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In cases of significant hypovolemia purchase olmesartan on line amex heart attack 0 me 1, there is a physiologic increase in p 7 Extra re na l los s e s Glucocorticoid deficiency Ac u te o r c h ro n ic Ne phrotic s yndrome buy olmesartan 20mg visa blood pressure study. In hypovolemia buy cheap olmesartan 20 mg online blood pressure chart of human body, the kidney should be avidly retaining sodium, so the urine sodium level should be less than 20 mmol/ L. If the patient is hypovolemic, yet the urine sodium level is more than 20 mmol/ L, then kidneys do not have the ability to retain sodium normally. Either kidney function is impaired by the use of diuretics, or the kidney is lacking necessary hormonal stimulation, as in adrenal insufficiency, or there is a primary renal problem, such as tubular damage from acute tubular necrosis. When patients are hypovolemic, treatment of the hyponatremia requires correction of the volume status, usually replacement with isotonic (0. It commonly occurs as a result of congestive heart failure, cirrhosis of the liver, or the nephrotic syndrome. Renal failure it self can lead t o h ypot on ic h yponat remia because of an inabilit y t o excret e dilut e urine. In any of these cases, t he usual init ial t reat ment of hyponat remia is administ rat ion of diuretics to reduce excess salt and water. Thus, hypovolemic or hypervolemic hyponatremia is often apparent clinically and often does not present a diagnost ic challenge. Euvolemic hyponatremia, h owever, is a frequent problem t hat is not so easily diagnosed. O nce t he clinician has diagnosed the patient with euvolemic hypotonic hyponatremia, the next step is to measure the urine osmolarity. This measurement is taken to determine whether the kidney is actually capable of excreting the free water normally (urine osmolality should be maximally dilut e, < 100 mO sm/ kg) or whet her t he free wat er excret ion is impaired (urine not maximally concent rat ed, > 150-200 mO sm/ kg). If t he urine is maximally dilut e, it is handling free wat er normally but it s capacit y for excre- tion has been overwhelmed, as in central polydipsia. More commonly, free water excret ion is impaired and t he urine is not maximally dilut e as it should be. Two import ant diagnoses must be considered at this point : hypothyroidism and adre- nal insufficiency. Thyroid hormone and cortisol both are permissive for free water excretion, so their deficiency causes water retention. In cont rast, pat ient s wit h primary adrenal insufficiency (Addison disease) also lack aldost erone, so t hey have impaired abilit y to retain sodium, and often appear hypovolemic and may even present in shock. Because of retention of free water, patients actually have mild (although clinically inapparent) volume expansion. Additionally, if they have a normal dietary sodium intake, the kidneys do not retain sodium avidly. Therefore, modest natriuresis occurs so that the urine sodium level is elevated > 20 mmol/ L. Patients with severe neurologic symptoms, such as seizures or coma, require rapid par- tial correction of the sodium level. W hen there is concern that the saline infusion might cause volume overload, the infusion can be administered with a loop diuretic such as furosemide. The diuretic will cause the excretion of hypotonic urine that is essentially “half-normal saline,” so a greater portion of sodium than water will be retained, helping to correct the serum sodium level. When hyponatremia occurs for any reason, especially when it occurs slowly, the brain adapts to prevent cerebral edema. Solutes leave the intracellular compart- ment of the brain over hours to days, so patients may have few neurologic symp- toms despite very low serum sodium levels. If the serum sodium level is corrected rapidly, the brain does not have time to readjust, and it may shrink rapidly as it loses fluid t o the ext racellular space. It is believed that this rapid sh rin kage may trigger demyelinat ion of the cerebellar and pont ine neurons. T his osmotic cerebral demyelination, or central pontine myelinolysis, may cau se quadriplegia, pseudobul- bar palsies, a “locked-in” syndrome, coma, or death. D emyelin at ion can occu r even wh en fluid rest rict ion is the t reat ment used t o correct the serum sodium level. For any pat ient wit h h ypon at remia, the gen eral r u le is that ch ron ic h ypon at remia should be correct ed slowly, and acut ely developing hyponat remia can be correct ed more quickly. In chronic hyponatremia, the serum sodium concentration should cor