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By: B. Tempeck, M.A., M.D.

Vice Chair, Louisiana State University School of Medicine in Shreveport

Axial myopia medicine under tongue oxcarbazepine 150mg generic, characterized by elongation of the globe in the anteroposterior dimension medications with sulfa buy oxcarbazepine on line amex, is the most common cause of eye enlargement with no intraocular masses symptoms of mono generic oxcarbazepine 600mg with mastercard. Retinoblastoma is the most common intraocular tumor to produce generalized eye enlargement. Buphthalmos ("ox eye"): diffuse extreme enlargement of the eye in children secondary to increased intraocular pressure, caused by congenital or infantile glaucoma. May occur in orbital blow-out fracture, silent sinus syndrome, neurofibromatosis with absence of part of the sphenoid bone, breast carcinoma metastases, and Cockayne syndrome. Coronal reformatted section shows caudal-lateral luxation of the lens (arrow) in to the vitreous body on the left side. Coronal reformatted section reveals loss of the normal spherical contour of the right globe. The detached posterior hyaloid membrane may be seen as an intravitreal curvilinear image extending toward the optic disk. Blood or other fluid accumulation occurs in the subretinal space between the sensory retina and the retinal pigment epithelium. The leaves of the detached and folded sensory retina are limited at the ora serrata and at the optic disk and converge toward the optic disk, thereby producing a characteristic V-shaped configuration. Comments In adults older than 50 y, usually caused by accelerated vitreous liquefaction with myopia, surgical and nonsurgical trauma, and intraocular inflammation. A tractional retinal detachment occurs when fibrovascular tissue, caused by an injury, inflammation, or neovascularization, pulls the sensory retina from the retinal pigment epithelium. Secondary, serous, or exudative retinal detachment results in fluid accumulating underneath the retina without the presence of a hole, tear, or break. It occurs due to inflammation, injury, vascular abnormalities, and primary or metastatic choroidal tumors. Hemorrhagic choroidal detachment may occur spontaneously or as a complication of ocular surgery, ocular trauma, hemoglobinopathies, and anticoagulation therapy. Choroidal detachment Choroidal detachment is caused by the accumulation of fluid or blood in the potential suprachoroidal space. The choroid is firmly attached at the ciliary body and tethered at the vortex veins. This results in the typical appearance of choroidal detachment: it appears as a smooth, ring-shaped, crescentic, or dome-shaped, semilunar area of variable attenuation values. The detached choroids can extend frontal to the ciliary body and result in ciliary detachment. Irregular lesion of increased density, similar to uveal melanoma, related to hemorrhage in the retinal and subretinal space. Frequently complicated by scar formation or liquefaction of the vitreous with posterior hyaloid detachment. Macular degeneration Disciform degeneration of the macula in the elderly is a leading cause of legal blindness. The earliest changes at the macula are hyalinization and thickening of Bruch membrane, followed by ingrowth of choroidal neovascularization. Acellular accretions of hyalinelike material on or near the surface of the optic disk that become calcified. Occasionally, drusen are associated with ocular diseases, such as retinitis pigmentosa. May be familial and asymptomatic or present with headache, visual field defects, and pseudopapilledema. In contrast to optic neuritis, pain is exacerbated with retrodisplacement of the globe, and patients are slightly older (mean age 39.

