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Examples of the angles are the retentive features G-A and I-A for the gingivoaxial and incisoaxial line angles buy toprol xl 50mg free shipping hypertension values, respectively purchase cheap toprol xl on line blood pressure 8660. Key for the facial approach (C): F cheap toprol xl 50mg visa blood pressure and pregnancy, facial; A cheap toprol xl 50mg on-line blood pressure chart on age, axial (blue); G, gingival; L, lingual. However, the more patient’s concern for esthetics are important factors conservative method of affording retention and reduc- when deciding whether or not to restore the tooth. These two portions may join at an angle called occurs when the tooth corner fractures off due to a blow the axiogingival line angle. The loss of an incisal angle is plainly vis- A composite restoration that restores one incisal ible upon clinical examination. An alternative as always, must be analyzed to be sure that there is treatment is a veneer of porcelain bonded to the facial room for the restoration when the patient chews and surface of the tooth, replacing the fractured incisal area incises, especially in a protrusive direction. If the preparation is most commonly achieved by acid-etch techniques that permit resin tags to bond the composite to the tooth. A thin overlapping sleeve of excess composite mate- rial can cover beveled enamel that has been acid etched to maximize retention (Fig. View of the lesion showing the of curvature, adjacent to the gingiva, where the natural gingival and axial portions of the defect. After smoothing the cleansing action of the lips, tongue, and cheeks is inef- preparation and acid etching the enamel, the restored tooth with a sleeve (thin layer of bonded resin) that overlaps the fective. This area of the tooth is susceptible to plaque etched enamel surface, thus establishing maximum retention accumulation and resultant caries. Incipient (beginning) facial lesion that is seen as chalky and discolored and is flaking away. An obvious cavitated class V facial lesion that has destroyed much of the enamel on the buccal surface of the crown and adjacent cementum and dentin of the root. Class V demineralization: a chalky white area (arrows) seen in the cervical third of a maxillary lateral incisor with incisal wear is evidence of the first stages of dental caries. If this demineralization continued and did not reverse itself (through excellent oral hygiene, diet, and use of topical fluoride), this area could develop a cavitation (hole) that would need to be restored. Also, notice the inflammation of the adjacent gingiva (gingivitis), which is also caused by bacterial plaque. As with a radiograph of a class I lesion, the class V With decreased salivary flow and/or poor oral hygiene, lesion is superimposed over buccal or lingual surfaces the incidence and severity of caries increase in this area of enamel that show up whiter (radiopaque), thereby (Fig. As a class V lesion begins to form, it appears as a By the time a class V lesion is evident on radiographs, chalky white or stained surface (Fig. In these it has progressed far beyond the incipient stage and beginning (incipient) lesions, care should be taken with will require a much larger restoration than would have the explorer not to break through an area of beginning been required if it were clinically diagnosed at its earli- demineralization that has not yet cavitated since excel- est stages. Therefore, the examiner should not depend lent oral hygiene and fluoride have been shown to on radiographs for detection of these lesions. These lesions may be hid- when discovering a cervically located radiolucency den slightly apical to the level of inflamed gingiva so on a radiograph, the dentist should carefully evaluate that the use of the tactile sense obtained through the the tooth to clinically prove or disprove the presence explorer is critical for detection of cavitation9 and for distinction between these lesions (which are cavitated) and a calcified buildup of calculus (which is felt as a bump attached to the surface of the tooth). Other areas of cavitation (or depressions) located in the cervical of the crown and the adjacent root sur- face include defects formed from erosion by acids, or from abrasion (most commonly caused by abrasive toothpastes and improper tooth brushing [as seen in Fig. Maxillary anterior teeth showing cervical sion, the cementum, which is much less mineralized abrasion, possibly due to poor tooth brushing technique and than enamel, is more susceptible to caries compared abrasive pastes. Each tooth should be evaluated carefully to is occurring more frequently in our aging population determine if application of a desensitizing solution or a (Fig. Chapter 10 | Treating Decayed, Broken, and Missing Teeth 315 decay could respond to fluoride and improved oral hygiene and actually remineralize so that no restoration is required. Also, these defects could be areas of arrested (old, inactive) decay, or noncarious cavitated defects due to abrasion, erosion, or abfraction. Class V lesions require restorations when tooth structure is soft or cavi- tated (as seen in Fig. Restorations should also be considered to protect noncarious defects (like abra- sion defects) that occur in this part of the tooth if the tooth is sensitive and does not respond to desensitizing agents, if the lesion is very deep and cannot be kept clean, or if it appears that it will continue to advance due to poor oral hygiene or parafunctional habits. Root caries (arrow) on an area of exposed consists of five walls: