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By A. Tarok. Sterling College, Sterling Kansas. 2018.

The son also notes that for several years viagra vigour 800 mg cheap, his father has talked in his sleep and that he has “night- mares” almost every night buy viagra vigour 800mg overnight delivery. He is concerned that his father has “old-timer’s” disease, and he seeks your opinion. Which of the following statements regarding dementia with Lewy bodies (DLB) is true? The clinical presentation of DLB is identical to that of AD B. As with AD, the patient with DLB has no changes in level of arousal D. The rapid eye movement sleep behavior disorder (RBD) is highly spe- cific for DLB Key Concept/Objective: To know the clinical distinction of DLB and AD The term DLB is in vogue as a label for patients who have spontaneous (i. The cogni- tive disorder of DLB can closely resemble AD, but in many patients, there are some notable differences. These differences in DLB include a slightly less prominent deficit in learning and memory and more prominent difficulties with visuospatial functions, performance on timed tasks, and executive functions. The parkinsonism in DLB can range from a relative- ly isolated gait instability with frequent falling to a typical pattern of Parkinson disease 30 BOARD REVIEW with rest tremor, rigidity, bradykinesia, and postural instability. Patients with DLB often experience marked fluctuations in their alertness and level of arousal from one day to the next. In RBD, patients engage in dream enactment, thrashing about in bed or talking in their sleep. RBD can often precede the dementia and the move- ment disorder by years and is highly specific for DLB. A 72-year-old woman is referred to you for evaluation of 2 to 3 years of gradual memory loss. Although she clearly has significant difficulties with memory and slowed speech, she seems surprisingly apathetic toward her condition. She has hypertension and mild osteopenia but is otherwise healthy; she has no history of head trauma. Her Mini- Mental State Exam (MMSE) score is 21/30; her neurologic exam is normal. Laboratory evaluation for other causes of dementia is negative. Which of the following is the most appropriate diagnosis for this patient? Polypharmacy Key Concept/Objective: To know the diagnostic criteria for Alzheimer disease This patient has at least two areas of cognitive dysfunction (memory and speech), con- firmed by neuropsychological testing. She has no evidence of other disorders, such as the motor dysfunction expected with progressive supranuclear palsy or the ataxia and incon- tinence associated with normal-pressure hydrocephalus. It is unlikely that a low dose of hydrochlorothiazide would be responsible for significant cognitive dysfunction, particu- larly in the absence of laboratory abnormalities. The patient meets criteria for probable Alzheimer disease.

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If these are abnormal 800 mg viagra vigour with mastercard, you should then also assess for accommodation order viagra vigour 800mg with amex. By using the “swinging penlight” test in assessing the response to light, afferent defects—in which the consensual response is more pronounced than the direct response—are more easily detected. This method is performed by holding the light source in front of the patient, so that it is directed toward one eye. At this point, observe both pupils, noting the direct response of the eye receiving the direct light and the consen- sual response in the opposite eye. Leave your attention on the opposite eye, continuing to note the consensual response as you briskly swing the light source in the direction of this eye. Note whether the pupil response is a slight constriction, slightly more pronounced with direct light as is normal, or the pupil slightly relaxes, so that the response is slightly less pro- nounced with direct light, which is an abnormal, Marcus Gunn effect. Then observe the oppo- site eye, swinging the light back to that eye as you note any change between the indirect and direct responses. In some optic nerve disorders, such as ischemic optic neuropathy or optic neuritis, as well as other conditions that affect the pathway anterior to the optic chiasm, this afferent defect may be the only objective finding. Associated with ptosis, and appearance that eye is “sunken” on affected side, with lack of sweating on opposite side. Benign anisocoria Some asymmetry of the pupil size is considered normal if the difference is 0. Argyll Robertson pupils The pupil is small and may have an abnormal shape. Although the pupil does not respond to light, it exhibits a brisk response to accommodation (near vision). Tonic pupil No response to light (direct or consensual). Caused by denervation of the ciliary muscle and sphincter. DIFFERENTIAL DIAGNOSIS OF CHIEF COMPLAINTS Visual Disturbances Visual disturbances include a wide range of complaints, including blurred vision, loss of vision, blind spots, and altered color perception. When the patient presents with altered vision as the chief complaint, it is crucial to be alert for indications of potential irreversible loss of vision. Most important is the complaint of a sudden loss of vision, regardless of whether the disturbance is partial or complete and whether or not it is accompanied by pain. Altered vision can refer to decreased vision where there is a decreased visual acuity, with- out loss of partial or full visual field. This is a common complaint and, with age, is associ- ated with the development of cataracts. It can also be associated with relatively benign refractive errors or with hyperglycemia and diabetes, macular degeneration, or glaucoma. In contrast, the loss of vision—whether limited to a specific visual field or area, one eye, or both eyes—is typically indicative of a very significant health problem and one that may result in permanent visual loss and disability.

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Hypnotic medications should not be used for chronic insomnia purchase 800mg viagra vigour visa. The best treatment for patients with chronic insomnia consists of a combination of sleep-hygiene measures (e purchase viagra vigour 800mg otc. Sedative-antidepres- sants should be used for insomnia associated with depression. Melatonin has been found to be useful in some persons with jet lag and shift-work sleep disorders and in patients with non–24-hour circadian rhythm disorders. A 53-year-old man who is otherwise healthy presents with excessive daytime somnolence. The patient has been increasingly fatigued during the day for the past several years and is now experiencing an over- whelming need for a nap during the day. He does not feel refreshed upon awakening in the morning. He sleeps alone and has no unusual awakenings during the night. What should be the next step in the management of this patient’s condition? Referral to an ENT specialist for uvulopalatopharyngoplasty B. Weight loss Key Concept/Objective: To understand the treatment approaches for a patient suspected of hav- ing obstructive sleep apnea syndrome (OSAS) This patient has excessive daytime somnolence. This may result from decreased sleep quantity, OSAS, narcolepsy, or sleep disturbance caused by restless leg syndrome. Excessive daytime somnolence caused by OSAS is commonly associated with an airway obstruction. Respiration may be disturbed during normal sleep because of an increase in upper airway resistance. This increase occurs as a result of the loss of muscle tone in the upper airways during sleep. Ventilatory responses are also decreased during sleep. Although excessive body weight is a risk factor for OSAS, approximately 30% of patients who have OSAS have normal body weight. For the decrease in respiration to be considered pathologic, the sleep apnea or hypopnea must last for at least 10 seconds, and these episodes must occur at a rate of at least five times per hour of sleep. The diagnosis is suggested by the patient’s history and is confirmed by sleep study. A 52-year-old man presents with fatigue that has been increasing for the past 9 months. He describes an inability to stay awake during the midafternoon hours. He has symptoms of mild benign prostatic hyper- plasia with 2 awakenings during the night to urinate.

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