By D. Jared. Chicago-Kent College of Law.
The first time the male patient has trouble reaching an erection order 10mg pravachol visa, he begins to believe he is “over the hill pravachol 10 mg with mastercard. Sometimes 20 mg pravachol fast delivery, in search of variety in his sexual life, a married man may 515 decide to find a new sexual partner. When the moment of truth arrives, he may be unable to get an erection because of the associated guilt involved. After his first failure, the fear of a repeated performance may make him impotent not only in extramarital relations but also in marital relations. Young men, whether married or unmarried, may “fall into impotence” quite by accident because of alcoholic intoxication. As Shakespeare correctly surmised, “alcohol provokes the desire, but it takes away the performance. When sober once more, he may begin a pattern of failure to get an erection simply because of the fear that it will happen again and he will be embarrassed beyond belief. Some other supratentorial causes of impotence are endogenous: depression, schizophrenia, latent homosexuality, repressed hostility toward the partner, and fear of pregnancy. It is important to note that all of the above psychologic causes may occur in the female patient as well as the male. A careful examination of the external genitalia, the prostate, and secondary sex characteristics is essential. The laboratory workup may include a glucose tolerance test, blood testosterone, free testosterone, serum prolactin and cortisol levels, thyroid function studies, a spinal tap, a skull x-ray, and a chromosomal analysis. If the physical examination is normal, it may be wise to administer psychometric tests or to refer the patient to a psychiatrist before doing an extensive endocrine and neurologic workup. A sympathetic physician may be able to find the supratentorial cause and cure it with a few long discussions with the patient. Case Presentation #54 A 56-year-old diabetic man complained of increasing erectile dysfunction. Physical examination revealed diminished dorsalis pedis and tibialis pulses in both lower extremities. Given your knowledge of anatomy and physiology, what is your differential diagnosis? His examination discloses diminished femoral pulses and bruits over the femoral arteries and abdominal aorta. The pathway of voluntary control of this function begins in the cerebrum and travels through the brain stem, spinal cord, and nerve roots, to the “end organ,” which is the rectal sphincter. Cerebrum: This should help recall the incontinence of Alzheimer disease, normal pressure hydrocephalus, and other causes of organic brain syndrome. It will also prompt the recall of the incontinence in functional psychosis and epilepsy. Brainstem and spinal cord: This would bring to mind trauma, multiple sclerosis, transverse myelitis, syringomyelia, and brainstem and spinal cord tumors in which there is loss of voluntary control due to pyramidal tract damage. Nerve roots: This should prompt the recall of cauda equina tumors, tabes dorsales, and spinal stenosis. Rectal sphincter: Primary rectal sphincter incompetence leads to the release of small amounts of stool associated with anal fissures, hemorrhoids, and postoperative incontinence following a fistulectomy or episiotomy. Approach to the Diagnosis 519 Before beginning an expensive diagnostic workup, pay attention to the history and physical examination. If the incontinence is sporadic, look for organic brain syndrome, epilepsy, or functional psychosis. If the neurologic examination reveals pathologic or hyperactive reflexes in the lower extremities, consider a spinal cord or brain stem lesion. If there are hypoactive reflexes in the lower extremities, consider the possibility of cauda equina tumor or tabes dorsalis. Anorectal manometry and defecography will assist in the diagnosis of anal and rectal sphincter dysfunction. Stress incontinence occurs on coughing or straining and is due to damage to the urethra or pelvic floor from pregnancy and delivery. Loss of voluntary control: The neurologic causes include multiple sclerosis, normal pressure hydrocephalus, neurosyphilis, syringomyelia, encephalitis, cerebral arteriosclerosis, frontal lobe tumors and abscesses, senile dementia, and transverse myelitis from trauma or infection. The local causes are a cystocele (often following a hysterectomy) and a damaged urethral sphincter from prostatectomy. Bladder neck obstruction: Benign prostatic hypertrophy, chronic prostatitis, prostate carcinoma, median bar hypertrophy, vesical calculus, and