distal, occlusal, mesial, gingival, cementum after gingival recession. These preparations have eight line angles: axiomesial, axiogingival, axiodistal, axio-occlusal, of class V caries. Darker (radiolucent) areas of cervical mesiogingival, distogingival, mesio-occlusal, and disto- abrasion, as well as older types of radiolucent restor- occlusal. The axio-occlusal and axiogingival line angles ative materials, can appear like class V or root surface are prepared with retentive grooves labeled as A-O and caries on radiographs. Not all areas at the cervical of the tooth that are white For example, a buccal amalgam on tooth No. Typically, the term facial (F) is applied to anterior teeth, whereas buccal (B) is applied to posterior teeth. In gingival abrasion lesions and areas of root caries, the dentist may restore the tooth with a glass ionomer or resin-modified glass ionomer because they both bond to dentin and contain fluoride. In rare cases, primarily at the patient’s request, a cast metal inlay (or porcelain inlay) could be used to replace lost tooth contour. The preparation for a class V composite restora- tion is usually kept as conservative as possible (Fig. Prevention of future caries occurs through patient cent (dark looking on the radiograph) composite restoration. Key for nomenclature: O, occlusal; M, mesial; A, axial (blue); D, distal; G, gingival. When defined as the cavity or defect found on the tips of cusps using composite, similar retentive grooves could be 9 or along the incisal edges of incisors. If the shade of the material is excellent, these restorations are difficult to detect, and their surface grittiness felt by a dental instrument might be confused for incipient calculus formation. This with a conservative restoration and only a thin shell of restoration is called a cast post and core (Fig. To prepare a tooth for and filling around which a complete crown can be a complete crown, the previously restored anatomic constructed. When the remaining tooth crown ally extends gingivally beyond the core filling material, is almost completely gone, a cast metal core (resembling so that the crown margins end on sound tooth struc- a tooth prepared to receive a crown) must be designed ture. Full cast metal crown preparations end at the gin- with a metal post, which fits snugly into one of the gival cavosurface with a rounded shape called a chamfer previously endodontically treated and prepared root (Figs. The visible portion of a post and core is the core that can be seen forming the missing part of the crown preparation. The post can be seen on this radiograph extending well down within the root to provide retention for the crown that will be placed A B over the post and core. This restoration is called a metal ceramic restoration (also called a porcelain fused to metal crown) and is seen on tooth No.
Within the stent generic 100mg toprol xl amex arrhythmia effects, beam hardening artifacts depend on the individual stent structure and may look like repeated dark spots inside the stent lumen (arrows in Panel C ) purchase 50 mg toprol xl overnight delivery hypertension natural remedies. They preclude rule-out of in-stent restenosis in this 56-year-old male patient purchase toprol xl in india arrhythmia alcohol, which thus had to be excluded by conventional coronary angiography generic toprol xl 50 mg overnight delivery blood pressure danger zone. The corresponding angiogram in Panel D shows only mild focal wasting (arrow) but no relevant stenosis mainly caused by partial volume effects. Whenever a voxel way above those of body tissue and – in the window- includes two different densities (e. The improved resolution shows greater detail, but also increases noise (Panel A), whereas there is pronounced blooming and reduced lumen visibility with thicker slices (Panel B). Both datasets were reconstructed at a slice increment equal to two thirds of the slice thickness (0. One of reminded that a scanner’s temporal resolution is best 13 the most bothersome effects of blooming is artificial at the center of the scan feld since the infuence of the lumen narrowing. There is a smooth impression, but reduced stent lumen visibility using the soft kernel (Panel A) compared to the grainy appearance (higher image noise) of the sharper kernel in Panel B, which however allows better in-stent lumen assessment. The recommended reconstruction fltering or iteration loops, smoothing algorithms will kernels for the evaluation of coronary artery stents are decrease and edge-enhancing flters will enhance back- frequently identical to those used in the presence of ground image noise. Of course, standard deviation as a surrogate of image noise shows higher values in Panel B In addition, reconstruction algorithms may contain impression of our images deviates from what we are used corrections for local artifacts such as beam hardening or to and deteriorates again (Fig. False-high in-stent densities can be reduced by which may contain low-density sof tissue, e. However, whenever wishes have to be put into standard reconstruction algorithms, iterative recon- practice, some trade-ofs arise. At present, it is impossi- struction algorithms perform repeated calculations from ble to provide all of the above at once. Interactive multiplanar reading and curved struction can be overdone as well: as the number of itera- multi-planar reformation using thin-slice isotropic data- tion loops is increased (5 or more), the more the visual sets are recommended for evaluation of the stent lumen. Note the reduction in overall image noise, whereas adequate delinea- tion