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A: It is a degenerative disease of the synovial joint characterized by focal loss of articular hyaline cartilage with proliferation of new bone and remodelling of joint contour super p-force 160mg fast delivery erectile dysfunction injections australia. Secondary: to some other diseases order super p-force cheap erectile dysfunction pills philippines, usually asymmetrical, commonly involves the weight- bearing joints. A: It is a primary generalized osteoarthrosis, which is autosomal dominant and occurs mainly in middle-aged women. Investigation: • X-ray of the affected joints: shows joint space narrowing, osteophyte and marginal sclerosis. Charcot’s joint of both elbow Charcot’s joint of both knee Charcot’s joint of both feet Q:What is Charcot’s joint? A: It is the complete destruction and disorganization of the joint, usually secondary to loss of proprio- ception of the joint sense. However in some long case such as diabetes mellitus or any neurological case, fundoscopy is usually necessary. Proceed as follows: Before examining the eyes, the patient should sit at the edge of the bed facing the examiner. Look at the face to see any facial asymmetry (in hemiplegia, Bell’s palsy), myasthenic, myotonic, tabetic face and thyrotoxic or hypothyroid face. Ptosis (complete or partial), squint, exophthalmos, eyebrows (fall of lateral one-third or all), xanthelasma, lid retraction, puffy face with baggy eyelids and heliotrope rash. Proceed as follows: • The patient should be examined either in sitting or lying down in a dark room. Opacity in media of the eye (cornea, anterior chamber, lens and vitreous) will appear as black specks or lines against red refex. Normal optic disc is rich in yellow colour, rest of fundus is rich in red colour). It appears darker than the surrounding retina and in young individuals has a central yellow point called ‘fovea centralis’. A: 3 types: • Primary (due to optic neuritis, compression in the optic nerve, glaucoma). Secondary to optic neuritis, which may be due to: • Demyelinating disease (multiple sclerosis). Optic atrophy is the degeneration of the optic nerve head, sometimes a sequel to optic neuritis. A: In this condition, there is infarction of anterior part of optic nerve resulting in acute severe loss of vision. Presentation of a Case: (Mention in Which Eye, Right or Left or Both) • There is bilateral papilloedema, more marked in right or left eye. Papilloedema (Left eye) Papilloedema (Right eye) Papilloedema with haemorrhage and exudates in fundus (malignant hypertension) Q:Could it be malignant hypertension? A: Transient obscurations of vision due to temporary impairment of retinal blood fow. B: Remember the following points: • Visual Acuity is usually preserved but may be affected in late stage. Stages are: • Early sign: Absence of spontaneous pulsation of retinal veins and increased pink or red colouration of the disc. A: It is the infammation of optic nerve head is called papillitis or intraocular optic neuritis. A: Infammation of the orbital or posterior portion of optic nerve is called retrobulbar optic neuritis or orbital optic neuritis. Central scotoma Present Absent, there is peripheral constriction of visual feld 5. A: It is characterized by a frontal lobe tumour compressing optic nerve causing ipsilateral optic atrophy but contralateral papilloedema due to raised intracranial pressure. Predisposing factors are: • Drugs: Tetracycline, nalidixic acid, oral contraceptive pill, Hypervitaminosis A, nitrofurantoin, sulphur drugs, phenytoin, steroid (both therapy and withdrawal). If no response, Surgical treatment: • Lumbo-peritoneal shunt or venticulo-peritoneal shunt, especially if progressive visual loss. A: As follows: • In mild case without macular involvement: there is no visual disturbance. My diagnosis is Hypertensive retinopathy (or grade 4, may be malignant hypertension). A: Unknown, probable mechanisms are: • Fibrinoid necrosis of the wall of small artery and arteriole, which results in end organ damage. A: 4 grades (Keith–Wagener–Barker classifcation): • Grade I: Thickening of arterial wall, increase tortuosity, narrowing of arteriole and increased light refex (silver wiring). Presentation of the Case: • There are few haemorrhages (mention the location), some are fame shaped and some are irregular in outline. Dot haemorrhage and Dot and blot haemorrhage Dot and blot haemorrhage microaneurysm (soft exudate) (hard exudate) Q:What is microaneurysm? A: Microaneurysms are the out pouching of capillary walls due to pericyte loss, appears as small red dots. Microaneurysm is always along the vessel wall, it may be confused with haemorrhage. A: These are lipid and protein residues of serous leakage from the vessels, yellowish in colour and irregular in outline with sharply defned margin. A: As follows: • Control of diabetes mellitus, stop smoking and control of hypertension (if any). Diabetic maculopathy is one of the common causes of loss of vision in patient with non-proliferative retinopathy. Maculopathy Preproliferative Proliferative retinopathy Proliferative retinopathy retinopathy (Severe vitreous haemorrhage) Q:How to treat such a case? Plus • There are multiple photocoagulation scars (appears like exudate, with areas of small brown or yellowish spot of variable size and shape). My diagnosis is Proliferative diabetic retinopathy, treated with photocoagulation. A: Unknown, probably there is production of angiogenic factors from the area of ischaemic retina. These new vessels are very fragile and leaking, liable to rupture causing haemorrhage (intraret- inal, preretinal or vitreous). Serous protein leakage from these vessels stimulates connective tissue reaction called retinitis proliferans. Q:What are the indications of laser photocoagulation therapy in diabetic retinopathy? Presentation of a Case: • There are multiple areas of black pigmentation like bone spicules with variable size and shape, some in criss-cross pattern, at the periphery of fundus. A: It is a progressive degenerative disease of retina with pigmentary epithelium in a bone spicule pattern.