Turner syndrome (45 treatment group purchase 300 mg oxcarbazepine,X): In addition to primary amenorrhea and absent breasts kerafill keratin treatment discount oxcarbazepine 150 mg with amex, these patients have other somatic abnormalities: short stature (most prevalent) medications xerostomia purchase oxcarbazepine with visa, webbing of the neck, short fourth metacarpal, and cubitus valgus, cardiac abnormality, renal abnormalities, and hypothyroidism. At puberty, the patient is given estrogen and progesterone to allow for secondary sexual characteristics. Structurally abnormal X chromosome: May have the same abnormalities as Turner syndrome patients. They have hypertension, hypernatremia, and hypokalemia due to excess mineralocorticoid. Despite low levels of sex steroids, pregnancies have been achieved with in vitro fertilization/embryo transfer. Hypothalamic-pituitary disorders: Low levels of estrogen are due to low gonadotropin release. Lesions: Anatomic lesions of the hypothalamus or pituitary can result in low gonadotropin production. These patients should receive estrogen-progesterone supplementation to induce breast development and allow for epiphyseal closure. Isolated gonadotropin deficiency (pituitary disease): Associated with: Prepubertal hypothyroidism. Breasts Present, Uterus Absent An 18-year-old G0, presents with complaints of never having started menses. Breasts are present; uterus and axillary/pubic hair is absent in androgen insensitivity. Androgen insensitivity (testicular feminization): this condition results from the absence of androgen receptors or lack of responsiveness to androgen stimulus. Patients with this condition have no male or female internal genitalia, have normal female external genitalia, and have either a short or absent vagina. Intra-abdominal testes or those in the inguinal canal have an risk of developing a malignancy (gonadoblastoma or dysgerminoma), usually after age 20. The gonads should be removed after puberty to allow for breast development and adequate bone growth. Remove gonads after puberty to avoid risk of malignancy (gonadoblastoma or dysgerminoma). They may undergo surgical reconstruction of the vagina or use vaginal dilators to make the vagina functional (see Table 17-1). Breasts Present, Uterus Present Normal breast and pubic hair + no menses + cyclic pelvic pain + bulging blue mass at the introitus = hematocolpos from imperforate hymen. This is the second largest category of individuals with primary amenorrhea (chromosomal/gonadal dysgenesis #1). These patients present with cyclic pelvic pain due to menstrual blood not having an egress. A hematocolpos (accumulation of menstrual blood in the vagina from an imperforate hymen) can be palpated as a perirectal mass on physical exam. Galactorrhea: Antipsychotics, Reglan (metoclopramide) can cause hyperprolactinemia. Headaches, vision problems, fatigue, polyuria, polydipsia: Hypothalamic/pituitary disorders. Breast development (Tanner staging): Marker of ovary function and estrogen action. Weight loss/anorexia nervosa: Those who are malnourished have a reproductive ability. Lesions: the pituitary gland can be damaged from anoxia, thrombosis, or hemorrhage.

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Of these treatment definition statistics order oxcarbazepine 150 mg free shipping, talar neck fractures are the most common and typically depict a vertical fracture course medicine you cannot take with grapefruit best oxcarbazepine 600 mg. The modified Hawkins classification differentiates four types of talar neck fractures 98941 treatment code order 600mg oxcarbazepine with visa. Type 2 refers to a talar neck fracture with associated dislocation of the subtalar joint. Type 3 is a talar neck fracture with dislocation of both the ankle and subtalar joint. Type 4 is also associated with subluxation or dislocation in the talonavicular joint. Osteonecrosis of the proximal fracture fragment is a common complication of talar neck fracture. It is relatively rare in Hawkins type 1 fractures but may reach close to 100% in type 4 fractures. The appearance of a linear subchondral lucent area (Hawkins sign) in the talar dome after 1 to 3 months relates to hyperemia and continuity of blood supply and should not be misinterpreted as a crescent sign of osteonecrosis. At this stage, osteonecrosis manifests itself as relatively increased density in the proximal talar fragment when compared with the distal one. The lateral talar process is a large, broad-based, wedge-shaped prominence of the talar body and includes two articular surfaces. A comminuted fracture of the talus with numerous loose fragments and displacement of the rotated talar body posteriorly is seen. Differentiation of an os trigonum from a posterior process fracture may be difficult at times, particularly when the former is diseased. Differentiation of an osteochondral fracture from osteochondritis dissecans is not always possible based on imaging examinations alone. A subtalar (peritalar) dislocation has to be differentiated from a total talar dislocation. A subtalar dislocation involves simultaneous dislocations of the talocalcaneal and talonavicular joint. Up to 85% of dislocations are medial, in which the calcaneus and the rest of the foot are displaced medially. The navicular is located medial and sometimes dorsal to the head and neck of the talus. Lateral subtalar dislocations are second in frequency, followed by anterior and posterior subtalar dislocations. In the total talar dislocation, the ankle is, besides the talocalcaneal and talonavicular joint, also completely dislocated (not only subluxed), resulting in a "floating talus. Extra-articular calcaneal fractures are typically caused by either twisting forces, resulting in fractures of the tuberosity, sustentaculum tali, or anterior process, or a pull by the Achilles tendon, resulting in a beaklike avulsion fracture of the posterosuperior aspect of the calcaneus. Intra-articular fractures occur in vertical falls in which the talus is driven in to the calcaneus. Calcaneal fractures can be classified based on both anatomical location and injury mechanism. Based on the oblique coronal plane perpendicular to the posterior facet, this structure is divided in to three equal segments, defined as lateral (A), central (B), and medial (C). All nondisplaced articular fractures (2 mm), regardless of the number of fracture lines, are designated as type 1 fractures. Three types are differentiated, depending on the location of the fracture line in the lateral segment (2A), central segment (2B), or medial segment (2C). Type 3 are three-part fractures that usually feature a centrally depressed fragment. Type 4 are four-part or multipart highly comminuted fractures of the posterior facet. In the navicular bone, dorsal avulsion fractures related to the talonavicular or naviculocuneiform ligament insertion are Pelvis and Lower Extremity 573. Type 1: Fractures of the tuberosity (T), sustentaculum tali (S) containing the middle subtalar facet, or anterior process (A). Type 2: Beak fracture or avulsion fracture at the insertion of the Achilles tendon. The assessment is made on the oblique coronal image in the plane of the posterior facet. For this purpose, the posterior facet is divided in to three equal parts, defined as lateral (A), central (B), and medial (C) segments.

