By F. Thorek. National American University. 2018.

Leg control exercises are initiated when the cruciate ligament reconstruction buy 100mg trandate otc. Am J Sports Med patient demonstrated full hyperextension and 1993 generic trandate 100mg overnight delivery; 21: 558–564 trandate 100mg cheap. Complications following arthroscopic anterior cruciate ligament tubing discount trandate 100 mg mastercard, step-ups onto a box order trandate 100mg line, single-leg knee reconstruction: A 2- to 5-year follow-up of 604 patients extensions, and step-downs. Continued focus with special emphasis on anterior knee pain. Knee Surg though should be maintained on hyperexten- Sports Traumatol, Arthrosc 1999; 7: 2–8. Pain after use patient can demonstrate a full, symmetric active of the central third of the patellar tendon for cruciate ligament reconstruction: 33 patients followed 2–3 years. If there is any loss of hyperexten- isometric exercises in the recruitment of the vastus medi- sion, flexion exercises should be decreased until alis oblique in persons with and without patellofemoral full hyperextension returns. Extensor demonstrated full range of motion, both hyper- mechanism function after patellar tendon graft harvest extension and flexion. Strengthening exercises for anterior cruciate ligament reconstruction. Am J include leg press, step-downs, knee extensions, Sports Med 1992; 20: 519–525. Graft selection, and low-impact conditioning exercise such as a placement, fixation, and tensioning for anterior cruci- stationary bicycle, Stairmaster, or elliptical cross ate ligament reconstruction. Prevention of Anterior Knee Pain after Anterior Cruciate Ligament Reconstruction 293 9. Patellofemoral tendon graft and participation in accelerated rehabilita- problems after anterior cruciate ligament reconstruc- tion. Pathogenesis of anterior knee pain syndrome and graft. Accelerated rehabilitation Am J Knee Surg 1999; 12: 29–40. Treatment of limited eralis activity while ascending and descending steps. J motion after anterior cruciate ligament reconstruction. Classification ment reconstruction with autogenous patellar tendon and management of arthrofibrosis of the knee after ante- graft followed by accelerated rehabilitation: A two- to rior cruciate ligament reconstruction. Outcome of knee pain after anterior cruciate ligament reconstruc- untreated traumatic articular cartilage defects of the tion. Primary anterior cruciate (Supplement) 2003; 85-A: 8-16. Ligament stability two to six years after anterior cruci- 23. Int Orthop ate ligament reconstruction with autogenous patellar 1999; 23: 341–344. Millett, Kimberly Hydeman, and Matthew Close Abstract comes in the treatment of recalcitrant anterior We report the clinical results of an anterior knee pain after ACL reconstruction. Failure of nonop- regarding postoperative complications after erative treatment was defined by recalcitrant ACL reconstruction remains quite sparse. Minimum clinical follow- and has been reported as the most common com- up was 2 years. All anterior interval release proce- plaint after ACL surgery. Prior to pain even after hamstring or allograft ACL recon- anterior interval release, Lysholm score aver- struction. Postoperative Lysholm anterior knee pain remains elusive and contro- score averaged 85 (range 68–100) (P < 0. Postoperative instability examina- “infrapatellar contracture syndrome (IPCS),” an tions were all graded zero using the International “exaggerated pathologic fibrous hyperplasia” of Knee Documentation Committee (IKDC) system. IPCS can create significant arthrofibrosis, Early operative intervention with an anterior loss of knee motion, decreased patellar mobility interval release has been shown in this series to (“patellar entrapment”), and even patella infera. Seventeen priate identification and aggressive treatment, patients underwent concurrent meniscus IPCS after ACL reconstruction results in signifi- trephination, and no patients underwent a cant functional morbidity.