of the stent is preserved. One might suspect in- stent intimal hyperplasia within the proximal two thirds of the stent in Panel C. Pﬂederer, Erlangen) Maximum-intensity projections or three-dimensional 400/50) cannot be used. Attention should be paid Whereas earlier studies used a 700/200 or 1,000/200 win- to the window-level settings in reading stents. In order to dow-level setting, recent recommendations derived from not obscure vessel wall calcifcations and overestimate ves- phantom studies advise to go up to 1,500/300 for stent sel dimensions in case of high attenuation, standard medi- reading. No blooming and Slice thickness and matrix are subject to technical Use the thinnest detector collimation available, and try no artiﬁcial lumen limitations. We cannot go thinner than current detector to adapt X-ray input and image reconstruction (see narrowing elements. Noise in just air (electronic noise); and in humans, the amount of the ﬁnal image is also determined by the reconstruction photons cannot be deliberately increased. The demand for algorithm used, and here, unfortunately, noise and detailed images requires noisy reconstruction algorithms detail increase or decrease conjointly when using standard weighted ﬁltered back projection. If the presence of artifacts cannot be small stents, which are mainly due to insufcient spatial ruled out, the in-stent lumen becomes nondiagnostic resolution. Interestingly, the presence of tomatic individuals, whereas the beneft remains uncer- contrast agent within a distal vessel segment does not tain in symptomatic patients. First clinical studies rule out in-stent stenosis or even occlusion because of investigating image quality with use of iterative recon- possible collaterals. Yet further and larger studies will have to determine whether current recommendations need to be revised. Asymptomatic patients (if not part of an approved Whereas 16- and 64-row in-vitro data suggested study protocol) improved visualization of coronary artery stent lumen, 2. Patients with elevated heart rate and contraindica- single-center clinical trials, between 13 % and 51 % (16- tions to beta blockers (see Chap. In Panel B with 1,000/200, the increase in window width reduces blooming, but is still insuﬃcient to adequately visualize the in-stent lumen. In Panel C with 1,500/300, which is a reasonable trade-oﬀ, blooming is greatly reduced while vessel contrast is maintained. In Panel D with 1,700/650, window values are shifted closer towards “bone-window”-like settings. Here, blooming becomes less signiﬁcant but vessel contrast and the ability to depict noncalciﬁed plaque decreases considerably. In this case multiple black streaks, most likely artifacts caused by the stent struts, cross the lumen, making it uninterpretable (arrows in Panel A). Thus, conventional coronary angiography had to be performed to rule out signiﬁcant in-stent restenosis (Panel B). No signiﬁcant stenosis is present in the corresponding conventional coronary angiogram (Panel D ) (Images courtesy of S. Signiﬁcant stenosis is correctly ruled out (Panel A) using a curved multiplanar reformation along the left main and left anterior descending coronary artery in a 62-year- old female patient presenting with atypical angina pectoris. Absence of signiﬁcant left main in-stent stenosis is conﬁrmed on conven- tional coronary angiography (Panel B ). True-positive signiﬁcant in-stent restenosis in a proximal left anterior descending coronary artery stent in a 60-year-old male patient presenting with typical angina (Panel C). This curved multiplanar reformation along this proximal left anterior descending coronary artery stent with ﬁlling defects is suggestive of relevant in-stent stenosis (arrow). The corresponding con- ventional coronary angiogram in Panel D conﬁrms this diagnosis (arrow, 65 % diameter stenosis on quantitative coronary angiography) (Conventional angiograms courtesy of S. However, inherent to f at-panel detector use with its smaller detector elements is a pronounced increase in image noise, which would have to be compensated for by raising X-ray input. Furthermore, currently available fat-panel scanners still have a rather long gantry rotation time and comparably slow data read-out and are of limited use for in-vivo car- diac examinations in clinical routine but might become a valuable alternative in the future. Note the platinum markers indicating the dis- An exciting alternative to current metal struts is the use tal edges of the stent (arrowheads). Metal Stents) Investigators et al (2007) Temporary scafolding of 211 13 Recommended Reading coronary arteries with bioabsorbable magnesium stents: a prospec- Schepis T, Koepfi P, Leschka S et al (2007) Coronary artery stent tive, non-randomised multicentre trial. Eur Radiol 17:1464–1473 Diagnostic accuracy of in-stent coronary restenosis detection with Schlosser T, Scheuermann T, Ulzheimer S et al (2007) In vitro evaluation multislice spiral computed tomography: a meta-analysis. Invest Radiol 42:536–541 ography for coronary artery stent assessment: in vitro experience. Invest Radiol 40:8–13 the assessment of coronary in-stent restenosis: a systematic review. J Am Coll Cardiol 48:2423–2431 eluting stent with a standard stent for coronary revascularization. However, none coronary artery wall before luminal narrowing devel- of the current invasive or noninvasive imaging modali- ops. In symptomatic patients with suspected luminal ties can reliably identify vulnerable lesions. It is likely that stenosis, identiﬁcation and characterization of nonob- such imaging will require molecular or genetic markers structive plaque provides prognostic data incremental of lesion biology beyond simple anatomy.