urethral stricture are important mechanical causes of obstruction. Flaccid neurogenic bladder: Drugs such as atropine, 520 tranquilizers, and anesthetics and diseases of the cauda equina and nervi erigentes such as diabetic neuropathy, poliomyelitis, tabes dorsalis, and cauda equina tumors will cause a flaccid neurogenic bladder with overflow incontinence. Catheterization and examination, smear, and culture of the urine are essential at the outset. Surgical repair of a cystocele or a parasympathomimetic drug in cases of a flaccid neurogenic bladder and oxybutynin (Ditropan) for spastic neurogenic bladders may be all that is necessary. A neurologist and urologist often need to cooperate in the diagnosis and treatment of these unfortunate individuals. Transrectal ultrasound (benign prostatic hyperplasia) Case Presentation #55 A 48-year-old white woman is brought to your office by her daughter who complains that she is getting forgetful and frequently wets herself. She denies that her mother abuses drugs but admits she consumes a moderate amount of alcohol and falls occasionally. The causes are easy to arrive at by merely asking the question, “Why would food cause these symptoms? Air swallowing from nerves is a frequent cause of belching, especially in talkative individuals. Chronic appendicitis and regional ileitis may cause partial obstruction or paralytic ileus. Yes, the application of the “target” method to the anatomy of the internal organs. Approach to the Diagnosis The association of other symptoms and signs is important. If there is relief by antacids, esophagitis, gastritis, or an ulcer may be present. Awareness that a systemic disease such as an electrolyte disturbance or uremia may be the cause will suggest the need for other studies, especially if there are systemic symptoms, fever, or shortness of breath. Lactose tolerance test Case Presentation #56 A 55-year-old obese black mother of five complained of indigestion that she described as a fullness in the stomach and belching following meals. She denies abuse of alcohol or drugs but takes occasional aspirin for arthralgias. Utilizing the target method described above, what would be your differential diagnosis?
Other indications are the clinical presence of the fol- esophagus order 10mg pravachol with amex, trachea buy pravachol 10 mg on-line, bronchi pravachol 20mg for sale, or lungs. The clinical pneumocystis jiroveci pneumonia; and progressive multi- picture does not include a description of herpetic or aph- focal leukoencephalopathy and cerebral toxoplasmosis. Indeed, unless there is a break in the mucosa that exudes blood the risks, even in the vignette presented, are minimal, but into the saliva; thus, the shared toothbrush is a risk. Urine, available as 150 mg lamivudine/300 mg zidovudine, taken saliva, perspiration, and even vaginal secretions normally twice daily for a recommended period of 4 weeks. New York/Chicago : McGraw-Hill/Lange ; nosis of exclusion (see Question 5 and its discussion). Adult acquired immune deﬁciency syn- cognitive changes but motor problems in Alzheimer dis- drome. Breathing appears to be mildly (A) Stage 3 carcinoma of the cervix labored and shallow, but the lung fields are “clear” to (B) Streptococcus pyogenes auscultation and percussion. Of the following that (C) Actinomyces israelii are present in the differential diagnosis of these (D) Staphylococcus aureus symptoms, which one is the most likely? The stools were grayish, (E) Myasthenia gravis turbid, without fecal odor, and voluminous in fluid volume. Cramping was minimal, and he was afebrile, 5 A 50-year-old diabetic man complains of rapidly but the patient was lightheaded when he stood up by developing redness of the right (anatomical) leg over the second day. The man complains of pain (B) Cholera (rice water stools) that extends several centimeters beyond the area of (C) Travelers diarrhea visible inflammation while noting hypesthesia at the (D) Shigellosis dysentery (bloody) viable site. The area is warm to touch and the patient (E) Typhoid fever manifests systemic symptoms consisting of fever (temperature of 100. Her membranes had ruptured about (B) Blood culture 24 hours before her reporting to the emergency (C) Complete blood cell count department of the hospital. Upon examination, you hear a heart mur- macular rash of pink lesions that appears on the mur that was never mentioned in your notes, includ- palms, soles, wrists, forearms, and ankles. He is alert but uncomfortable family in North Carolina from 2 weeks ago until and manifests no neck stiffness. Today, he