r ect n o fast er t h an 0. For pat ient s wit h ch ron ic h yper volemic h ypon at remia, as in h ear t failure or cir- rhosis, vasopressin antagonists (tolvaptan and conivaptan are approved for use in the United States) are now available and are very effective in increasing free water excret ion and raising serum sodium concent rat ions. T herapy wit h t hese agent s is typically initiated in the hospital with close monitoring of sodium concentration. H is serum sodium level is init ially 116 mEq/ L and is cor r ect ed t o 120 mEq/ L over the n ext 3 h ou r s wit h h yp er t on ic salin e. H e h as never h ad any h ealt h problems, but h e h as smoked a pack of cigarett es per day for about 35 years. H is physical examinat ion is not able for a low t o normal blood pressure, skin hyperpigment at ion, and digital clubbing. You tell him you are not sure of the problem as yet, but you will draw some blood tests and schedule him for follow-up in a week. T h e laborat or y calls that n igh t an d in forms you that the pat ient’s sodium level is 126 mEq/ L, pot assium level is 6. Which of the following is the likely cause of h is h yponat remia given h is present at ion? H er medical history is remarkable only for hypertension, wh ich is well cont rolled wit h hydroch lorot h iazide. H er examinat ion and laborat ory t est s sh ow no signs of infect ion, but h er serum sodium level is 119 mEq/ L, and plasma osmolarity is 245 mO sm/ kg. O n the fir st p ost op er at ive d ay, h e is n ot ed t o h ave sign ifican t h yp on at r em ia wit h a sodium level of 128 mEq/ L. You suspect t hat t he hyponat remia is due to t he int ravenous infusion of hypot onic solut ion. In the post operat ive st at e or in sit uat ions wh ere the pat ient is in pain, the serum vasopressin level may rise, leading to inappropriate retent ion of free wat er, wh ich leads t o dilut ion of the serum. H yponat remia in the set t ing of hyperkalemia and acidosis (low bicarbon- ate level) is suspicious for adrenal insufficiency. T his pat ient’s examinat ion is also suggest ive of t he diagnosis, given his complaint s of fat igue, weight loss, low blood pressure, and h yperpigment at ion. In this case, the cau se of the adr en al glan d d est r u ct ion is pr obably eit h er t uber cu lo- sis or lung cancer. Because the patient is hypovolemic, probably as a result of the use of diuretics, volume replacement with isotonic saline is the best initial therapy. Hyponatremia caused bythiazide diuretics can occur byseveralmechanisms, including volume deplet ion. In a patient with hyponatremia due to the infusion of excessive hypo- tonic solution, the serum osmolarity should be low. The kidneys in respond- ing normally should attempt t o ret ain sodium and excret e water ; h ence, the urine sodium concentration should be low, and the urine osmolality should be low. When the infusion of hypotonic solution is used, the serum potas- sium level will also be low.
Syndromes
Sur- very large increase in the nasal valve angle cheap olmesartan master card blood pressure chart pregnant, it will inevitably geon factors include surgical experience order olmesartan with a mastercard blood pressure chart uk pdf, the use of adjunctive place significant pressure on the skin envelope and pyriform techniques to optimize results order olmesartan 10mg with visa blood pressure kits at walgreens, and variation in outcome meas- aperture, which was painful and did not settle with conserva- urement techniques. It is important to use a graft flow are infrequently employed and have been shown to not length that is adequate but not excessive. The amount rigidity through the nasal side wall as well as increasing the of increased sidewall tension and rigidity as well as the increase in nasal valve angle. It addresses both internal and external nasal nasal valve angle and cross-sectional area are determined by the valve dysfunction. It appears to be a powerful technique with length of the graft, which can be varied according to need. It is a useful additional tool in the treatment of nasal of patients showed a statistically significant reported improve- valve dysfunction in rhinoplasty. One clear advantage of the graft is its ability to be applied to patients with either internal References or external valve dysfunction. Aesthetic Plastic The type of cartilage used in the graft is also an important con- Surgery: Rhinoplasty. J Laryngol Otol 1996; 110: of rigidity and flexibility to achieve the ideal amount of spring. Use of alar batten grafts for cartilage is frequently too brittle or too weak to achieve adequate