By X. Mamuk. Thomas Jefferson University. 2018.

There have been reports of depres- 2 DERMATOLOGY 31 sion and suicide in isotretinoin-treated patients buy discount nolvadex 20 mg line women's health clinic riverside campus. This association remains controversial purchase 20 mg nolvadex women's health issues 2012, but this risk must be discussed with the patient before starting therapy. A 16-year-old female patient comes to your office complaining of pimples. She states that the pimples appeared on her face 2 to 3 months ago. She has also noticed some deepening of her voice and the appearance of an increasing amount of hair on her chin and breasts. Her menses were regular until 4 or 5 months ago, when she started noticing irregular and short-lasting periods. On physical examination, the patient has papules and pustules on her face. Hirsutism is noted on her face, arms, breasts, and infraumbilical area, and she has an enlarged clitoris. Which of the following is the most appropriate step to take next in the treatment of this patient? Evaluate the patient for the possibility of ovarian or adrenal tumors B. Start oral contraceptives for presumed polycystic ovarian syndrome (PCOS) and provide reassurance C. Start low-dose hydrocortisone for presumed late-onset congenital adre- nal hyperplasia and follow up in 2 months D. Start benzoyl peroxide with topical metronidazole in the morning and topical retinoids at night E. Administer a pregnancy test and consider isotretinoin therapy Key Concept/Objective: To know the secondary causes of acne Acne is very common in the adolescent population; however, it is important to recognize acne as a secondary manifestation of a primary process. Acne can be caused by medica- tions such as isoniazid, corticosteroids, phenytoin, lithium, and progestins. Acne can also be a manifestation of androgen excess; this patient had acne of rapid onset, and there were other manifestations of androgen excess, such as changes in her voice, oligomenorrhea, clitoromegaly, and hirsutism. This rapid onset is characteristic of tumors producing andro- gens, which are frequently located in the ovarian or adrenal glands. Levels of testosterone, free testosterone, and dehydroepiandrosterone sulfate should be measured; if the results are high, imaging studies are indicated. PCOS can cause oligomenorrhea, hirsutism, and acne; however, it should not cause clitoromegaly or voice changes. Late-onset congenital adrenal hyperplasia (CAH)—21-hydroxylase deficiency in particular—is in the differential diagnosis. However, it would be atypical for it to present in such a rapid manner. If the workup for the presence of a tumor is negative, further workup for CAH would be indi- cated. A 38-year-old man presents to your clinic complaining of hair loss. He reports that the hair loss began several years ago but is more noticeable now. His hair has been thinning out on the sides as well as on the top of his head. He reports that several family members have the same problem. Which of the following is the most appropriate therapy for this patient’s condition? Topical 2% minoxidil applied to the scalp twice daily B. Medium- to high-potency topical steroids applied daily C. Topical immunotherapy with the sensitizing chemical diphencyprone D.

The patient has optic neuritis buy nolvadex 10mg menstrual urination; she is at no risk of progressing to MS in the future D trusted nolvadex 10 mg menstruation calculator. The patient has MS; she should be started on mitoxantrone Key Concept/Objective: To know the association between optic neuritis and MS Optic neuritis is an acute inflammatory optic neuropathy. The cardinal symptoms are uni- lateral vision loss and retrobulbar pain with eye movement. Treatment with intravenous methylprednisolone followed by oral prednisone hastens recovery of vision. Even without treatment, almost all patients begin to recover vision within 4 weeks. The relationship of optic neuritis to MS is controversial. Some regard optic neuritis as a distinct entity, but oth- ers consider it part of the clinical continuum of MS. More than half of all patients with MS have optic neuritis at some time during the course of disease. Of patients who present with optic neuritis and who have no other neurologic deficit, almost 40% have one or more ovoid periventricular lesions on brain MRI; clinically definite MS eventually develops in 60%. Patients with completely normal results on MRI and comprehensive CSF evaluation seldom progress to MS. A 44-year-old man comes to the hospital complaining of progressive lower extremity weakness and decreased sensation. He also complains of having difficulties with bowel movements and urination. He recalls having an upper respiratory infection 1 or 2 weeks ago. His physical examination is remarkable for decreased sensation starting at the level of T10, symmetrical severe lower extremity weakness, urinary retention, and decreased rectal tone. The muscle tone and deep tendon reflexes in his lower extremities are diminished. T2-weighted MRI of the spinal cord shows a hyperintense lesion that involves the majority of the cross-sectional area of the cord; the lesion extends from T6 to L3. Of the following, which is the most likely diagnosis? MS Key Concept/Objective: To be able to recognize transverse myelitis Acute transverse myelitis is a syndrome of spinal cord dysfunction. It has a rapid onset; it may occur after infection or vaccination or it may occur with no discernible precipitant. Symptoms include paraparesis, which is ini- tially flaccid and then spastic; loss of sensation with a sensory level in the trunk; and bowel and bladder dysfunction. MRI is extreme- ly helpful for excluding other structural lesions and for confirming the presence of an intramedullary lesion, which is typically hyperintense in T2-weighted imaging. No treat- ment has proven to be beneficial, but corticosteroids are often used. Neuromyelitis optica is also known as Devic disease. It is characterized by the simultaneous or sequential involvement of the optic nerves and spinal cord; it often has a malignant course. Acute dis- seminated encephalomyelitis is a monophasic syndrome that is usually preceded by a viral exanthema, an upper respiratory infection, or vaccination. Onset is rapid and is charac- terized by meningeal signs, headache, seizures, and altered mental status. The neurologic deficits include hemiplegia, paraplegia, sensory loss, vision loss, and transverse myelitis. In this patient, the lack of multiple lesions and the monophasic nature of the disease make the diagnosis of MS less likely. A 43-year-old woman with a 14-year history of MS with lower-extremity spasticity presents with increased spasticity, mild confusion, abdominal discomfort, and a temperature of 100° F (37. Which of the following choices best combines medical indication and favorable cost-benefit ratio?