has also begun to com- an urgent care center 2 weeks ago and was given a plain of headache, cough, and pleuritic chest pain. Complete blood count shows gation, that the young man has been using illicit intra- thrombocytopenia, hyponatremia, and hyperbiliru- venous recreational drugs. Upon examination, he manifests conjunc- shows infectious infiltrates in various places in both tival injection, sore and fissured lips, palmar and lungs. Which of the following sites would be most solar erythema with desquamation of the tips of one likely to be the seat of the infection? He complains also of the (E) Hypertrophic cardiomyopathy recurrence over 4 days of soreness and focal redness on the left side of his nose, manifesting a flame- 12 A 35-year-old woman complains of a rash of variable shaped region of erythema involving the left naris. She had been camping denies sore throat, and a rapid flocculation test for in the New England states and had been in the wil- beta-hemolytic streptococcus is negative. She does not recall any prior skin lesions since the Which of the following is the most likely diagnosis? Examination reveals a general- (A) Scarlatina ized rash of red lesions, some annular, some target (B) Kawasaki syndrome like, some more intense centrally. Which of the fol- (C) Secondary syphilis lowing is the most likely cause of these symptoms? He complains also of (E) Lyme disease Other Infectious Diseases in Primary Care 191 13 Regarding the reemergence of pertussis, each of the (D) Suppressant therapy can reduce the recurrence following is true, except which one? She was recently (D) Timely treatment with macrolide antibiotics discharged from a hospital, with likely diagnosis of reduces the severity and length of the period of Legionnaires disease in the patient. The symp- depicted is typical for actinomycosis with its slow and toms are those of anticholinergic poisoning, and there is a insidious course, characterized by granulomatous spread curare-like effect on the skeletal muscles (i. Dyspnea is due to paraly- “lumpy jaw” but can involve the intestines, and in the sis of the diaphragm and intercostal muscles. Myasthenia gravis smear virtually rules out cancer in a process so far and Guillain–Barré syndrome should be considered, but advanced as that in the vignette. Surgical exploration, probable debri- dement, and biopsy are crucial in the clinical picture 2. Narcotizing soft tissue infection, appreciated results in watery gray stools (rice water stools) and mas- increasingly in the past 10 years, usually begins acutely, sive fluid loss. The fluid loss in full-blown cases is massive, up to 15 L/ Originally thought to be caused by an evolved virulent day and sometimes 1 L/hour, and is the cause of death if strain of beta-hemolytic group A streptococcus, it has fluid therapy is not aggressively pursued. Travelers diarrhea generally causes severe that is most frequently due to Staphylococcus epidermidis, cramps as well as diarrhea for a brief period but not the beta-hemolytic strep, Enterococcus organisms, E. While stool cultures will Proteus mirabilis, Klebsiella pneumoniae, Pseudomonas reveal Vibrio cholerae, confirming the diagnosis, the dis- aeruginosa, and species of Streptococcus, Bacteroides, Pre- ease is caused by the toxin adenylyl cyclase elaborated votella, and Clostridium, as well as anaerobic cocci and thereby. Aerobic and anaerobic organisms may be found in ment (addressing physiological amounts of saline), and combination. Each of the other studies mentioned are the course can be shortened by tetracycline, ampicillin, relevant, but none is diagnostic. It occurs usually quite early after delivery in the fasciitis, is often so devastating in its course, suspicion form of pneumonia but may be expressed in more subtle must yield to surgical debridement. Biopsy permits the clinical form as in this case, with hypotonia and poor diagnosis of the etiologic organisms and of the pathophys- feeding. Botulism is found in essentially three The blanching macular rash evolves into a petechial erup- forms: the foodborne form, as in the ingestion of pre- tion. The cause is Rickettsia rickettsii, passed through the formed toxin in canned, smoked, or vacuum-packed foods, bite of a tick with an incubation period of 7 to 14 days. Con- produced in the gastrointestinal tract of infants, and trary to the implications of its name, 56% of cases occur in wound borne botulism. The latter is found most often in one of five states, North Carolina, South Carolina, Tennes- injection drug users, probably most likely in