By T. Karmok. National University.

This procedure has been shown to improve severe refractory angina in patients who could not be treated with conventional revascularization techniques (PCTA or CABG) purchase evista 60mg. For the patient described here, CABG is the preferred procedure. A 65-year-old woman presents to the emergency department with anterior chest pain that has been radi- ating to her left arm for the past 10 minutes. She had just run one block to catch a bus before she called the paramedics. Her pain was quickly relieved by two sublingual nitroglycerin tablets given by the para- medics. Her blood pressure is 110/60 mm Hg; pulse, 80 beats/min; and respirations, 20 breaths/min. Examination reveals a moderately obese woman in no apparent distress. Heart rate and rhythm are regular, without murmur, and the lungs are clear to auscultation. Beta blockers, such as metoprolol, are the cornerstone of angina treatment because they are the only antianginals shown to reduce the risk of death and myocardial infarction. Diabetes and use of hypoglycemic medica- tions are not contraindications to beta-blocker therapy, because there is no increase in hypoglycemic events or hypoglycemic unawareness with the use of beta blockers. Nitrates, such as isosorbide dinitrate and nitroglycerin, are effective antianginals, but they do not reduce the risk of cardiac events or death. Calcium channel blockers are effective antiang- inals. Short-acting agents such as immediate-release nifedipine may increase the risk of vascular events and are associated with hypotension, and therefore, they should be avoid- ed. If calcium channel blockers are used, those agents with a long half-life or slow-release formulations should be used. A 72-year-old man with a history of myocardial infarction 10 years ago and angina presents with com- plaints of recurrent chest pain, which he has been experiencing over the past 4 months. This pain is ret- rosternal, is brought on by exertion, and is relieved by rest.

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The corti- cal somatosensory evoked potentials on stimulation of the S1 dermatome and the pudendal nerve are unobtainable on the symptomatic side cheap evista 60mg with amex, whereas the responses on stimulation of the L4 and L5 dermatomes are normal. There is also an abnormal bulbocavernosus reflex on the left or symptomatic side ©2002 CRC Press LLC 5 Chronic pathological changes The effects of acute and cumulative trauma result in ciated with degenerative changes and disc herniation progressive degenerative changes that affect both the can have profound effects on the sensitive structures intervertebral disc and the posterior facets and can within the spinal canal and the spinal musculature. Multilevel degenerative changes can result in decreased mobil- SPINAL STENOSIS ity of the spine and even fusion between the inter- vertebral bodies. Disc herniation, especially when The expansion of the facet joints as a result of degen- painful, also results in reduced mobility and dimin- erative changes can encroach on the central canal ished levels of activity. These chronic changes asso- and the lateral foramina. Courtesy Churchill-Livingstone (Saunders) Press ©2002 CRC Press LLC Figure 5. There is stenosis or narrowing of the central canal at both a levels due to osteophytes protruding into the canal at the level of the disc. Courtesy Churchill-Livingstone (Saunders) Press Figure 5. The spinal fluid has a bright signal intensity and the compression of the intrathecal rootlets is apparent. On the axial T2 MR This CT transverse section through the lumbar spine shows image (b), the central canal stenosis is caused by thickening of marked central canal stenosis. The posterior muscle has been the posterior neural arch and ligamentum flavum, and over- partially replaced by fibrofatty tissue. Courtesy Churchill- growth of the posterior facet joints. This causes significant flat- Livingstone (Saunders) Press tening of the normally ovoid-appearing thecal sac ©2002 CRC Press LLC Figure 5. Anteroposterior (a) and lateral (b) views of the lumbar spine following a myelogram, demon- strating a complete block of the contrast at the L2–L3 level Continued become quite marked, especially in the presence of MUSCLE TRAUMA, IMMOBILIZATION AND large osteophytes from the vertebral bodies, and can ATROPHY result in significant stenosis of the central canal and lateral foramina.

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His spleen is palpable 2 cm below the left costophrenic angle purchase 60mg evista otc. Laboratory results reveal the following: Hb, 18; Hct, 61; platelets, 500,000; leukocytes, 17,000. Which of the following is the most appropriate diagnosis for this patient? Chronic myeloid leukemia Key Concept/Objective: To understand the clinical characteristics of polycythemia vera and primary polycythemia and differentiate these characteristics from those of other types of polycythemia Polycythemia vera is an acquired myeloproliferative disorder that is characterized by over- production of all three hematopoietic cell lines with predominant elevation in red cell counts. This overproduction is independent of erythropoietin. Facial plethora is charac- teristic of all patients with polycythemia vera. Polycythemia vera is slightly more common in men than in women and is most frequently diagnosed in persons between 60 and 75 years of age. Patients commonly complain of pruritus, especially after a hot bath. Gaisböck syndrome, also known as relative polycythemia, is usually found in men from 45 to 55 years of age; they are most often obese, hyperten- sive men who may also be heavy smokers. Pickwickian syndrome, or obesity-hypoventi- lation syndrome, is characterized by obesity with hypoxemia and hypercapnia; some patients experience nocturnal obstructive sleep apnea and daytime hypersomnolence. Although polycythemia vera and chronic myeloid leukemia are both classified as myelo- proliferative disorders, the dominant features of chronic myeloid leukemia are dramatic leukocytosis, the presence of the Philadelphia chromosome, and certain evolution to acute myeloid leukemia. A 62-year-old woman presents with a history of intermittent headache and vertigo.