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Q. Cruz, M.B. B.CH. B.A.O., M.B.B.Ch., Ph.D.

Vice Chair, Minnesota College of Osteopathic Medicine

Patients with a positive family history are at greater risk of developing the disorder. Etiology (See also physiology and pathophysiology of aqueous humor circulation): the cause of primary open angle glaucoma is not known, although it is known that drainage of the aqueous humor is impeded. The primary lesion occurs in the neuroretinal tissue of the optic nerve as compression neuropathy of the optic nerve. Symptoms: the majority of patients with primary open angle glaucoma do not experience any subjective symptoms for years. However, a small number of patients experience occasional unspecific symptoms such as headache, a burning sensation in the eyes, or blurred or decreased vision that the patient may attribute to lack of eyeglasses or insufficient correction. The patient may also perceive rings of color around light sources at night, which has traditionally been regarded as a symptom of angle closure glaucoma. Primary open angle glaucoma can be far advanced before the patient notices an extensive visual field defect in one or both eyes. It is crucial to diagnose the disorder as early as possible because the prognosis for glaucoma detected in its early stages is far better than for advanced glaucoma. Where increased intraocular pressure remains undiagnosed or untreated for years, glaucomatous optic nerve damage and the associated visual field defect will increase to the point of blindness. Elevated intraocular pressure in a routine ophthalmic examination is an alarming sign. Fluctuations in intraocular pressure of over 5 ­ 6 mm Hg may occur over a 24-hour period. The angle of the anterior chamber is open and appears as normal as the angle in patients without glaucoma. Examination of the optic nerve reveals whether glaucomatous cupping has already occurred and how far advanced the glaucoma is. Where the optic disk and visual field are normal, ophthalmoscopic examination of the posterior pole under green light may reveal fascicular nerve fiber defects as early abnormal findings. Noise field perimetry is suitable as a screening test as it makes the patient aware of scotomas and makes it possible to detect and describe them. The patient is shown a flickering monitor displaying what resembles image noise on a television set. Special programs (such as the G1 program on the Octopus perimeter and the 30 ­ 2 program on the Humphrey perimeter devices) reveal the earliest glaucomatous changes. In advanced glaucoma, kinetic hand perimetry with the Goldmann perimeter device is a useful preliminary examination to evaluate the remaining field of vision. Differential diagnosis: Two disorders are important in this context: Ocular hypertension. Patients with ocular hypertension have significantly increased intraocular pressure over a period of years without signs of glaucomatous optic nerve damage or visual field defects. Some patients in this group will continue to have elevated intraocular pressure but will not develop glaucomatous lesions; the others will develop primary open angle glaucoma. The probability that a patient will develop definitive glaucoma increases the higher the intraocular pressure, the younger the patient, and the more compelling the evidence of a history of glaucoma in the family. Patients with low-tension glaucoma exhibit typical progressive glaucomatous changes in the optic disk and visual field without elevated intraocular pressure. These patients are very difficult to treat because management cannot focus on the control of intraocular pressure. Often these patients will have a history of hemodynamic crises such as gastrointestinal or uterine bleeding with significant loss of blood, low blood pressure, and peripheral vascular spasms (cold hands and feet). Patients with glaucoma may also experience further worsening of the visual field due to a drop in blood pressure. Caution should be exercised when using cardiovascular and anti-hypertension medications in patients with glaucoma. O Glaucomatous changes in the optic cup: Medical treatment should be initiated where there are signs of glaucomatous changes in the optic cup or where there is a difference of more than 20% between the optic cups of the two eyes. O Increasing glaucomatous changes in the optic cup or increasing visual field defects: Regardless of the pressure measured, these changes show that the current pressure level is too high for the optic nerve and that additional medical therapy is indicated. This also applies to patients with advanced Lang, Ophthalmology © 2000 Thieme All rights reserved. The strongest possible medications are indicated in these cases to lower pressure as much as possible (10 ­ 12 mm Hg). O Early stages: It is often difficult to determine whether therapy is indicated in the early stages, especially where intraocular pressure is elevated slightly above threshold values.