those cases in see, Oklahoma, and Arkansas. Up to 40% of patients do which the addict has run out of functional surface veins not recall the tick bite. There is a 3% to 5% case mortality, Other Infectious Diseases in Primary Care 193 more likely in elderly and infirm. Diagnosis is made following types: injected pharynx, erythema, swelling by serial serological studies, a process that may take or fissure of the lips, strawberry tongue 2 weeks, or by immunofluorescent antibody. Meningococcemia, because of the serious- verse grooves in the fingernails) ness, must be considered and ruled out. Toxic shock syndrome now occurs as fever is characterized by a rash, but nearly always mani- frequently in non-female menstrual situations as in the fests gastrointestinal symptoms, usually evolving into originally described association with the retained tam- “soupy diarrhea. The vesicular changes of the palms and soles lead to tis is made by spinal tap for identification of Neisseria the well-known desquamation seen in the late stages. Scarlatina may be considered long enough to rule out reserved for pregnant women to avoid tetracycline side quickly because the rash of scarlatina is quite different, effects in the fetus.
Prasugrel order pravachol in united states online, clopidogrel purchase 10mg pravachol visa, and ticlopidine require a wait period of 14 days (Answer A) after taking this medication before donating platelets by apheresis 20 mg pravachol overnight delivery. The remainder of the choices from Questions 15 and 16 are incorrect based on the Table 4. His past medical history includes coronary artery disease but he has not had any symptoms in over 1 year and has no restrictions on activities of daily living. He currently takes 81 mg aspirin once daily for preventative measures and he states that he has had no further complications. In addition, he also takes several nutritional supplements in order to “keep in shape. He is eligible to donate platelets 2 days after his last dose of nutritional supplements and he can keep taking the aspirin 4. Antibiotics (oral or intramuscular) No deferral if course of medication is completed and donor is asymptomatic Prophylactic antibiotics No deferral Antifungals No deferral if course of medication is completed and donor is asymptomatic Antivirals No deferral if course of medication is completed and donor is asymptomatic Anticoagulants Defer for 7 days since last dose Accutane, Absorica, Amnesteen, Claravis, Myoris, Defer for 1 month Sotret, Zenatane (isotretinoin) Proscar, Propecia (fnasteride) Defer for 1 month Avodart, Jalyn (dutasteride) Defer for 6 months from last dose Soriatane (acitretin) Defer for 3 years from last dose Pituitary-derived human growth hormone; Defer indefnitely pituitary-derived thyrotropin Tegison (etretinate) Defer indefnitely Bovine insulin Defer indefnitely if, since 1980, received an injection of bovine (beef) insulin made from cattle from Europe Reprinted and modifed with permission from L. He is eligible to donate platelets 2 days after his last dose of aspirin and he can keep taking the nutritional supplement D. He is eligible to donate platelets 7 days after his last dose of aspirin and he can keep taking the nutritional supplement E. He is eligible to donate platelets 7 days after his last dose of aspirin and 2 days after the last dose of nutritional supplements Concept: Selected medication deferrals include medications that may affect the quality of the product. Answer: C—There is no waiting period for aspirin with whole blood donation; however, there is a 48-h waiting period after taking aspirin or after taking a medication that contains aspirin when donating apheresis platelets (Answers A, B, D, and E). If the donor is on warfarin, heparin, dabigatran, rivaoxaban, enoxaparin, or other prescription blood thinners, they should not donate blood unless a doctor discontinues the treatment and then they should wait 7 days before donation. If a donor is on clopidogrel, they must wait 14 days after the last dose before donating platelets by apheresis. Over-the-counter oral homeopathic medications, herbal remedies, and nutritional supplements are acceptable to take and require no waiting period (Answers B, D, and E). An adult male goes with his mother (a regular donor) to donate blood for the frst time. He discloses that he was diagnosed with genital herpes and was recently detained for 48 h, released home for 78 4. BlooD Donation anD ColleCtion 48 h, and subsequently jailed for 14 additional consecutive days. Twelve months from the genital herpes