By E. Renwik. University of Tennessee, Chattanooga.

Hoarseness While the causes of hoarseness are typically self-limiting order azulfidine 500 mg, it is important to consider a range of potential causes: laryngeal growths; gastroesophageal reflux; vocal cord paralysis; and tumors of the larynx, lung, or mediastinum. History When a patient presents with complaint of hoarseness or voice alteration, it is important to obtain an explanation of how the voice has changed—whether in tone, volume, and so on. Determine whether the onset was sudden or gradual, as well as whether the change has been constant or intermittent. It is also essential to determine the patient’s typical pattern of voice use, including whether any unusual use occurred before the onset of hoarseness. Examples of voice use would include singing, lecturing, shouting, and similar. The presence of asso- ciated symptoms, such as sore throat, neck pain, postnasal drainage, heartburn, and/or cough, is important. Identify past medical history of such conditions as thyroid disorders, pulmonary disease, gastroesophageal reflux, and malignancy. Ask about previous surgical history, as well as any trauma to the neck or chest. Physical Examination The physical examination specific to a complaint of hoarseness should include the ears, nose, throat, neck, and lungs, as well as cranial nerves (particularly CNs IX and X). When hoarseness is persistent or laryngeal structural disorders are considered, laryngoscopy should be performed to view any redness, edema, motion, and masses or polyps. Diagnostic Studies Diagnostic studies are not warranted for most cases of hoarseness, but chest radiographs are recommended to rule out pulmonary or mediastinal masses when the symptom persists or in individuals with history of smoking. OVERUSE Voice overuse/stress is a common cause of hoarseness. It can occur at any age and may be a recurrent problem for patients who use their voice extensively in lecturing, singing, or speaking in loud environments.

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The dark gray level here implies lower density and/or elasticity buy 500 mg azulfidine with amex; light gray level implies higher density and/or elasticity. Second, wherever two or more adjacent osteons were abutting, the gray levels of their outermost lamellae appeared to interdigitate. Finally, within an osteon all the lamellae did not have the same gray levels. The interdigitation overlap of the darkest gray levels is clearly seen, implying overlap of density and/or elastic properties. Of particular interest is the lower reflectivity (darker shade of gray) observed for the outermost lamellae of each Haversian system. The Haversian systems are well defined and separated from neighboring Haversian systems. The second lumen slightly above and to the left of the Haversian canal appear to be a second canal based on the appearance of lamellae surrounding the opening. The Haversian system is well defined and separated from its neighboring Haversian systems. To determine whether these outermost lamellae do indeed belong to distinctly different osteons, a second technique delineating structural features must be used. In this case, backscatter scanning electron microscopy (BSEM) was chosen. In the rush to make the structural observations, the proper drying procedures to limit cracking artifacts were not used. Fortunately, the crack artifacts do not obscure the structural information as seen on Figs.

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This patient has secondary hypo- gonadism generic 500 mg azulfidine with visa, so testicular biopsy and ultrasound are not indicated. Furthermore, testicular biopsy usually provides no more information about spermatogenesis than does sperm analysis. Karyotype should be considered in the evaluation of some congenital disorders, such as Klinefelter syndrome; however, this disorder causes primary hypogonadism. A 55-year-old man presents to your clinic complaining of swollen breasts. His symptoms started 3 or 4 months ago, when he noticed tenderness and swelling in both breasts. His medical history includes con- gestive heart failure and hypertension. His medications are benazepril, metoprolol, furosemide, and spironolactone. Review of systems is positive only for occasional dyspnea on exertion. Physical exami- nation shows bilateral gynecomastia in the periareolar area, with some tenderness to palpation. Which of the following would be the best step to take next in the evaluation and management of this patient? Cessation of spironolactone Key Concept/Objective: To know that spironolactone can cause gynecomastia Gynecomastia is the development of glandular breast tissue in a man. In most cases of gynecomastia, the stimulation of glandular tissue appears to result from an increased ratio of estrogen to androgen. Mechanisms behind this change in the estrogen-to-androgen ratio include exposure to exogenous estrogen, increased estrogen secretion, increased peripher- al conversion of androgens to estrogens, and inhibition of androgen binding. The diagno- sis of gynecomastia is confirmed by physical examination. Gynecomastia is generally bilateral, although it is occasionally unilateral. If the tissue is tender, the gynecomastia is more likely to be of recent origin.