For example, protein analysis, in the forensic context, proved to be of academic interest and was not adopted at an operational level. The debate aroused by the work of Gaudette has waxed and waned over the years (see Chapter 7). Following recent rulings in the United States in light of the application of so-called Daubert standards, there may be renewed interest in the studies of Gaudette. In 1982 I contrasted the views on the value of hair examination held on the two sides of the Atlantic. Other chapters of this volume deal with significant aspects of hair examination, past, current and the future. This chapter will serve as the binder or glue to fill gaps and provide the skeleton, the framework, based on microscopic examination providing the foundation on which other complementary approaches fit. The examination of human hairs is, nevertheless, only a specialized example of the general examination of hairs. Indeed, the first question which must be considered in any hair examination is whether the hair is of human or non-human origin. The attempted identification of non-human hairs requires that the fine detail associated with these regions be studied in a systematic way. With non-human hairs, different types of hair can be present in the fur or peltage. Usually these are visually clearly different, based on their degree of coarseness. While different classification systems exist, the most commonly found types are guard- and under-hairs. Guard-hairs also display the widest range of microscopic features, which makes them the most useful for identification. Non-human animal hairs should be examined from their root end to their tip end, and variation in the features given in Table 2. In particular, changes in medulla and scale pattern appear to be consistent enough to have value in identification. It is helpful to use a checklist to record features; this also encourages systematic observation. Where possible, questioned animal fibres should always be compared with authenticated standards. Many scientific papers contain descriptions of the microscopy of animal hairs, but few are of real assistance. Usually, they deal with only a very small group of species and take into consideration only those features which have most value in discriminating the members of that group. Often the descriptions also assume that the scientist has a bulk sample, whereas in forensic work each hair often has to be 81 Forensic Examination of Hair treated separately. Thus, the identification of all but the more common hairs is often not possible and analysis becomes comparative. Fibres from other animals such as various breeds of goat and llama are also referred to as wool. While an experienced wool grader can distinguish different breeds of sheep by examining unprocessed bulk samples, the identification of breed from single fibres or even very small samples is beyond the expertise of the forensic examiner. Raw wool fibres are classed into four groups based on the degree of coarseness: kemps, outercoat, coarse and fine. The only features readily assessed are the presence or absence of medulla and scale features. Unequivocal identification of fibres as wool is not possible, especially when the fibres transferred during contact situations have indistinct or damaged scales. Cat and Dog Hairs There is a wide variation in colour, length and profile in hairs from cat and dog breeds. It must be stressed that these are general characteristics, and there is a great deal of variation within and between cat and dog hairs. As previously stated, the progression of features along the hair shaft provides useful information and, according to Peabody et al. Root shape · Cat: elongated, no distinct shape, fibrils often frayed at base of root.

It is characterized by fever, rash, eosinophilia, and renal anomalies (hematuria, increased serum creatinine, and oliguria). While passing stones through the penile urethra can be painful, it does not typically cause an obstruction. The prostatic urethra is not a typical location for renal stones to obstruct flow. While staghorn calculi may develop in the renal pelvis or calyces, they do not typically produce obstructive symptoms until they have grown to a considerable size. That is, more compound X is excreted in the urine than is filtered at the glomerulus. The descending limb of the loop of Henle is poorly permeable to solute and instead allows passive efflux of water from the filtrate. The proximal convoluted tubule is responsible for most ultrafiltrate reabsorption. However, if compound X underwent net reabsorption, its clearance would Renal Chapter 15: Renal · Answers 411 tension alone would not cause the pathology shown in the image. Minimal change disease is a glomerular disease most frequently seen in pediatric patients. Most patients respond to steroid therapy although a small fraction are at risk for chronic renal failure years later. Calcium is reabsorbed in three areas along the nephron: the proximal tubule, the thick ascending limb of the loop of Henle, and the distal tubule. In the thick ascending limb, however, calcium reabsorption is dependent on the function of the Na+-K+-2Cl- co-transporter. Calcium reabsorption occurs paracellularly, driven by the electrochemical gradient created by this transporter. Thiazide diuretics inhibit the sodium chloride symporter in the distal convoluted tubules. Calcium delivery plays a role in driving calcium reabsorption, but the transluminal gradient established by the sodium-potassium-chloride co-transporter is more important. The triple transporter maintains a lumen positive charge; positive ions are reabsorbed to maintain electroneutrality. This patient has experienced cardiogenic shock, as evidenced by his hypotension (systolic blood pressure <90 mm Hg) after a myocardial infarction. This has led to decreased renal perfusion, which has, in turn, led to prerenal failure. When the glomerular filtration rate drops, there is an increase in sodium and water reabsorption in the proximal tubule. This leads to an increase in tubular urea concentration, which favors increased reabsorption of urea. It would present with pain on urination and is unlikely in the setting of cardiogenic shock. Signs and symptoms include rash, fever, eosinophilia, eosinophiluria, and elevated IgE levels. Urine output is controlled mainly by two factors: the hydration state of the body and the level of kidney function. Therefore, low urine output is seen only in the setting of dehydration or kidney dysfunction. Stress by itself will not cause low urine output unless it is coupled with dehydration or an acute renal disease process. Under light microscopy, the glomeruli appear enlarged and hypercellular, with neutrophils and subepithelial immune complex depositions described as "lumpy-bumpy. This condition normally presents a few weeks after a streptococcal infection with peripheral and periorbital edema, dark urine, and proteinuria. Linear subendothelial patterns are seen in vasculitides such as Goodpasture syndrome. The patient described in this vignette has hepatorenal syndrome, which is a progressive functional renal failure caused by a reduction in the glomerular filtration rate due to declining hepatic function. It is characterized by splanchnic vasodilation and concomitant vasoconstriction in the renal vascular beds due to the production of mediators and to the activation of the reninangiotensin system. The combination of these two factors causes a prerenal type azotemia that develops, most commonly, without severe oliguria. One of the features of hepatorenal syndrome is that kidney anatomy is completely unaffected, and thus visualization of the kidneys by most modalities would reveal normal size and shape.

