By X. Hauke. Southern Oregon University. 2018.
She is afebrile but has mild tachypnea and tachycardia discount nicotinell 52.5mg with mastercard. Lung examination reveals moderate air movement purchase nicotinell 52.5mg overnight delivery, diffuse wheezes nicotinell 52.5mg overnight delivery, and egophony in the left upper lung zone without change in tactile fremitus buy cheap nicotinell 17.5mg online. Chest radiography shows a segmental infiltrate of the left upper lobe with fingerlike shadows and dilated central bronchi. Which of the following diagnoses best explains the constellation of clinical findings and radiologic changes? Alvelolar cell carcinoma with endobronchial invasion C. Bronchiolitis obliterans organizing pneumonia (BOOP) D. Caplan syndrome Key Concept/Objective: To understand the differential diagnosis of a segmental infiltrate and the classic presentation of allergic bronchopulmonary aspergillosis Allergic bronchopulmonary aspergillosis, which is also associated with asthma, is a hypersensitivity disease that primarily affects the central airways. Immediate and delayed hypersensitivity to Aspergillus are involved in the pathogenesis of this disorder. Onset of disease occurs most often in the fourth and fifth decades, and virtually all patients have long-standing atopic asthma. Even those few patients who do not have a history of documented asthma exhibit airflow obstruction when they present with this disorder. The typical patient has a long history of intermittent wheezing, after which the illness evolves into a more chronic and more highly symptomatic disorder with fever, chills, pulmonary infiltrates, and productive cough. The chest x-ray may show a segmental infiltrate or segmental atelectasis, most commonly in the upper lobes. Caplan syndrome is characterized by pulmonary nodules; it is seen exclusively in patients with rheumatoid arthritis. The constellation of long-standing asthma, wheez- ing on physical examination, and the presence of central dilated bronchi are not asso- 16 BOARD REVIEW ciated with either alveolar cell carcinoma or BOOP. In the patient with typical symp- toms, the branching, fingerlike shadows from mucoid impaction of dilated central bronchi are pathognomonic of allergic bronchopulmonary aspergillosis. After a careful history is obtained, no occupational or toxic exposures are readily identified. The patient is concerned that her symptoms are secondary to idio- pathic pulmonary fibrosis (IPF). Chest radiography shows prominent hilar adenopathy with a diffuse interstitial process. What is the correct response to this patient with regard to the appropriate workup of sarcoidosis? In general, transbronchial biopsy is most useful in the diagnosis of sarcoidosis or diffuse infiltrative lung diseases of infectious cause. If the working diagnosis is neither infection nor sarcoidosis, then lung biopsy would likely be indicated. Open lung biop- sy is a very invasive procedure and should be reserved for other types of diffuse infil- trative lung disease. A 38-year-old white man is referred to you for treatment of sarcoidosis. The patient reports that he has decreased exercise tolerance as well as a chronic cough. The patient has an 11-year history of injecting drug abuse. He brings records from his previous physician, which include a report of negative results on an HIV test, a chest x-ray report that reads, "diffuse interstitial process without hilar adenopathy," and a pathology report of noncaseating granulomas that gave sarcoidosis as the final diagnosis. Of the following, which is the most appropriate approach to the treatment of this patient? Inform the patient that given his chest x-ray findings, he has a 65% chance of spontaneous remission C. Assess arterial blood gases; if the patient is not hypoxic, schedule a follow-up appointment in 3 to 6 months D. The pathologic changes in the lung seen with inject- ing drug abuse are secondary to talc, which is used as “filler,” most commonly with heroin. No treat- ment should be initiated until the proper diagnosis has been made.
