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By: F. Silvio, M.B. B.A.O., M.B.B.Ch., Ph.D.
Associate Professor, Yale School of Medicine
A distinction may be drawn between abulia major (= akinetic mutism) and abulia minor purchase glyset with a visa, a lesser degree of abulia associated particularly with bilateral caudate stroke and thalamic infarcts in the territory of the polar artery and infratentorial stroke discount glyset. Abulia may result from frontal lobe damage order 50 mg glyset otc, most particularly that involving the frontal convexity purchase glyset 50 mg overnight delivery, and has also been reported with focal lesions of the caudate nucleus, thalamus, and midbrain. The behavioural and motor consequences of focal lesions of the basal ganglia in man. Cross References Akinetic mutism; Apathy; Bradyphrenia; Catatonia; Frontal lobe syndromes; Psychomotor retardation Acalculia Acalculia, or dyscalculia, is difficulty or inability in performing simple mental arithmetic. This depends on two processes, number processing and calculation; a deficit confined to the latter process is termed anarithmetia. Acalculia may be classified as: · Primary: A specific deficit in arithmetical tasks, more severe than any other coexisting cognitive dysfunction. Secondary: In the context of other cognitive impairments, for example of language (aphasia, alexia, or agraphia for numbers), attention, memory, or space perception. Acalculia may occur in association with alexia, agraphia, finger agnosia, rightleft disorientation, and difficulty spelling words as part of the Gerstmann syndrome with lesions of the dominant parietal lobe. Isolated acalculia may be seen with lesions of: · · · dominant (left) parietal/temporal/occipital cortex, especially involving the angular gyrus (Brodmann areas 39 and 40); medial frontal lobe (impaired problem solving ability? Selective acalculia with sparing of the subtraction process in a patient with a left parietotemporal hemorrhage. This reflex may be elicited in several ways: by a blow with a tendon hammer directly upon the Achilles tendon (patient supine, prone with knee flexed, or kneeling) or with a plantar strike. The latter, though convenient and quick, is probably the least sensitive method, since absence of an observed muscle contraction does not mean that the reflex is absent; the latter methods are more sensitive. Loss of the Achilles reflex is increasingly prevalent with normal healthy ageing, beyond the age of 60 years, although more than 65% of patients retain the ankle jerks. Cross References Age-related signs; Neuropathy; Reflexes Achromatopsia Achromatopsia, or dyschromatopsia, is an inability or impaired ability to perceive colours. This may be ophthalmological or neurological in origin, congenital or acquired; only in the latter case does the patient complain of impaired colour vision. Ishihara plates), although these were specifically designed for detecting congenital colour blindness and test the red-green channel more than blue-yellow. Sorting colours according to hue, for example with the FarnsworthMunsell 100 Hue test, is more quantitative, but more time-consuming. Difficulty performing these tests does not always reflect achromatopsia (see Pseudoachromatopsia). These inherited dyschromatopsias are binocular, symmetrical, and do not change with time. Acquired achromatopsia may result from damage to the optic nerve or the cerebral cortex. Optic neuritis typically impairs colour vision (red-green > blue-yellow) and this defect may persist whilst other features of the acute inflammation (impaired visual acuity, central scotoma) remit. Cerebral achromatopsia results from cortical damage (most usually infarction) to the inferior occipitotemporal area. Area V4 of the visual cortex, which is devoted to colour processing, is in the occipitotemporal (fusiform) and lingual gyri. Lesions in this region may also produce prosopagnosia, alexia, and visual field defects, either a peripheral scotoma, which is always in the upper visual field, or a superior quadrantanopia, reflecting damage to the inferior limb of the calcarine sulcus in addition to the adjacent fusiform gyrus. Transient achromatopsia in the context of vertebrobasilar ischaemia has been reported. The differential diagnosis of achromatopsia encompasses colour agnosia, a loss of colour knowledge despite intact perception; and colour anomia, an inability to name colours despite intact perception. Loss of the radial pulse may occur in normals but a bruit over the brachial artery is thought to suggest the presence of entrapment. A brief topographical overview of age-related signs includes · Cognitive function: Loss of processing speed, cognitive flexibility, efficiency of working memory (sustained attention); Preservation of vocabulary, remotely learned information including semantic networks, and well-encoded new information. Reflexes: Phasic muscle stretch reflexes: depressed or absent, especially ankle (Achilles tendon) jerk; jaw jerk; Cutaneous (superficial) reflexes: abdominal reflexes may be depressed with ageing; Primitive/developmental reflexes: glabellar, snout, palmomental, grasp reflexes may be more common with ageing. Sensory system: Decreased sensitivity to vibratory perception; +/- pain, temperature, proprioception · Neuroanatomical correlates of some of these signs have been defined.