In such cases purchase nolvadex 10mg without prescription breast cancer 5k run, most of described by McKeever and different types of the gliding surfaces are covered by healthy patellectomies also have some clinical experi- hyaline cartilage and only a limited area has ence buy discount nolvadex 20 mg on-line women's health issues developing countries, but these operations cannot be recom- been destroyed. Although some studies have mended to treat cartilage damage of the observed that such defects may have limited patellotrochlear surfaces. Deterioration of surrounding car- elements of the subchondral bone marrow. Traditional cartilage surgical armamentarium that aim to serve as repair techniques require a sufficient direct con- long-lasting and successful chondral resurface- nection between the bone marrow cavity of the ment. These operative treatment options can be spongiosa and the articular surface. Because of classified into two main groups: “traditional” the limited mechanical characteristics of the and “modern” cartilage repair procedures. In response to these limita- the natural regenerative potential of certain tions, several researchers have carried out Treatment of Symptomatic Deep Cartilage Defects of the Patella and Trochlea with and without Patellofemoral Malalignment 209 extended experimental and clinical studies pre- variable combination with the aforementioned senting a new trend of resurfacing strategies. The main goal is to create a gliding sur- been reported by other authors. Jackson84 found face appropriate for demands of weight-bearing 68% improved in 1988, Bert13 66% in 1989, areas. Such procedures may shield the joint Baumgartner7 52% in 1990, and Rand147 67% from further degeneration. However, in the case of full-thickness focal cartilage defects, most authors believe that Traditional Techniques we cannot only expect fair results from debride- The main goal of these techniques is to promote ment in the long term. Formal open debridement the natural healing process. As this repair results arthrotomy is now, by and large, reserved for in only fibrocartilage, these treatment options selected rheumatoid cases. Pridie Drilling Debridement alone cannot promote a sponta- Debridement neous fibrocartilage repair in the region of a A primary goal in any treatment of cartilage full-thickness cartilage defect. Debridement addresses ments to engage in the repair process. Mere shaving of the damaged sur- the subchondral cancellous bone and the joint face does not appear to achieve a positive space, and in this way, increases the potential to restorative effect,91,121 but removal of frag- mobilize more mesenchymal stem cells from the mented cartilage may lessen the reactive syn- bone marrow to the joint surface. When originally pro- the widely used diameters to provide these posed, surgical cleaning of the joint had been direct contacts to promote bloodborne heal- recommended to treat severe osteoarthritic ing. At the very least, the partial success to numerous clinicians such as Pridie,146 Insall,79 of arthroscopic debridement and lavage has and Johnson,90 we60 have observed immediate fostered a renaissance in the effects of minimal pain relief after the Pridie decompression. Unfortunately, this effect sents a viable option when endoprosthetic is transient, explainable by the rapid capping of replacement is contradicted. Pridie drilling of cartilage damage is often the subject of such the trochlear surfaces in certain cases can be arthroscopic shaving techniques. Overall objec- performed arthroscopically but patellar drilling tive evaluation of the end results of the proce- usually requires an open approach. Predictable dure remains elusive in large part due to the deterioration with time has been the rule as a 210 Etiopathogenic Bases and Therapeutic Implications application of Johnson’s abrasion arthroplasty has declined in popularity. Microfracture Upon analysis of abrasion arthroplasty, the use of small surface cavities for punctuate bleeding could be improved upon for the deliverance of marrow healing elements to the surface. This consideration led to the development of the microfracture technique. In the course of the treatment, the superficial bone layer must be penetrated and the whole base of the defect care- fully fractured. The surgical awls are tapped into the subchondral cortical bone to a 3–4 mm depth at 3–5 mm intervals. In the postoperative course the beneficial effect of the use of CPM has been reported. Five-year-old intraoperative picture of a patellar surface 160 treated by Pridie drilling. In the opinion of several authors, however, the microfracture technique, suitable weight-bearing surface cannot be pro- like its predecessors, cannot produce more than duced (Figure 12. Another disadvantage of fibrocartilage in the long term. Nonetheless, this the procedure is that the thick and deep holes procedure is a step forward since the regener- can weaken the subchondral layer to such an ated tissue is more extensive and contiguous extent that the bone can collapse, producing than that produced by earlier traditional carti- areas of articular incongruity. Presently it repre- sents the most widely accepted and used Abrasion Arthroplasty operation among the traditional cartilage surface Maintenance of the original curvature of the producing techniques.