome, syringomyelia, and amyotrophic lateral sclerosis. Multiple sclerosis and gliomas may involve the roots of the ambiguus nucleus as they pass through the brain stem white matter. Approach to the Diagnosis A careful examination of the larynx with a laryngoscope or the fiberoptic bronchoscope is essential. The indirect laryngeal mirror is difficult to use and probably should be discarded by those unfamiliar with its use. If no local disease is found, evidence of vagal nerve palsy will be noted by the cord paralysis.

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