Although the terms extranodal and extralymphatic are sometimes used interchangeably buy glyset overnight delivery, extranodal means that the lymphoma does not arise in a lymph node but may arise in one of the lymphatic tissues mentioned above buy generic glyset 50 mg online, while extralymphatic means the lymphoma arises in a nonlymphatic organ or tissue discount glyset 50mg with visa. When referring to nodal or extranodal lymphomas order glyset once a day, it is important to identify the primary site of the tumor, which may not be the site of the biopsy or the site of spread or metastasis. For example, diffuse large B-cell lymphoma can be either a nodal or a primary extranodal tumor. The biopsy may be of a lymph node, but the bulk of the primary disease may be in a primary extranodal organ. Staging information from imaging studies is the only reliable method of making this distinction but may not be readily available to cancer registries. If it appears that the primary site is not lymph nodes, unknown primary site (C80. This distinction is important because extranodal lymphomas may have a better prognosis. A tumor can grow in place without the potential for spread (/0, benign); it can be malignant but still growing in place (/2, noninvasive or in situ); it can invade surrounding tissues (/3, malignant, primary site); or even disseminate from its point of origin and begin to grow at another site (/6, metastatic). Myeloid sarcoma is a leukemic deposit in an organ or tissue and should be coded to the site of origin. The grade, differentiation, or phenotype code provides supplementary information about the tumor. However, "spindle cell cancer" could refer either to "spindle cell sarcoma" or to "spindle cell carcinoma". Most cancer registries collect data only on malignant and in situ neoplasms, that is, /3 or /2 of the behavior code. Behavior codes /6, malignant, metastatic site, and /9, malignant, uncertain whether primary or metastatic site, are not generally used by cancer registries. For example, if a person has a carcinoma that has spread to the lung and the site of origin is unknown, the appropriate code is C80. By far the largest number of in situ carcinomas are diagnosed in the cervix uteri. In recent years, several other closely related terms have been used by cytologists and pathologists, notably intraepithelial neoplasia. Unfortunately this description includes both carcinoma in situ and severe dysplasia. On the other hand, the cancer registrar would report only (b) the primary site and morphology with a behavior code /3. Each of these five terms has the same four-digit morphology code, 8140, indicating a neoplasm of glandular origin. If a diagnosis of "adenocarcinoma of lung, uncertain whether primary or metastatic site" was reported in a clinical or pathology records, it could be coded to 8140/9. It would not be used by cancer registrars who, as previously explained, normally only include /2 (in situ) and /3 (malignant neoplasm, primary site) in their registries. In the second example (B), three terms are listed under the four-digit morphology code number 9000. The primary difference between the two groups lies in the use of the behavior code. A pathologist may receive several specimens from the same patient, for example: (a) a biopsy, (b) the resected primary site, and (c) a metastatic site (Table 19). The pathologist wants to keep track of all three of these specimens; the cancer registrar is only interested in the primary. Use of behavior code in pathology laboratories Examples of specimen coding in a laboratory Topography code Morphology code 8490/6 8490/3 8490/6 a. Biopsy diagnosis: Supraclavicular lymph node, metastatic signet ring cell adenocarcinoma, most likely from stomach *b. Metastatic site: Upper lobe bronchus, metastatic signet ring cell adenocarcinoma * Codes for this case as recorded in registry. If a diagnosis of "malignant Brenner tumor" were reported, however, its correct code would be 9000/3; similarly a diagnosis of "Brenner tumor, borderline malignancy" would be correctly coded 9000/1. They are available for use when appropriate; for example, 9000/2 would be used for "Brenner tumor in situ" if such an entity were to be identified.
A 70-year-old woman comes to the office because of a 1-month history of gradually worsening shortness of breath discount 50 mg glyset with visa. Pulmonary examination discloses dullness to percussion three-quarters of the way up on the left buy cheap glyset 50 mg on line. A 57-year-old woman comes to the office for a preoperative evaluation 2 weeks before undergoing scheduled laparoscopic cholecystectomy generic glyset 50 mg visa. Family history is significant for stable angina in her father and rheumatoid arthritis in her mother discount glyset 50 mg with visa. The patient has a 102-year-old grandmother who resides in a nursing care facility and has Parkinson disease. Physical examination discloses thickening and hardening of the skin over the dorsum of the hands and forearms, as well as mild kyphosis. Prior to surgery, further evaluation is indicated for which of the following conditions in this patient? Medical history is also remarkable for pneumonia 3 years ago that required hospitalization. Today, he says that he lost his job 6 months ago, is now homeless, and cannot afford to buy his antiretroviral medications. A 29-year-old woman comes to the emergency department because she has had increasingly severe lower abdominal pain and nausea for the past 2 days. Physical examination discloses abdominal tenderness in the lower quadrants bilaterally with rebound and guarding. Pelvic examination discloses leukorrhea at the cervical os and tenderness of the uterus to palpation. A 12-year-old girl is brought to the emergency department by her mother because of a 1-week history of worsening swelling in her legs. She had an upper respiratory tract infection and sore throat 1 week ago that caused her to miss several days of school. Physical examination discloses erythema of the posterior pharynx, mild cervical lymphadenopathy, and 3+ pitting edema to both knees. A 50-year-old woman comes to the office for the first time because of recurrent abdominal pain. Review of her extensive medical chart, which she has brought with her, discloses that she has a long history of varying physical symptoms. Definitive causes for these symptoms have not been found despite extensive diagnostic studies, consultations with many physicians, and several surgical explorations. She gives dramatic and exaggerated descriptions of her present and past symptoms, and she makes conflicting statements about her history. A large shipyard firm has provided the asbestos exposure records of all employees during the past 50 years. The health insurer for the workers has provided claims data that documents all chest x-rays and diagnoses of mesothelioma among current workers and retirees. The study enrolled shipyard workers who were diagnosed with mesothelioma and shipyard workers who were not diagnosed with mesothelioma. Which of the following is the best rationale for selecting a comparison group that had chest x-rays? A previously healthy 32-year-old woman comes to the physician 8 months after her husband was killed in a car crash. She has been rechecking the door lock five times before leaving her house and has to count exactly five pieces of toilet paper before she uses it. She says that she has always been a perfectionist but these urges and rituals are new. A 35-year-old man is brought to the emergency department because of altered mental status. You last saw him 2 weeks ago; at that visit his serum glucose concentration was 150 mg/dL 3 hours after eating. On physical examination pupils are constricted; funduscopic examination of the left eye following dilation is shown. A physician is conducting a retrospective review of a trial involving the use of Drug X in patients with a specific disease. It is known that Drug X is associated with an increased probability of cancer in patients who use the drug.