correction of nasal valve collapse. Arch Otolaryngol Head Neck Surg 1997; sidewall pressure and maintain the increased nasal valve angle. Plast Reconstr Surg 1997; 99: 943–952, discus- wing graft: a technique for the replacement of lower lateral cartilages. Turn-in folding of the cephalic portion of the lateral Otolaryngol Head Neck Surg 2004; 130: 283–290 crus to support the alar rim in rhinoplasty. Split humptech- 306–310 nique for reduction of the overprojected nasal dorsum: a statistical analysis [23] Sen C, Iscen D. Use of the spring graft for prevention of midvault complica- on subjective body image in relation to nasal appearance and nasal patency tions in rhinoplasty. Plast Reconstr Surg 2007; 119: 332–336 in 97 patients undergoing aesthetic rhinoplasty. Spreader graft: a method of reconstructing the roof of the middle [26] Naito K, Cole P, Chaban R, Oprysk D. Plast Reconstr Surg 1984; 73: 230–239 obstruction, and rhinoscopic findings compared. The flaring suture to augment the repair of the dysfunctional nasal the nasal airway—which is better? Correction of nasal valve stenosis with lateral suture sus- [28] Ghidini A, Dallari S, Marchioni D. Inspiratory nasal obstruction secondary to alar and 117: 2100–2106 nasal valve collapse: technique for repair using autogenous cartilage. Alar rim grafting in rhinoplasty: indications, techni- Tech Otolaryngol Head Neck Surg 1990; 1: 215–218 que, and outcomes. Plast Reconstr Surg 1998; 102: 2169–2177 241 31 Normal and Variant Anatomy of the Part 5 Nasal Tip 244 32 Structural Support and Dynamics at Tip Rhinoplasty the Tip 252 33 Applications of the M-Arch Model in Nasal Tip Refinement 259 34 Functional Support of the Nasal Tip 266 35 Nuances in Tip Modification: Specific Applications of Cartilage Splitting in Rhinoplasty 272 36 Nasal Tip Projection: Nuances in Understanding, Assessment, and Modification 278 37 Control of Tip Rotation 287 38 Rhinoplasty: Open Tip Suture Techniques – A 25-Year Experience 295 39 Creating Elegance and Refinement at the Nasal Tip 304 40 Versatile Grafting at the Nasal Tip 309 41 Nuances of the Nasal Tip: Rhinoplasty of the Thin-Skinned Nose 315 42 The Crooked Nasal Tip 322 43 The Asymmetric Nasal Tip 335 44 Correction of the Retracted Alar Base 345 45 Improving the Hanging Ala 352 46 Surgical Treatment of the Nasolabial Angle in Balanced Rhinoplasty 358 47 Alar Base Reduction: The Boomerang- Shaped Excision 365 5 Tip Rhinoplasty 31 Norm al and Variant Anatom y of the Nasal Tip Amy S. Dobratz A thorough understanding of nasal tip anatomy is a prerequisite nasal spine, increased projection, and strong cartilages with a to understanding the nuances of restructuring the nasal tip. This results in increased tip projection with The nasal tip is the most dynamic and detailed part of the nose, more vertically oriented, narrow nostrils. The definition of the and as such, proper alteration of the nasal tip structures tip is increased due to the stronger cartilages and thinner skin. The interrelationships between these structures deter- the intermediate crura (including the dome), and the lateral mine the form and function of the nasal tip. This conceptual idea allows one to project reader with a foundation for understanding the nuances of changes to the tip position through alteration of the various nasal tip restructuring described in other articles in this jour- cartilaginous limbs of the tripod. The structures that contribute to the The medial crura become the intermediate crura as they shape and position of the nasal tip are: (1) the bony skeleton, begin to diverge away from one another up to the nasal domes. The anteriormost point of projection of tomic structures may lead to a wide variation in shape, volume, the nose, or tip-defining point, is located within the dome at and symmetry of the nasal tip among patients,2 particularly the junction of the intermediate crus and lateral crus. A classic example of this is the The lateral crura begin at the nasal dome near the area of the platyrrhine (African) nose where a poorly defined nasal spine, tip-defining point. The lateral cfura should have a mildly convex decreased vertical projection of the columella, weak cartilages, architecture as they form the lateral support of the nasal tip. The tip lobule is represented by green, the paired alar lobules are red, the paired soft tissue triangles are blue, and the columellar subunit is yellow. The yellow space represents the sesamoid cartilage and fibrofatty tissue that connects the lower lateral cartilage to the maxilla. Variations in the convexity of this lateral portion