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Extrahepatic tumors Tumors of adrenal medicine game oxcarbazepine 150 mg with amex, kidney symptoms anemia buy generic oxcarbazepine online, stomach medicine 54 357 order oxcarbazepine 150 mg without a prescription, and gallbladder can invade or displace the liver and thus have an appearance similar to that of primary liver tumors. Segmental to global hypoperfusion of the liver depending on extent and localization of the thrombus. In chronic thrombosis, usually enlarged collaterals termed cavernous malformations. Diagnostic pearls: Clotted portal vein with segmental/global hepatic hypoperfusion on all scans. Hemangiomas show similar centripetal progression of contrast attenuation, but enhancement pattern is more patchy/nodular. Clotted portal vein with segmental hepatic hypoperfusion is clearly visible on axial (a) and coronal (b) images. Comments Typically caused by cardiac failure such as constrictive pericarditis, cardiomyopathy, right-side valvular disease, or congestive heart failure. Thus, typically accompanied by pericardial and pleural effusion, hepatomegaly, and ascites. Inversion of contrast between vessel (hyperdense) and liver parenchyma (hypodense). Nonreversible parenchymal destruction accompanied by fibrosis, nodular regeneration, and abnormal reconstruction of normal lobar architecture. Idiopathic liver cirrhosis of unknown etiology due to chronic destruction of intrahepatic bile ducts. Causative agents may be alcohol, cytotoxic drugs, obesity, diabetes mellitus, hepatitis, steroid treatment, hyperalimentation, or liver transplantation. Contrast inversion between vessel and liver parenchyma indicates 10% to 15% intrahepatic fat. Three subtypes of cirrhosis depending on the type of nodular regeneration: micronodular (0. Splenomegaly, ascites, collateral veins, colonic interposition, and small bowel edema are associated findings. Histologic features are damaged epithelial cells, necrotic bile ducts, and fibrosis of portal triads. Nodular liver contour with multiple hyperdense intrahepatic nodules, atrophy of the right liver lobe, and compensatory hypertrophy of the left liver lobe. Inflammatory periportal reaction followed by nodular liver cirrhosis due to sinusoidal and periportal copper deposition. Nonspecific hepatosplenomegaly with diffuse small noncaseating granulomas in the liver of patients with known Boeck disease (sarcoidosis). Diagnostic pearls: Always consider in patients with lymphadenopathy and hepatosplenomegaly. Diagnostic pearls: Global or focal hypoattenuation of liver parenchyma on pre- and postcontrast scans. Comments Two subtypes of hemochromatosis: primary hemochromatosis, an autosomal recessive disorder of iron metabolism, with excessive deposition of iron in the liver, pancreas, myocardium, endocrine glands, joints, and skin; and secondary hemochromatosis, with iron deposition in the reticuloendothelial cells due to either increased iron intake (multiple transfusions, nutritive), or alcohol-induced toxic liver disease. Toxic levels of copper accumulate in the liver, brain, and cornea secondary to impaired biliary excretion. Wilson disease Sarcoidosis Histologically, noncaseating epithelioid granulomas with multinucleated giant cells of Langerhans type. Granulomas usually more apparent in the portal triad regions than in the liver parenchyma. Up to 80% of all patients with sarcoidosis present with involvement of abdominal organs, particularly of the liver and spleen. Deposition of fibrils of light-chain immunoglobulins in a perivascular location within the spaces of Disse. Diagnostic pearls: Multiple micronodular hypodense lesions seen on pre- and post-contrast scans. Multiple high-attenuating hepatic lesions ranging in size from a few millimeters to several centimeters.