The seizure involved movement of all four of his extremities and was associated with loss of consciousness. When emergency personnel arrived at the home 35 minutes later, the patient continued to show signs of tonic-clonic activity without return to full consciousness. Which of the following agents is an effective medication to be given at this point? On physical examination, the physician notes a new-onset murmur along with white spots on the retina. Which agent, if used alone, is most likely to be used to treat this patient prior to the results of blood culture? A 43-year-old woman in a psychiatry ward is admitted from a medical floor after attempting suicide by overdosing on extra strength Tylenol. She states that she recently broke up (for the fifth time) with her boyfriend, who disapproves of her cocaine and marijuana use. She also states that she and her ex-boyfriend fight constantly, and that she has made "hundreds" of suicide attempts and has been hospitalized many times. Physical examination reveals reddened conjunctivae, an eroded nasal septum, and numerous small, uniformly sized punched-out skin lesions on the upper and lower extremities. A 20-year-old man is brought to the emergency department by the police after being picked up in the streets for acting violently towards others. Full-length exams (A) Ceftriaxone (B) Ciprofloxacin (C) Erythromycin (D) Gentamicin (E) Vancomycin 44. A 5-year-old boy is in the intensive care unit because of an intraventricular hemorrhage sustained in a car accident. A blood sample is drawn from an intravenous line that has been kept patent by intermittent flushing with heparin. For accurate coagulation studies to be obtained, the first 5 mL of blood drawn from such lines must be discarded prior to blood collection. Which of the following laboratory results is most likely in this patient if the first 5 mL of blood are not discarded? A 64-year-old woman presents to the physician because of new onset postmenopausal bleeding. Ultrasonography reveals a small mass in the left adnexa, along with a thickened endometrial stripe. Sulfamethoxazole, as is the case with all sulfonamides, binds to and will displace unconjugated bilirubin from albumin. In a newborn this can lead to kernicterus, also known as bilirubin encephalopathy. The condition results from bilirubin deposition and accumulation in the brain because of an incompletely formed blood-brain barrier. Infants who survive can develop seizures, mental retardation, deafness, choreoathetoid movements, and decreased upward eye movements. Blastomycosis can present with flu-like symptoms: fevers, chills, productive cough, myalgia, arthralgia, and pleuritic chest pain. It is most common in the upper Mississippi and Ohio River basins as well as around the Great Lakes. Diagnosis is made by use of potassium hydroxide prep to reveal big, broad, budding organisms in sputum or tissues. Some patients will fail to recover from an acute infection and progress to develop chronic pulmonary infection or widespread disseminated infection. Fluconazole or ketoconazole is used for the treatment of local blastomycosis, and amphotericin B is used for the treatment of systemic infections. Coccidioidomycosis is the second most common fungal infection encountered in the United States and is usually contracted in the Southwest. There are several cutaneous signs including erythema nodosum ("desert bumps"), erythema multiforme, and toxic erythema. Severe forms of the infection can present with blood-tinged sputum, loss of appetite, weight loss, a painful red rash on the legs, and change in mental status. Triazole antifungals are first-line drugs for most cases of coccidioidomycosis, but amphotericin B is used in severe cases. Symptoms of this infection include hypo-pigmented skin lesions that occur in hot and humid conditions.