Control of hyperglycemia in patients with type 2 diabetes mellitus is more controversial buy nicotinell 35mg free shipping, as there are conflicting results of this approach in the literature generic nicotinell 17.5mg visa. This may be related to the fact that renal lesions resulting from type 2 diabetes are more heterogeneous than the typical lesion from type 1 diabetes buy nicotinell 35mg without a prescription. Because uncontrolled hypertension can contribute to the pro- gression of renal disease generic 35 mg nicotinell fast delivery, target blood pressure values have been established. These val- ues vary slightly, depending on the source of the recommendation, but in general, a blood pressure of 130/80 mm Hg or less should be sought. Microalbuminuria is a risk factor for progression to end-stage renal disease in diabetic and nondiabetic patients with renal disease. Smoking is an independent risk factor for microalbuminuria in both hypertensive and normotensive patients. Finally, a low-protein diet can easily lead to malnutrition and calorie deficiency and therefore must be closely monitored. A previously healthy 54-year-old woman presents with a 3-week history of arthralgias and edema. Her examination is remarkable for a blood pressure of 170/106 mm Hg, bibasilar pulmonary crackles, and lower extremity edema. A freshly voided urine reveals red blood cells and red cell casts. Her serology is positive for antineutrophil cytoplasmic antibody (ANCA). For this patient, a renal biopsy with immunofluorescent staining would be expected to show which of the following? Positive staining for immune deposits IgG and C3 C. Positive staining for linear deposition of IgG and C3 E. Negative staining for antibody or C3 12 BOARD REVIEW Key Concept/Objective: To understand that ANCA–associated glomerulonephritis is not asso- ciated with staining for immunoglobulin, complement, or immune deposits ANCA-associated glomerulonephritis involves a vasculitic process of the small- and medium-sized blood vessels that usually presents as a focal segmental necrotizing glomerulonephritis. Renal involvement is usually acute, severe, and progressive, and glomeruli contain crescents. ANCA-associated glomerulonephritis is one of the causes of rapidly progressive glomerulonephritis, which many authors consider a medical emergency. ANCA-associated glomerulonephritis can be limited to the kidney or coex- ist with systemic illness such as Wegener granulomatosis. In contrast to many other kinds of glomerulonephritis, immunofluorescent staining fails to reveal the presence of antibody, complement, or immune complexes. This type of glomerulonephritis is also referred to as pauci-immune glomerulonephritis. If the disease is left untreated, the prognosis is poor. Initial treatment consists of corticosteroids and immunosuppressive therapy. A 45-year-old man presents for a routine examination. His history is remarkable for a bleeding peptic ulcer at age 30 that required transfusion of several units of packed red blood cells. His physical examination reveals a blood pres- sure of 154/98 mm Hg, confirmed on several occasions, but is otherwise not remarkable. His laboratory evaluation was remarkable for ALT and AST levels that were 2. Serum antibody testing for hepatitis C Key Concept/Objective: To understand the pathogenic link between chronic hepatitis C infec- tion and glomerulonephritis Membranoproliferative glomerulonephritis can present with either the nephrotic syn- drome or the nephritic syndrome. Type 1 membranoproliferative glomerulonephritis is caused by immune complex deposition in the subendothelium, most commonly im- mune deposits from hepatitis C virus (HCV) antigens and cryoglobulins.
It appears shortly after the initiation of menstruation in young girls on the upper outer thighs and buttocks and con- tinues to worsen with the passage of time proven 52.5mg nicotinell. Cellulite seems to affect tall and short nicotinell 35mg with amex, fat and thin cheap nicotinell 17.5mg visa, asthenic and curvy females generic nicotinell 52.5mg free shipping. For many women, cellulite marks the end of the idyllic youthful body and the onset of the aging, declining female shape. Certainly, there must be something that technologic medical science can offer. Even in the 1960s, cellulite treatments abounded with the vibrating belt machines designed to firm the buttock and thighs while minimizing cellulite. At the time of this writing, there are many creams, devices, and proce- dures that attempt to deal with the ubiquitous problem of cellulite, but an organized scientific treatise is lacking. This text is the first serious evaluation of the etiology and treatment of cellulite. The editors have assembled an international panel of cellulite researchers and clinicians to share their combined knowledge on the subject. The book is nicely organized with an introduction into the social impact of cellulite, followed by a characterization of the problem through visual and noninvasive techniques, with a major focus on the various treatment modalities. The editors thus provide a full critical evaluation of how each of these treatments impacts the appearance of cellulite. Most dermatologists would agree that not a day goes by in clinical practice without a patient asking about cellulite treatments. To date, it has been difficult to find any reputable reference source on the subject. This text is a large step forward in characterizing the etiol- ogy of cellulite and evaluating worthwhile treatment approaches. The editors and their v vi & FOREWORD authors should be congratulated for tackling a complex subject and organizing a text to highlight and discuss the controversies. This book is an illuminating treatise on the cloudy topic of cellulite. Department of Dermatology Wake Forest University School of Medicine Winston-Salem, North Carolina, U. Preface Beauty has been extolled and made a cult object in all cultures and civilizations, whatever their geographic distribution, ethnic origin, or religion. In ancient Egypt, beauty was associated with a sacred nature and personified by Queen Nefertiti, a woman who had high brows, wide and well-delineated eyes, rich lips, a dignified countenance, and an upright bearing, the very image of subtle energy; the ancient Egyptians regarded beauty closely akin to ‘‘holiness. The Greek aesthetic ideal was characterized by ‘‘perfect proportions’’ in the sense of the geometric relationships defining body harmony. Aphrodite, the goddess of beauty, was also worshipped as the goddess of love. Among the Etruscans, the Venus of Melos repre- sented beauty and harmony; this has remained intact and unpolluted throughout subse- quent civilizations. PREFACE & ix During the Renaissance, the tall figures of Aphrodite and Venus, slim but muscular at the same time although somewhat androgynous, became impressive and important, as is evident in the works of Rembrandt and Rubens. The beauty of women was embodied in figures with abundant localized adiposity, though not obese: the faces were round and blissful and expressed a superb femininity and kindness that conveyed the idea of motherhood and protection. After the French Revolution, the standard representation of the woman took a new turn. The feminine body started to express activity, labor, functionality, precision, and har- mony, losing some traits of Renaissance femininity. In the new society established after the Revolution, women slowly acquired new roles, carried out new activities, and achieved an unprecedented independence. As time went by, women even started to smoke cigarettes and practice sports. There were no objections to this new role as long as the exaggeration and myths of a sculptured body—such as those characteristic of the 1960s—are avoided.