It is lateral of the visceral space medicine escitalopram order 300mg oxcarbazepine mastercard, medial of the sternocleidomastoid muscle treatment brachioradial pruritus buy genuine oxcarbazepine, and ventral of the carotid space medications given im quality oxcarbazepine 150 mg. Large masses elevate the sternocleidomastoid muscle, displace the carotid space vessels posteromedially, and may compress the thyroid gland lobe. The larynx has a framework consisting of a cartilaginous skeleton connected by membranes and ligaments and moved by muscles. The laryngeal skeleton consists of the hyoid bone, cricoid, thyroid, epiglottis, and paired arytenoid cartilages. The supraglottis extends from the tip of the epiglottis above to the laryngeal ventricle below. The glottis includes the true vocal cords and both the anterior and posterior commissures. The subglottis extends from the inferior border of the glottic region to the inferior edge of the cricoid cartilage. There are three intralaryngeal compartments: the paired lateral paraglottic space and the midline preepiglottic space. The paraglottic space lies between the mucosa and the laryngeal framework and is paired and symmetric. The preepiglottic space is a triangular, C-shaped, fat-filled space set between the hyoid bone anteriorly and the epiglottis posteriorly. Ossified cartilage shows a high-attenuating outer and inner cortex and a central low-attenuating medullary space due to fatty tissue. Nonossified hyaline cartilage and nonossified fibroelastic cartilage have the attenuation values of soft tissue. The abducted position of the true vocal cords during quiet breathing facilitates evaluation of the anterior and posterior commissures. Additional scans obtained with phonation or modified Valsalva maneuvers facilitate evaluation of the aryepiglottic fold, laryngeal ventricle, and hypopharynx. Neoplastic cartilage invasion occurs preferentially where the attachments of Sharpey fibers interrupt the perichondrium, thus acting as direct pathways for tumor spread in to the cartilaginous tissue. These areas typically include the anterior commissure, the junction of the anterior one fourth and posterior three fourths of the lower thyroid lamina, the posterior border of the thyroid lamina, the cricoarytenoid joint, and the area of attachment of the cricothyroid membrane. The hypopharynx is the most caudal portion of the pharynx and extends from the level of the hyoid bone and valleculae to the upper esophageal sphincter. The hypopharynx includes the piriform sinuses, the postcricoid region, and the posterior hypopharyngeal wall. The piriform sinus is situated bilaterally between the thyroid cartilage and the aryepiglottic fold, and is adjacent to the paraglottic space and the cricoid cartilage. The postcricoid region extends from the cricoarytenoid joints to the lower edge of the cricoid cartilage (cricopharyngeus muscle). The posterior wall of the hypopharynx is the inferior 366 9 Infrahyoid Neck continuation of the posterior oropharynx wall. The mucosal surface of the hypopharynx frequently displays a distinct contrast enhancement; the muscular tissue is not enhancing. The hypopharynx may be filled with air or may be collapsed during quiet respiration (a modified Valsalva maneuver may distend this region and rule out the presence of a tumor). Thyroid lesions are primarily evaluated with radionuclide scanning and ultrasonography. After injection of contrast material, the thyroid gland enhances tremendously (drawback: because of iodine uptake from the contrast agent, thyroid localization with nuclear scintigraphy and radioactive iodine treatment must be delayed 4 to 8 weeks after administration of iodinated contrast agents). Thyroid nodules are common and comprise adenomas, cysts, focal thyroiditis, multinodular goiter, and malignant tumors. A multiplicity of nodules in an enlarged thyroid gland usually suggests a benign process or metastases. Calcification occurs in 13% of all thyroid lesions, including 17% of all malignancies and 11% of all benign processes.

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