diagnosis Concept: Lifestyle risk factors for obtaining a transfusion transmittable disease are criteria that are evaluated during donor screening. Such factors may include intravenous drug abuse or extended stays in a correction facility. The latter is because as the stay extends, there is a greater likelihood of sexual activity. Answer: D—A person who has been detained or incarcerated in a facility (juvenile detention, lockup, jail, or prison) for greater than 72 consecutive hours (3 days) is considered to be at higher risk for exposure to infectious diseases and therefore they are deferred for 12 months from the date of last occurrence (Answers A, B, and C). A diagnosis of chlamydia, venereal warts (human papilloma virus), or genital herpes (Answer E) are not a cause for deferral, as long as the donor is feeling well and meets other eligibility requirements. A potential frst time blood donor joined her coworkers at their workplace blood drive. On the donor health questionnaire, she reports that today she is healthy, but reveals that about 15 years ago she suffered headaches, blurry vision, and a seizure. She was diagnosed with a meningioma for which she underwent resection and received a dura matter graft in the United States. She also says that she is on doxycycline for dry eyes for the past 2 months and remembers getting a belly button piercing on a trip to Las Vegas several years ago and doesn’t recall whether the facility was licensed. Accept her today knowing that it has been over 12 months from the date of tissue transplant and assume the piercing facility was licensed C. Accept her today knowing that it has been over 12 months from the date of tissue transplant and also since it has also been over twelve months from the date of piercing (to be safe since she cannot verify whether the facility was licensed) D. Defer her indefnitely Concept: Donors may have multiple reasons for deferral even if they are currently “healthy. Answer: E—Since this donor received a dura mater transplant or graft, she is indefnitely deferred and cannot donate today (Answer A). Donors that receive an allogeneic organ transplant must wait 12 months before donating blood. Body piercings (Answers B and C) are acceptable if they are performed with the use of sterile or single-use equipment. If there is any question on the use of sterile or single-use equipment, the donor must wait 12 months. Antibiotic use (Answer D) must be evaluated to determine if the donor could transmit an infection and a donor with an infection should not donate. A female who received human derived pituitary-derived growth hormone as a child, no sexual history as donor is practicing abstinence 4. A female who had sexual contact with her husband who has hemophilia and he received clotting factor concentrates a few months ago when he had bleeding into his joints D. A male who has paid “in the thousands of dollars” for sexual entertainment with the last encounter being 3 years ago, just fnished pharmacologic treatment for Neisseria gonorrhea (gonorrhea) yesterday with the infection cleared (no longer experiencing pus-like discharge) Concept: One of the main goals of the donor history questionnaire is to detect risk factors in potential donors that might identify them as a higher risk for donating blood that is potentially infectious. Second, there may be no reliable screening test available for a disease and for that reason screening questions are the best way to identify high-risk behavior. Answer: D—Though the potential donor in answer choice D has some high-risk behavior, none of it disqualifes him from donating at this time. A donor who has had either Treponema pallidum (syphilis) or Neisseria gonorrhea (gonorrhea) (Answer E), or who has been treated for either syphilis or gonorrhea, is deferred for 12 months from completion of treatment or from day of presentation if treatment has not yet begun. If a donor has received a dura mater transplant or pituitary growth hormone (Answer A), they are indefnitely deferred. Body piercings are acceptable if they are performed with the use of sterile or single-use equipment. If there is any question on the use of sterile or single-use equipment, the donor must wait 12 months. A person who has had sexual contact with someone who has hemophilia and has used clotting factor concentrates is deferred for 12 months from the date of last sexual occurrence due to a theoretical risk of infectious disease transmission. A person who has had sexual contact with someone who has hemophilia and has not used clotting factor concentrates