The second stage involves an upholstered ‘‘skin of the capitone’’ type where fibroblastic reactions consolidate and adipocyte-deform-´ ing collagen proliferates buy cheap nicotinell 35 mg online. Slowly but continuously purchase 52.5mg nicotinell visa, these alterations lead to a fibrosclerotic condition mainly located in certain areas (abdomen discount 35mg nicotinell with amex, thighs order 52.5mg nicotinell amex, and internal side of knees). These complex clinical and ultrastructural conditions constitute the final stage of EFP. EFP involves venous alterations, especially at the macrocirculatory level. The deter- mining pathogenic situation is recurrent edema of the adipose tissue with a concomitant venule–capillary permeability increase that unleashes the disease itself. In localized adiposity, the characteristic is adipocyte hypertrophy with preserved morphology, histochemistry, and biochemistry. The main cause of adipocyte hypertrophy is associated with genetic and hormone evolutionary factors. Hence, EFP may be considered as a pathological process of the adipose tissue, whereas localized adiposity is borderline functional because no regressive adipocytic or stromal alterations may be detected. Treatments should be different because etiopathogenesis and evolution are different. The term ‘‘cellulite’’ should be qua- lified somehow to avoid such confusions (59,60). In other words, localized adiposity and EFP are two different stages of closely related clinical and semiological events. It might be said that EFP occurs on a favorable bed: hypertrophy of some areas of adipose tissue, especially in the lower limbs. Such localized adiposity provides the basis for the development of EFP. Let us do without the term ‘‘cellulite’’ tout court, and substitute ‘‘cellulite’’ qualified by a specification of the pathology involved. There are also references in the literature to cellulite being derived from venous– lymphatic insufficiency, but this is not always the case. PATHOPHYSIOLOGY OF CELLULITE & 71 Because microcirculatory flow is slowed down, current literature mentions a stasis characteristic of hypotonic phlebopathy, because no sign of venous hypertension has been detected in this pathology. Such venous–capillary stasis with accompanying higher capillary permeability and edema leads to adipocyte damage, as many studies have confirmed, even at breast level. Partsch and coworkers (28) injected lymphography contrast liquid into subcu- taneous tissue and found structural alterations of the adipose lobe in liposclerotic patients. If we aim at establishing sound bases for treatment, all cases involving microcircu- latory alterations that entail adipocyte hypertrophy should be taken into account, as well as disorders with manifest connective alterations or showing the typical hormone micro- climate favorable to this disease (61–71). There are many etiological and physiopathological factors. Hence, we are forced to suggest various therapies to achieve satisfactory results. Aesthetic pathology suggests glo- bal treatments that include cosmetic or biocosmetic therapies, physical therapies, medical techniques, and surgical techniques that have resulted in actual and effective solutions. Aspect morphohistochimiques du tissue adipeux dans la dermohypodermose celluli- tique. Linfedema, lipedema, liposclerosi, una questione nosologica. Il lipolinfedema: riflessioni e osservazioni cliniche. Price en charge de l’oedeme de l’insuffisance veineuse cronique. Atti Congresso Nazionale Collegio Italiano Flebologia, Torino 1998; 2(1):27–32.