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S. Jack, M.B. B.CH., M.B.B.Ch., Ph.D.

Deputy Director, Marian University College of Osteopathic Medicine

Generally caused by one of three processes: A structural problem affecting the brain stem. An electrical problem (ongoing seizure activity even if not clinically apparent-e. Central scotoma caused by inflammation of the optic disk (optic neuritis) or optic nerve (retrobulbar neuritis). Bitemporal hemianopia caused by pressure exerted on the optic chiasm by a pituitary tumor. Right homonymous inferior quadrantanopia caused by partial involvement of the optic radiation by a lesion in the left parietal lobe. Right homonymous hemianopia from a complete lesion of the left optic radiation with or without macular sparing resulting from a lesion such as a posterior cerebral artery occlusion. Motor response to central and peripheral pain is also critical, as asymmetric responses suggest a focal intracranial lesion. Patients with coma caused by a structural problem generally have abnormal brain stem reflexes, as their coma is caused by direct compression of the brain stem. Most often performed in the L3 or L4 interspaces (at the level of the superior iliac crests). Opening pressure should be measured but is valid only when obtained with the patient in the lateral decubitus position. Also useful for preoperative evaluation of vascular supply to intracranial tumors. They are useful for studying and differentiating radiculopathies (spinal root injuries), motor neuron disease, neuropathies, neuromuscular junction diseases, and myopathies. A delay in response suggests that the conduction velocity along the visual pathway is slow, often a sign of demyelination. Sx/Exam: the following findings in patients with headache should prompt further investigation. Subtypes are as follows: Classic migraine (migraine with aura): Occurs in 20% of patients. The most common auras are visual, including "fortification spectra" and scotomas (blind spots). In patients with headache and focal neurologic deficits, a migraine variant remains a diagnosis of exclusion. Tension headache is usually a nonthrobbing, bilateral head pain that is not usually associated with nausea, vomiting, or prodromal visual disturbances. Ergotamines: Also to be avoided in patients with vascular disease and in pregnant women. Others: Acetaminophen/butalbital/caffeine (Fioricet): Butalbital is a barbiturate and has addictive properties. Headaches occur many times daily at distinct times over several weeks; onset with sleep is especially characteristic. Clusters spontaneously remit for months to years before recurring, typically at the same time of year as previous attacks. Prophylactic medications are started once cluster headaches begin but are not used during remissions given that months to years may elapse between clusters. Such medications include verapamil (first-line prophylactic treatment for cluster headache), prednisone (a taper of oral steroids is often used at the beginning of a cluster), lithium, valproate, and methysergide. Intranasal lidocaine ointment: Produces a block of the sphenopalatine ganglion and aborts the headache. Any abnormalities on exam, including sensory loss of the face in the distribution of the pain, suggests an alternative diagnosis and mandates further evaluation. Alternatives include oxcarbazepine, valproate, phenytoin, baclofen, gabapentin, and benzodiazepines. Serial ophthalmologic evaluation is mandatory for these patients, as visual loss can be severe and permanent. This obese young women with pseudotumor cerebri was misdiagnosed as a migraineur until fundus examination was performed showing optic disk elevation, hemorrhages, and cottonwool spots.

Microangiopathies: Mechanical: Hypersplenism production Essentially any cause of marrow suppression can produce thrombocytopenia in isolation. Acetaminophen, H2 blockers, sulfa drugs, furosemide, captopril, digoxin, and -lactam antibiotics are all associated with thrombocytopenia. Never forget heparin-induced thrombocytopenia (see the discussion of clotting disorders below). Stratify by degree of thrombocytosis A platelet count < 600k is unlikely to be essential thrombocythemia. A platelet count > 1000k is less likely to be reactive thrombocytosis, but many "platelet millionaires" still have reactive thrombocytosis. Consider a bone marrow biopsy Megakaryocyte morphology can suggest essential thrombocythemia. A prolonged eosinophilia of unknown cause with the potential to affect multiple organs by eosinophil infiltration. Note that several drugs (nitrofurantoin, penicillin, phenytoin, ranitidine, sulfonamides) and toxins (Spanish toxic oil, tryptophan) have been reported to cause eosinophilia. Differentiated as follows: Intrinsic bone marrow failure: Aplastic anemia, myelodysplasia, acute leukemia, myeloma, drugs (chemotherapy, chloramphenicol, sulfonamides, antibiotics). Drugs: Gold, chloramphenicol, clozapine, sulfonamides, tolbutamide, phenytoin, carbamazepine, and many others. Abnormal erythropoiesis: Hereditary spherocytosis, sickle cell anemia, drugs (phenytoin, chloramphenicol). Bone marrow biopsy: Abnormal erythroid maturation and characteristic giant pronormoblasts are seen in parvovirus B19 infection. Its prognosis is related to the percentage of blasts, cytogenetics, and the number of cytopenias (see Table 9. Supportive care with transfusions and growth factors (generally associated with a poor response). Syndromes have considerable clinical overlap, and it is often difficult to distinguish them (see Table 9. The most common of the myeloproliferative disorders, it shows no clear age predominance. Symptoms are related to higher blood viscosity and expanded blood volume and include dizziness, headache, tinnitus, blurred vision, and plethora. Erythromelalgia is frequently associated with polycythemia vera and is characterized by erythema, warmth, and pain in the distal extremities. Diagnostic criteria from the Polycythemia Vera Study Group are outlined in Table 9. Helpful medications include the following: Hydroxyurea or anagrelide to keep platelet count < 400,000; both medications have been shown to prevent thromboses. The current standard is to recommend low-dose aspirin in patients with erythromelalgia or other microvascular manifestations. B4: Characteristic bone marrow colony growth (almost never used) or low serum erythropoietin. Bone marrow biopsy is not necessary for diagnosis but is often done to determine the prognosis. The disease has three phases based on the percentage of blasts in peripheral blood: Chronic phase: Bone marrow and circulating blasts < 10%. Major remissions can virtually always be achieved with imatinib mesylate (Gleevec). The durability of these responses remains uncertain, but after five years > 80% of patients remain in cytogenetic remission. Myelofibrosis (Agnogenic Myeloid Metaplasia) Fibrosis of bone marrow leading to extramedullary hematopoiesis (marked splenomegaly, bizarre peripheral blood smear).

Syndromes

• For how long the child was abused
• A colonoscopy is similar to a sigmoidoscopy, but the entire colon can be viewed.
• Fainting or feeling light-headed
• Malnutrition
• Peabody Picture Test Revised
• Forgetfulness
• Tumors of the stomach or esophagus
• Before the test starts, you will be given a mild sedative to help you relax.
• How much do you sleep?
• The amount swallowed