of the thick and the cartilage is relatively thin. Thicker skin may create an aura of blunting may also significantly affect the appearance of the tip lobule to the nasal tip. In contrast, if the skin is thin, the surgeon should perform meticu- lous beveling of cartilage incisions, suturing of free cartilage 31. The most anterior and superior point of the caudal septum is termed the “anterior septal angle” and is attached to 31. There is Nasal Tip a membranous septum, which is a thin area caudal to the carti- Structural support of the nasal tip is discussed in detail in Chap- laginous septum formed from the apposition of bilateral exten- ter 32. However, a brief discussion about support of the tip as it sions of septal mucosa prior to joining the columella. There are pertains to the anatomy of the muscle and ligamentous support ligamentous attachments extending from the caudal septum to structures of the nasal tip is warranted. The nasal muscles, Traumatic and iatrogenic injury to the caudal septum may such as the dilator naris and depressor septi nasi, and the liga- lead to weakening of the strut, which can result in loss of tip mentous attachments throughout the nasal tip also play an support. This may lead to decreased projection and derotation important role in the dynamic support of the nasal tip. In contrast, an stabilize and move the cartilaginous limbs of the tripod, contri- overly long caudal septum may lead to increased projection of buting to the ultimate support and shape of the nasal tip. The various ligamentous attachments of the nasal tip are not uniformly defined between patients6 and may result in varying degrees of tip support. However, they should still be taken into consideration when planning an operation on the nasal tip. Dis- ruption of attachments resulting from a surgical incision or approach can be strategically used to help create the desired effect on the nasal tip, though only moderate change is possible. Disruption of the ligaments can also counteract the gains already made by cartilage manipulation or suturing techniques. This should be taken into account during the careful planning of how to execute the desired changes to the tip. Oftentimes, grafts and sutures are used to help recreate some of the support that is lost through disruption of these attachments. The tip-defining points that are represented by purple circles should be symmetric.
Syndromes
Bim an ual e xam in a- tion reveals a small uterus and no adnexal masses are appreciated cheap olmesartan 10 mg with amex blood pressure chart low diastolic. I n sp ect ion of the ext er n al fem ale gen it alia r eveals at r o p h ic purchase olmesartan 20mg amex prehypertension 120-139 over 80-89, wh it e olmesartan 20mg without prescription arrhythmia in child, t h in exco - riated tissue and retraction of the clitoris and constriction of the vaginal introitus wit h some bruising. Describe the characteristics of patients that present with lichen sclerosis, and the natural history of the disease. Recognize the anatomical boundaries of the vulva and aspects of good vulvar hygiene. Identify current treatment regimes for lichen sclerosis and the follow-up that is requisite. Co n s i d e r a t i o n s This postmenopausal woman is suffering from lichen sclerosis given her history and physical finding. The diagnosis is confirmed with biopsy of t he affected vulvar tissue, revealing a thinned epidermis, hyperkeratosis, and elongation of the rete pegs. An experienced dermat opat h ologist sh ould be able t o different iat e the two on biopsy specimen. Since our pat ient is post menopausal, t h erefore lacking est rogen, t he pH of t he area is raised and not amenable t o candidal infect ion unless she has poorly cont rolled diabet es or is immunosuppressed. Somet imes vaginal at rophy in t he post menopausal pat ient can lead to pruritus, but usually not to this ext ent. Psoriasis may present wit h prurit us but not usually, and the lesions are clas- sically described as silver scales, and are also present on t he extensor surfaces of the extremities. It is made up of the labia majora and minora, mons pubis, clitoris, vestibule of the vagina, urethral meatus, Skene glands, vaginal orifice, hymen, and Bartholin glands. Li c h e n S c l e r o s i s Lichen sclero sis is a chronic progressive inflammatory medical condition of which there is no definitive cure. Women with the disease usually present with the complaint of itch- ing wh ich can be worse at night, and is described by t he pat ient as vaginal itching. O n examination of the external genitalia, a figure-eight