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Therefore discount 100 mg trandate overnight delivery, all NSAIDs order 100 mg trandate free shipping, including COX-2 inhibitors generic trandate 100 mg without prescription, are likely to cause a reaction discount 100 mg trandate amex. Despite the classic triad 100 mg trandate overnight delivery, asthma and aspirin hypersensitivity often coexist in the absence of nasal polyps. Leukotriene modifiers are likely to be more effective in patients with aspirin hypersensitivity because of their effect on the COX pathway. A 28-year-old woman seeks a second opinion for asthma that has been recently worsening. She has had asthma for the past 14 years, but over the past 6 months her symptoms have been more severe. In addi- tion to wheezing, shortness of breath, and chest tightness, she has had intermittent fevers and flulike symptoms. She has been treated with multiple courses of antibiotics as well as increasing doses of inhaled steroids with no significant improvement. A chest x-ray shows patchy bilobar infiltrates, which are in different locations from those seen on a chest x-ray that she had 3 months ago. Which of the following statements about this patient is false? Her serum eosinophil count is probably elevated B. A sputum culture for Aspergillus is likely to be positive C. Any bronchial involvement is likely to be on the surface only, with- out tissue invasion D. She may need to be treated with systemic corticosteroids E. A trial of antifungal therapy will not be helpful Key Concept/Objective: To understand the pathophysiology, diagnosis, and treatment of aller- gic bronchopulmonary aspergillosis Allergic bronchopulmonary aspergillosis is a hypersensitivity reaction to colonization of the airways by Aspergillus. Recent studies have shown that the combination of the antifungal itraconazole and inhaled steroids may be effective treatment. If they fail, sys- temic corticosteroids may be necessary. Allergic bronchopulmonary aspergillosis typi- cally causes an elevated serum eosinophil count, and sputum cultures will test positive. It is very unlikely that there will be fungal tissue invasion. A 57-year-old patient who smokes cigarettes presents with chronic productive cough and persistent pro- gressive exercise limitation that is a result of breathlessness. For this patient, which of the following statements is true? Significant airway obstruction occurs in only 10% to 15% of people who smoke B. The best tool for assessing the severity of obstruction is the ratio of forced expiratory volume in 1 second to forced vital capacity (FEV1/FVC) C. Chronic bronchitis is a clinical diagnosis defined as the presence of cough and sputum production on most days for at least 3 consecu- tive months in a year 6 BOARD REVIEW D. Measurement of lung volumes in patients with chronic airway obstruction (CAO) uniformly reveals an increased residual volume and a decreased functional residual capacity (FRC) Key Concept/Objective: To understand the pathogenesis and pathophysiology of chronic obstructive pulmonary disease (COPD) Chronic bronchitis and emphysema are by far the most common causes of chronic air- flow obstruction. Chronic bronchitis is defined as the presence of cough and sputum on most days for at least 3 months of the year for a minimum of 2 years in succession. Emphysema is a destructive process involving the lung parenchyma and is defined in pathologic terms. Only 10% to 15% of smokers experience clinically significant airway obstruction. Although a low FEV1/FVC and a decrease in expiratory flow rates prove obstruction, the best measurement for assessing the severity of the obstruction is FEV1. Measurement of lung volumes uniformly reveals an increased residual volume (RV) and a normal to increased FRC. RV may be two to four times higher than normal because of slowing of expiratory flow and trapping of gas behind prematurely closed airways. FRC increases by two mechanisms: dynamic hyperinflation and activation of inspiratory muscles during exhalation. As a result, tidal breathing may take place at lung volumes as high as 1 to 2 L above normal levels.

If the patient has had direct hand-to-eye contact with an allergen such as pet dander discount 100 mg trandate, there may be unilateral involvement trandate 100 mg on line. The differential diagnosis includes viral or bacterial conjunctivitis: patients with infectious conjunctivitis more often have mucopurulent discharge with matting of eyelids purchase trandate 100mg on line, deeply red conjunctivae order 100 mg trandate free shipping, and less bothersome itching than patients with allergic conjunctivitis order trandate 100 mg mastercard. The first-line treatment con- sists of over-the-counter eyedrops containing a combination of antihistamine and decon- gestant (e. Other treatments include selective H1 receptor antihistamine drops and, in severe or refractory cases, ophthalmic glucocorticoid prepa- rations. Steroid eyedrops should be given only in consultation with an ophthalmologist because long-term use of these agents is associated with an increased risk of cataracts, glau- coma, and secondary ocular infection. An 18-year-old man comes to clinic complaining of nasal stuffiness, left-sided maxillary tooth pain, and postnasal drip. After the first 2 weeks of symp- toms, he was seen in a walk-in clinic and given a 5-day course of antibiotics, but his symptoms did not improve significantly. He has not had fever or chills but complains that he wakes up with a sore throat on most days; the throat pain tends to get better as the day goes on. On examination, he is afebrile, with mild tenderness to palpation over the left maxilla and left forehead. His posterior oropharynx is slight- ly erythematous, with yellowish drainage present, but there is no tonsillar exudate. Examination of the nares reveals hyperemic mucosa and mucopurulent discharge. Which of the following statements regarding this patient’s condition is true? Chronic sinusitis can be defined as sinus inflammation that persists for more than 3 weeks B. Sinus radiographs are the procedure of choice for evaluating patients suspected of having chronic sinusitis C. It is likely that anaerobic bacteria are the primary pathogens responsi- ble for this patient’s condition D. Nasal culture has sufficient sensitivity and specificity to guide further antimicrobial therapy E. In patients with medically resistant chronic sinusitis, further workup for conditions such as cystic fibrosis, structural abnormality, or fungal infection is appropriate Key Concept/Objective: To understand the approach to chronic sinusitis Rhinosinusitis can be classified as acute or chronic. Acute rhinosinusitis is defined as sinusitis that persists for more than 8 weeks in adults and for more than 12 weeks in chil- dren. Chronic sinusitis is defined as sinusitis that persists from 8 to 12 weeks or as docu- mented sinus inflammation that persists for more than 4 weeks after initiation of appro- priate medical therapy. This patient has findings consistent with chronic sinusitis, which may occur after acute sinusitis if mucopus is not sufficiently evacuated. Patients often have unilateral nasal congestion and discharge, purulent postnasal secretions, fetid breath, and facial pain. Although it was previously thought that anaerobic organisms were responsible for chronic sinusitis, it has recently been shown that aerobes are likely the primary pathogens. Chronic inflammation, rather than infection, may be the most important eti- ologic factor in many patients. Alhough nasal culture does not adequately reflect the bac- terial pathogens that may play a role in sinusitis, microscopic examination of nasal secre- tions may help in diagnosis; for instance, sheets of polymorphonuclear leukocytes and bacteria suggest sinusitis, whereas predominance of eosinophils suggests allergic rhinitis. The diagnostic value of plain films (which may demonstrate mucosal thickening, air-fluid levels, or opacification) is controversial; currently, limited coronal computed tomography of the paranasal sinuses is considered the radiographic test of choice. Whereas cost was 14 BOARD REVIEW once prohibitive, costs are roughly comparable between the two imaging techniques at present. CT may additionally give useful anatomic detail that radiographs cannot and can better rule out the possibility of an anatomic abnormality that has predisposed the patient to chronic obstruction of sinus drainage. Other important considerations in a patient who has failed to respond to appropriate therapy include cystic fibrosis (especially in a younger patient with recurrent or chronic sinusitis), infection with an atypical organism such as a fungus, and Wegener granulomatosis. A 43-year-old woman comes to your clinic complaining of nonhealing hives.