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Lung hysteresis is a complex phenomenon related to the properties of surfactant buy genuine super p-force on line erectile dysfunction diagnosis, the viscosity of the alveolar lining order 160 mg super p-force with amex erectile dysfunction humor, the law of Laplace (P = 2T/r), and the disordered sequence of alveolar reopening. It affects the relationship between mPaw and oxygenation as well as influencing the relationship between mPaw and haemodynamic effects. It is easier to keep open a lung unit that has been opened than it is to open a lung unit that has been allowed to close. In an injured lung there are pressures above which all recruitable units will open given sufficient time, and pressures below which all collapsible lung units will close. More interestingly, there is a conditional area between these values where lung unit opening will depend on the pre-existing state of the lung: if there are lots of closed lung units before airway pressure reaches the conditional zone, most will remain closed until they reach the threshold ‘opening pressure’. If there are many lung units open before airway pressure drops into the conditional zone, most will remain open until they reach the threshold ‘closing’ pressure. However, it is conceptually useful to explain the different gas exchange responses produced by different approaches to raising mPaw (see examples below). It also presupposes that the average threshold opening and closing pressures are known. Furthermore, the threshold opening pressure may be so high that regular increases in inspiratory pressure to such a level are known to be harmful. Increasing inspiratory pressure When the average opening threshold is breached by increasing inspiratory pressures inspiratory recruitment occurs, and gas exchange improves. If alveolae are not opened, then haemodynamics may deteriorate with no recruitment, and the resultant drop in SvO2 will lead to deteriorating arterial oxygenation. Increasing inspiratory time Increasing inspiratory time may improve oxygenation by two methods: • If inspiratory pressure is above threshold opening pressure, then spending longer in inspiration will improve recruitment and gas exchange. If inspiratory pressure is too low, then increasing inspiratory time may affect cardiovascular performance but not gas exchange. Classically inverse ratio ventilation is used (b Pressure- controlled ventilation, p 135). If the expiratory time is short enough, no part of the lung has time to collapse in expiration. However, the areas with short time constants will collapse early in expiration, and it may not be possible to shorten expiration enough to prevent such collapse in diseased lungs. Gas exchange improves significantly (inspiratory recruitment and prevention of expira- tory collapse). This may slowly improve gas exchange, but there will also be car- diovascular effects. There will be improved gas exchange, a reduction in atelectrauma, but marked cardiovascular effects. They are designed to help interpret gas exchange and cardiovascular responses to interventions, and to demonstrate that increasing mean airway pressure in different ways will have different effects. The consequences will differ from patient to patient, and from day to day in the same patient as the pathophysiology alters. Outcome data are lacking, and there is no consensus on the method to be used or the regularity of recruitment. Potential harm The adverse effects are similar to those listed under increasing airway pressure, but are more pronounced and take place over a shorter period. They may be dramatic in susceptible patients (such as those who are hypovolaemic). Be aware that other physiological changes produced by the same intervention may modify these effects, e. An improvement in compliance will facilitate larger Vt without the need for increased airway pressures. Increased respiratory rate Potential benefits • Simple way to increase alveolar ventilation. If the tidal volume falls by more than 25% when the respiratory rate increases, alveolar ventilation is likely to decrease despite the increased respiratory rate. Compliance can be increased by: • Recruitment • Avoiding over-distension • Addressing bronchospasm • Treatment of pulmonary oedema (see below) • Re-expansion of lung or lobar collapse • Improvement in chest wall compliance (e. Change ventilatory mode or strategy There is very little consensus about the best mode for ventilating patients with severe gas exchange abnormalities. It is best to think in terms of interventions required and then choose a mode to deliver these interventions, rather than always use the same mode for patients who are difficult to ventilate. Alter inspiratory airflow pattern Pressure-controlled modes of ventilation produce a rapid increase in inspiratory flow followed by an exponential decrease (see b Pressure- controlled ventilation, p 135). There is less end inspiratory gradient of pressure among regional units with heterogeneous time constants. Increase mixed venous oxygen saturation Increasing a low mixed venous oxygen concentration will reduce the overall effect of any shunt or areas of low V/Q and improve oxygenation. Reduce oxygen consumption Increased oxygen