pattern is seen around the vu lva an d an u s. T h e sk in is classically d escr ib ed as “c i g a r e t t e p a p e r ” a s i t a p p e a r s c r i n - kled and is fragile, thinned, and atrophic. Abr asion s may develop from scr at ch ing or attempted intercourse, and ultimately scarring may cause narrowing or a complete closure of the vaginal introitus, even in the parous woman. The scratching of the areas worsens the disease and can also lead to dyschezia, from constriction of the anus. Counseling of the patient is important including discussing components of vul- var h ygien e, avo id in g ir r it an t s t o the sk in su ch as so ap s an d b u b b le b at h s, cessa - tion of scratching the lesions, and wearing all cotton, white underwear. The patient should be made aware of t he chronicit y of t he disease and t he need for yearly sur veillance. Treat ment of t he disease is aimed at prevent ing relapses of int ense pruritus and the mainstay is corticosteroids. Initially, a potent steroid ointment, Clobetasol, may be necessary to provide relief, and should be used daily until symp- toms abate and then tapered to intermittent use. Ba r t h o l i n Gl a n d Ab s c e s s The Bartholin or greater vestibular glands are located at the 5- and 7-o’clock locat ions of the labia majora. The t reat ment opt ions include incision and placement of a small balloon cat h et er int o the gland or marsupializa- tion which is surgical fixation of the cyst wall everted against the mucosa of the vu lva. T h e p u r p o se of b ot h of t h ese t ech n iq u es is t o allow d r ain age of the in fect ion for several weeks. Bartho- lin gland infect ions are usually polymicrobial and not usually sexually transmitted. Involvement in women over the age of 40 years can be associated with cancer and should have a biopsy. Vu l v a r C a n c e r Becau se vu lvar can cer can pr esen t wit h n o symp t oms or wit h it ch in g, an y su spiciou s lesion of the vulva especially in a post menopausal woman sh ould undergo biopsy. Unfortunately, delay in diagnosis is usually the rule due to lack of clinical suspicion and prescript ion of various topical agent s. Younger women such as t hose in t heir 30s may develop vulvar cancer due to human papillomavirus; smoking is also a risk fact or. Regardless of the age, if vulvar cancer is diagnosed, then the patient should have surgical staging, with the primary lesion removed and the adjacent (ipsilateral) inguinal lymph nodes. Most vulvar cancers are squamous cell, but melanoma, basal cell carcin oma, an d ot h er subt ypes can occur. T h u s, pig- mented lesions of the vulva should be carefully considered for biopsy. If cu lt ure is don e, wh ich of the following or gan isms is most likely t o be foun d? You perform a punch biopsy of the lesion which reveals moderately differentiated squamous cell carcinoma. Complaints of dyspareunia, or painful intercourse, are not uncommon in t he post menopausal st at e. Without estrogen, the vaginal and vulvar tissue can atrophy leading t o bruising, t earing, and even bleeding of the vulva vagina wit h int er- cou r se. Pruritus of the vulva is not unique to lichen sclerosis, although the pre- dilection for the vulva and anus is. Examination of the vulva and anus with indicated biopsies and topical steroid oint ment is the t reat ment of choice. Diabetes can lead to candidal infection of the vulva which can cause fis- sures in the labial folds, and t he scrat ch ing of t he disease can somet imes spread t he infect ion. Psor iasis can affect the gen it al ar ea, an d the silver plaqu es on the elbow are a dead giveaway to t he disease. Treat ment of t his disease may prove difficult, and consult at ion with an experienced dermatologist is requisite. T h e most common bact er ia foun d in a Bar t h olin glan d abscess are polymi- crobial su ch as skin or gan isms, G r am-n egat ive rods, an d an aerobes. The most common location for spread of a squamous cell carcinoma of the labia majora is the ipsilateral inguinal lymph nodes. A midline lesion may travel to bilateral inguinal nodes, but a lateral lesion will almost always be isolated to the ipsilateral nodes. Frequent surveillance of the vulva is nec- essary as to prevent squamous cell carcinoma of the vulva. The explanations to the answer choices describe the rationale, including which cases are relevant. A 5-year-old female child is brought into the physician’s office for breast development and menses. A 32-year-old woman is noted to have 1200 cc of blood loss following a spont aneous vaginal delivery and delivery of t he placent a.