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Physical examination is significant for tachycardia discount 100mg trandate fast delivery, diminished bowel sounds buy trandate 100 mg without prescription, epigastric tenderness 100mg trandate overnight delivery, and a papular rash on his knees purchase trandate 100mg fast delivery. Laboratory studies are significant for the following: leukocytes order trandate 100 mg free shipping, 15,000 cells/mm3; blood glucose level, 450 mg/dl; amylase level, normal. Which of the following is the most likely diagnosis for this patient? Pancreatitis secondary to hypertriglyceridemia Key Concept/Objective: To be able to recognize hypertriglyceridemia as a cause of pancreatitis Many factors have been implicated as causes of acute pancreatitis. Gallstones and alcohol abuse account for 70% to 80% of all cases of acute pancreatitis. Other etiologies include sphincter of Oddi dysfunction; benign and malignant strictures of the pancreatic duct; congenital anatomic abnormalities and genetic disorders; drugs; toxins; trauma; infec- tions; and metabolic causes. Metabolic causes of acute pancre- atitis include hypertriglyceridemia and hypercalcemia. Serum triglycerides generally need to be in excess of 1,000 mg/dl to produce acute pancreatitis. This is most commonly seen in type V hyperlipoproteinemia and is usually associated with diabetes mellitus. Acute pancreatitis can itself raise triglyceride levels, but not to this degree. The diagnosis is usu- ally confirmed with a combination of laboratory tests and imaging studies. Serum amy- lase measurement has long been the most widely used confirmatory laboratory test. At least 75% of all patients will have elevations in serum amylase at the time of initial eval- uation. The serum amylase level may be normal in some patients with acute pancreatitis associated with alcohol use and in those with hyperlipidemic pancreatitis (marked eleva- tions in the triglyceride level can interfere with the laboratory assay for amylase); the serum amylase level may be normal in patients with acute pancreatitis if the measurement is made several days after the onset of symptoms. Measurement of serum lipase is often used as an adjunct to or in place of serum amylase as a confirmatory test. The presence of a papular rash on this patient is consistent with eruptive xanthomas, supporting the diag- nosis of pancreatitis secondary to hypertriglyceridemia. A 22-year-old man comes to your clinic for evaluation of chronic abdominal pain. Initially, the pain was episodic, but lately it has become constant. It is felt in the epigastrium and radiates to the back. Sometimes the pain is accompanied by nausea and vomit- ing. An upper endoscopy and abdominal CT scan are unremarkable. Which of the following would be the most appropriate test to confirm the diagnosis? Measurement of serum amylase and lipase C Direct pancreatic function tests D. Abdominal ultrasound Key Concept/Objective: To understand the different tests for assessing pancreatic function 10 BOARD REVIEW Diagnostic tests for chronic pancreatitis include those tests that detect functional abnor- malities and those that detect abnormalities of pancreatic structure. Serum amylase or lipase levels may be elevated during acute exacerbations, but these elevations are usually modest and are neither routinely present nor diagnostic for chronic pancreatitis. A low serum trypsinogen level (< 20 ng/ml) is highly specific for chronic pancreatitis, but the trypsinogen level only drops to this level in advanced disease. The bentiromide test utilizes the measurement in urine of a metabolite that can only be produced by the action of pan- creatic enzymes. The bentiromide test is no longer available in the United States. A 72-hour stool collection for fat is the gold standard to detect steatorrhea. Steatorrhea is only seen in far-advanced chronic pancreatitis.

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