consumption is associated with hypermetabolic states: fever, sepsis, shivering, thyroid storm, malignant hyperpyrexia, and malignant neuroleptic syndrome. If SaO2 is improved from 90% to 95% with ventilatory manipulation, but at the same time the cardiac output falls by 1L/min, there is a reduction of 150mL/min in oxygen delivery. This strategy often produces intravascular volume depletion, increased vasoconstrictor requirement, and potentially reduces other organ function. This is sometimes a price worth paying, and may prevent further deterioration in gas exchange, allow reduction in ventilatory pressures, and prevent a vicious downward spiral towards hypoxaemic death. Change patient position Prone positioning has been used as a method to improve oxygenation for over 30 years. Despite often dramatic improvement in oxygenation, trial evidence is lacking to support its use for unselected patients. It is the subject of considerable debate, and is discussed in b Adjuncts to ventilation, p 188. In lobar or unilateral disease, laying the patient with the affected lung superior and the good lung inferior increases blood flow to the lung or lobe with better ventilation and may improve gas exchange. Reduce asynchrony This problem is dealt with in b Asynchrony, p 262, and it is also discussed extensively in b Pressure support ventilation, p 144. In summary, neural inspiration and expiration should be closely matched by ventilator inspiration and expiration, and a change in patient effort should result in a change in volumes delivered by the ventilator. It is clear that these conditions are often not present, and this results in patient–ventilator asynchrony. Clinicians should be aware of the synchronization rules of the modes on their venti- lator and adjust to a better tolerated mode if dysynchrony is a problem. Consider paralyisis Paralysis is sometimes used as the option of last resort in hypoxaemia. It is assumed that fully controlling ventilation will allow an increased ability for the clinician to accurately manipulate precise physiological variables such as ventilatory pressures and I:E ratio.

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Th e p a t ie n t re la t e s t h a the se sym p t o m s h a ve b e e n p re s- ent over the p ast 12 months and have worsened slightly purchase on line super p-force iief questionnaire erectile function. He currently has p ain and tightness in both calves that develop a ter walking more than one block discount super p-force 160mg with amex erectile dysfunction causes and solutions, but the symptoms always resolve a ter several minutes o rest. The emoral pulses are nor- mal bilaterally; however, his popliteal, dorsalis pedis, and posterior tibial pulses are absent bilaterally. Risk factors for the condition: N on-modifiable r isk fact ors in clu de age, sex, an d et hnicit y. Modifiable risk fact ors include smoking, diabet es mellitus, hypert en- sion, renal insufficiency, and dyslipidemia. Next step: Assessment of disability, patient counseling to discuss natural his- tory of the disease process, treatment options, and risks/ benefits of invasive intervent ions. Best initial treatment: Lifestyle modification with smoking cessation, exercise program, and pharmacological treatment at reducing cardiovascular risks. Be able to recognize the indications for lower extremity revascularization and benefits and limit ations of open surgical and endovascular treatment approaches. Learn the noninvasive modalities available for the evaluation and follow-up of patients with claudication. Co n s i d e r a t i o n s This patient’s presentation is very typical for individuals with lower extremity arte- rial occlusive disease: a h ist or y of p ain in the lower extrem it y mu scles that d evelop s wit h exert ion and improves with rest. Pain in t he legs with exert ion can occur as t he result of a number of different disease processes other than arterial insufficiency, wit h different ial diagnoses that include bones and join abnormalit ies, and cent ral and peripheral neurologic causes. To help different iate arterial insufficiency from the other causes, it is important to obtain additional details regarding his symp- toms (Table 50– 1). Since arterial insufficiency pain is produced by inadequate blood flow to meet the metabolic demands associated with exercise, a patient with arterial insufficiency usually report s symptoms that are reproduced each and every time that he exerts the same work load. As for the location of the pain, symptoms produced by insufficient blood flow sh ould consist ent ly manifest in the muscle groups below t he location of the arterial obstruction or the flow-disturbing lesion(s). In this patient wit h bilateral calf claudicat ion, the locat ions of t he arterial occlusions are most likely in the superficial femoral art eries. In order to confirm t hat the symptoms are due to poor blood flow an d n ot an ot h er cau se su ch as p er iph er al n eu r op at h y, the p u lse exam in at ion, ankle/ brachial index, and noninvasive imaging studies are helpful for confirmat ion of arterial insufficiency. Our priorities in managing this patient are: (1) to identify, treat, and prevent pro- gression of the syst emic man ifest at ion s