is acceptable (Answer C). However, the prostitute, as a person that has been given money, drugs, or other forms of payment is indefnitely deferred from donating blood (Tables 4. A donor has polycythemia rubra vera, a neoplastic disease of the bone marrow resulting in excess red blood cell production. Her physician would like her to undergo periodic therapeutic phlebotomy to prevent her hemoglobin from rising to life-threatening levels. The physician’s order indicates that the donor should present for phlebotomy once a month and should have one unit of blood drawn when her hemoglobin is greater than 15 g/dL. Yes, as long as she passes the donor history questionnaire, physical exam, and infectious disease testing C.
Both pre- and critical collateral vessel pathways is important in planning postductal varieties are easily distinguished from pseu- therapeutic options order pravachol overnight delivery. Most commonly purchase 10mg pravachol fast delivery, stenoses involve long docoarctation of the aorta purchase 20 mg pravachol overnight delivery, which is thought to be caused segments, are smooth, and ofen progress to occlusions; by congenital elongation and kinking of the aorta without however, vessel dilatation and aneurysm formation may a functional stenosis, and can result in a typical ‘reverse 3’ occur uncommonly. Arteritis may result in stenosis or occlusion of Angiographically, the Ueno classiﬁcation as modiﬁed by the aorta and branch vessels. Pathologically, the integrity of all layers of the aortic wall is maintained in true aneurysms, while there is disruption of one or more of these layers in false aneu- rysms. On aortography, injected contrast usually discloses a dilated lumen; however, dilation of the opaciﬁed lumen may be absent in those instances where mural thrombus is present. Secondary signs of mural thrombus include a smooth aortic wall and calciﬁcation peripheral to the Figure 4. The corrugated irregular conﬁgu- ration of the intima related to scarring and termed ‘tree barking’ is diﬃcult to visualize on angiography. Syphilitic aortic aneurysms have become exceedingly rare follow- ing the introduction of eﬀective antibiotic therapy. Traumatic injuries to the aorta or great vessels may be related to penetrating or blunt insults and result in false aneurysms conﬁned by periaortic sof tissues. In signiﬁcant deceleration injuries, most commonly related to high-speed motor vehicle accidents, laceration of the aorta may occur. Aortic injuries are most commonly seen at the level of the isthmus (90%), followed by the proximal ascending aorta (5%), and distal descending aorta near the diaphragmatic hiatus (1−2%). Atention must also be paid to the origins of the great vessels where injuries also occur, particularly in cases of sternal, clavicular and upper rib fractures. The extent of injury can range from an intimal tear to complete transection with false aneurysm formation. Traumatic pseudoaneurysms appear as oval, rounded or lobulated contrast collections projecting beyond the normal conﬁnes at the isthmus (Figure 4. Occasionally, a linear radiolucency within the false aneurysm which represents the intimal/medial ﬂap may be seen; demon- stration of active contrast extravasation is rare. It is as a sequel to syphilitic infection up to three decades distinguishable by smooth margins and obtuse angles at later. A characteristic ‘pencil thin line’ of mural calciﬁca- its junction with the aorta. In those few patients who survive an aortic false aneurysms, saccular, lobulated and prone to laceration which is undiagnosed, a saccular pseudoaneu- rupture . They may be found anywhere along the rysm with mural calciﬁcation may develop at the isthmus thoracic aorta – including the arch – and may involve sites [11,12] (Figure 4. Chest X-ray may show aorta, which consists of the opaciﬁed true and false lumens widening of the mediastinum, disparity between the size separated by a thin intimal ﬂap (Figure 4. Diﬀerential of the ascending and descending aorta, or displacement opaciﬁcation of the two lumens may occur, dependent of intimal calciﬁcation centrally. Branch vessels may appear exams may be limited by motion artifact and diﬃculty occluded. Typically, the overall aortic lumen is increased in evaluating the coronary arteries and great vessels for in size and the larger lumen is usually the false lumen. These limitations are, however, decreasing If the false lumen is thrombosed, the true aortic lumen may as newer generation equipment becomes more ubiqui- appear atenuated, ﬂatened or scalloped (Figure 4. It is par- there is a breach of the intima and media related to ticularly useful in patients with renal insuﬃciency. Symptomatically, they ofen are Aortography can be extremely valuable in assessing painful as a result of enlargement of the ulcer or intramu- for valvular insuﬃciency, extension into the coronary ral extension proximally or distally. Angiographically, arteries and great vessels and in evaluating the abdomi- they have a typical appearance when viewed in proﬁle nal aorta and visceral vessels when there are signs of as a focal protrusion from the expected conﬁnes of the mesenteric or renovascular insuﬃciency. Depending on the quality of peripheral pulses, may undermine the intima and media when dissecting a femoral artery approach from one or both groins is intramurally. Great care in advancing location, such as those localized to the arch or the dis- the guidewire should be taken; if it hangs up, the wire tal descending thoracic aorta, may actually originate as should be redirected by means of a steerable catheter. The three resolution, shortened examination times, lower injected types of aortic diverticula. Diverticula of Kommerell ing superior visualization of small vessels and the abil- and aberrant subclavian arteries complicated by aneurysms. Pulmonary artery involvement in aor- pathways – and therefore remains a very useful diagnos- toarteritis: an angiographic study. Am Heart J will continue to play an important role in evaluating and 1977; 93: 94−103. Clinical manifestations Acknowledgement of Takayasu arteritis in India and Japan–new classification of angiographic findings. For this reason, it is almost invariably the modality of mit imaging of the entire thoracic aorta during a single choice for imaging patients with trauma and all other emer- breath held in for only a few seconds. It can easily diﬀerentiate vascu- for imaging during multiple phases of contrast enhance- lar from non-vascular causes of acute and chronic disease. By sampling available as well but is semi-invasive and probably the most the enhancement of the aorta until a pre-set threshold of operator-dependent of the imaging modalities. Patients with contrast density is reached, imaging can be triggered to substantial maxillofacial injuries, severe coagulopathy, his- occur during peak arterial enhancement. It cannot image the entire to evaluate solid and hollow abdominal visceral perfusion, thoracic aorta as ‘blind spots’ exist in the distal ascending and late enhancing vascular structures. For example, slow aorta, portions of the arch and proximal descending aorta ﬂow in a false lumen of a dissection can be mistaken for . Patients with pacemakers and other paramagnetic erally suﬃcient for diagnosing most diseases and nor- devices cannot be imaged. Raw image data should be acquired and reconstructed Catheter-based aortography is invasive, costly and at the thinnest practical slices for optimal 3D reconstruc- not readily available at all times. This can be useful for beter deﬁning the relationship of intraluminal aortic pathology (e. When possible, injection of such as valve leaﬂets, coronary sinuses and vessels can be contrast material in the lef upper extremity should be imaged and evaluated with conﬁdence. Cardiac Other solutions include the use of diluted contrast mate- gating also allows for visualization of the proximal coro- rial or lower extremity injection, though neither is rou- nary arteries, a region of anatomy not previously avail- tinely employed at most institutions. This added information favored due to the sometimes unpredictable timing of the can greatly inﬂuence patient management, since a com- contrast bolus. Injection of contrast material followed by mon problem in patients with ascending aortic dissection a saline solution bolus allows for a reduction in contrast is extension into the coronary arteries. This practice has become achieved when cardiac gating is performed as part of an standard in cardiac imaging and is becoming more wide- evaluation for undiﬀerentiated chest pain. It should be liberally used to the ascending aorta results from a combination of aortic reduce motion artifact resulting from ventricular systole. The character- Routine use improves imaging and reduces the pitfalls istic appearance of this lef anterior, right posterior cur- that lead to misdiagnosis in the proximal aorta (root, vilinear artifact should be recognized. Pitfalls and pearls Normal enhancing periaortic vascular structures can simulate aortic pathology to untrained reader.
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