of at h er osclerot ic disease; (2) t o impr ove fu n ct ion al st at u s of the pat ient. For this man wit h su sp ect ed femor al-p oplit eal occlusive disease and claudication, invasive treatments such as angioplasty/ stent- ing and bypass procedures are generally not indicated because t he majorit y of t hese patients will not progress to a limb-threatening situation. With invasive interven- tions, patients’ symptoms may improve, but there is an associated risk of failure, that may contribute to limb loss. In addition, diabetic patient need to be inst ruct ed on proper foot care and should be closely monit ored and aggressively treated for skin conditions and ulcers on their feet. The drawback of segmental pressure measurement is falsely high pressures are seen in diabetic patients secondary to calcified ar t er ies. Exer cise t est in g is u sefu l wh en the h ist or y, ph ysical exam in at ion, and pressure readings are ambiguous. Art eriography is the most invasive of t he imaging modalities used, but it is considered the “gold standard. The pat ient evaluat ion should always begin wit h h ist ory focusing on his/ her atherosclerotic disease risk factors and comorbidities, the patients’activ- it y levels, sympt omat ology, incit ing fact ors, durat ion of pain, locat ion of pain, and alleviat ing factors. Claudicat ion associated with insufficient arterial flow is generally manifested in t he largest muscle groups just below t he level of t he flow disturbing lesion(s). For example, patients with aorto-iliac occlusive disease may complain of pain in the upp er t h igh s an d but t ock r egion s wit h walkin g. In male patients with this problem, impotence may result from occlusive disease in the internal iliac arteries. The combinat ion of buttock and thigh claudication, impo- tence, an d diminished femoral pulses is referred to as Leriche syndrome. Pat ient s wit h superficial femoral artery occlusive disease most often manifest wit h calf clau dicat ion. In addit ion, t h ese pat ient s oft en have rest pain, which is described as pain locat ed predominat ely in the foot and t oes at rest, and rest pain is improved or relieved with dependent positioning of the extremit y. O n physical examination, patients with rest pain have chronic ischemic changes of the feet and lower legs including at roph ic and shiny skin and loss of leg hairs. Arte- rial occlusive disease can often be considered as inflow disease (above the inguinal ligament) or outflow disease (below the inguinal ligament). The durability and success of treatments for outflow diseases is further reduced for interventions performed to treat occlusive disease in the below-the-knee arteries such as the distal popliteal and tibial arteries. Diffe re n t ia l Dia g n o sis N ot all pat ient s present ing wit h effort -related lower ext remit y pain have vasculo- gen ic clau d icat ion. In som e cases, n eu r ogen ic cau ses n eed t o be d iffer en t iat ed from vascu lo gen ic clau d icat io n ( see Tab le 5 0 – 1 ). N eu r o gen ic clau d icat io n can o ccu r in associat ion wit h spinal st enosis, which can also produce excruciat ing lower ext remit ies pain during exert ion or wit h posit ional changes; however, t h ere are subt le differences that should be appreciat ed. Becau se this is a fu n ct ion of wor k load an d blood supply, the sympt oms are reproducible wit h t he same amount of work load each and every time. Physical findings such as skin temperature, capillary refill, and peripheral pulses are critical to help differentiate patients with neurogenic causes from those from vascu lar cau ses. In addition, patients need to be counseled regarding the import ance of life st yle modificat ions. It is important to convey to the patients, the reason to withhold operative or endovascular interventions is that the procedures can be associated with failures, and the failure of interventions can lead t o worsening isch emia. O verall, the int er vent ions for occlusive diseases in the aort a and iliac art eries are associat ed wit h great er long-term pat ency t han proce- dures performed in smaller vessels at the below-the-knee level. Increasing levels of arterial involvement usually affect blood flow more significant ly and usually are associ- ated wit h greater need for open or endovascular intervent ions. T h e classificat ion s of anat omic lesions are h elpful t o determine whether open surgical approaches or endovascular approaches are best for each of the ident ified ar t er y lesion s (see Table 50– 4 for pat en cy out comes aft er procedures). Type B lesions: Typ e B lesio n s h ave go o d r esu lt s u sin g the en d ovascu lar ap p r o ach es. The endovascular approaches are preferred unless open revascularization is needed for an ot h er lesion in the same an at omic region. Type C lesions: Type C lesions have better long-term result s wit h open revascular- izat ion t echniques so endovascular approaches sh ould be used only if t he pat ient is at high risk for open surgery. Type D lesions: Type D lesions have poor results with endovascular treatment, therefore open surgery is the primary treatment. T h e pat ient is a diabet ic and t akes an oral hypoglycemic agent, a long-acting β-blocker, and a statin.