Although many psychopathic individuals run into trouble with authorities discount 25 mg toprol xl with amex blood pressure tea, some are quite adept at evading accountability for the damage they do to others buy toprol xl 100mg with visa blood pressure medication olmetec side effects. Once referred to as having “moral insanity” (Prichard order toprol xl uk prehypertension young, 1835) order toprol xl online from canada heart attack 18 year old male, individuals with psychopathic personalities are commonly found in the borderline to the psychotic range of severity (Gacano & Meloy, 1994). Deutsch’s (1955) classic concept of the “impostor” fits within the psy- chopathic realm. Although the stereotype of antisocial personality involves aggression and violence, clinical writings over many decades (beginning with Henderson, 1939) have also noted more passive, parasitic versions of psychopathy, such as the person who operates a scam or Ponzi scheme within a relational matrix. Psychopathic people feel anxiety less frequently and intensely than others (Ogloff & Wong, 1990; Zuckerman, 1999). People with diagnosed antisocial personality dis- order have a higher-than-normal craving for stimulation and may seek it addictively (Raine, Venables, & Williams, 1990; Vitacco & Rogers, 2001). Psychopathic individ- uals lack the empathy and the moral center of gravity that, in people of other person- ality types, tames the striving for power and directs it toward socially valuable ends. Psychopathic individuals may be charming and even charismatic, and they may read others’ emotional states with great accuracy (Dolan & Fullam, 2004). They may be hyperacutely aware of their surroundings, but think and act from a self-referential stance and for egoistic purposes. Their own emotional life tends to be impoverished, and their expressed affect is often insincere and intended to manipulate. Their affec- tive connection to others is minimal; they typically lose interest in people they see as no longer useful. Their indifference to the feelings and needs of others, including their char- acteristic lack of remorse after harming others, may reflect a grave disorder of early attachment. Neglect, abuse, addiction, chaotic undependability in caregivers, and pro- foundly bad fits between a child’s temperament and those of responsible adults have been associated with later psychopathy, but there also appear to be temperamental contributing factors. Therapists working with psychopathic individuals may find themselves feeling initially charmed and then deeply disturbed. They lack the usual sense of emotional connection and may find themselves feeling uncharacteristically apprehensive, jittery, or even “under the thumb” of their psychopathic patients—all countertransferences that are highly informative. Recent empirical studies have identified clinicians’ emo- tional reactions of being criticized and overwhelmed while working with psychopathic patients (Colli et al. Any known history of violence in a patient that coexists with these distressing emotional reactions should impel a thera- pist to give first consideration to issues of his or her own safety. Personality Syndromes—P Axis 51 Treatment in which therapists persistently try to reach out sympathetically may come to grief with psychopathic patients, who regard kindness as signs of weakness. It is possible, however, to have a therapeutic influence on many psychopathic individu- als if their clinicians convey a powerful presence, behave with scrupulous integrity, and recognize that these patients’ motivations revolve primarily around the desire for power. The prospects for any therapeutic influence are better if a psychopathic indi- vidual has reached midlife or later, and has thus felt a decline in physical power and encountered limits to omnipotent strivings. Sadistic Personalities Sadistic personality organization is found mainly at the borderline or psychotic level and is organized around the theme of domination. Internally, the sadistic person may experience deadness and affective sterility, which are relieved by inflicting pain and humiliation—in fantasy and often in reality. Yet, despite the fact that sadism and psy- chopathy are highly related (Holt, Meloy, & Strack, 1999), they are not identical. Not all psychopathic people are notably sadistic, nor are all sadistic people psycho- pathic. Except for studies of criminal sexual sadism, there has been very little empirical research on sadistic personality patterns or disorders. Sadistic individuals are seen mainly in forensic settings, in which professionals may confront numerous people whose over- riding motivation involves controlling, subjugating, and forcing pain and humiliation on others. Meloy (1997) cites the man who smiles broadly and shamelessly while recounting his battering of his wife, and the child “who does not angrily kick a pet, but instead tortures animals with detached pleasure” (p. Although many people strike out when they feel provoked or attacked, sadistic people tend to inflict their tortures with a dispassionate calm (perhaps originally a defense against being overwhelmed by rage). Thus forensic scientists distinguish between “affective” (catathymic) and “predatory” violence (e. The hallmark of sadism is the emotional detachment or guiltless enthusiasm with which domination and control are pursued. This detachment, which may include the systematic, step- by-step preparation of a sadistic scenario, has the effect (and probably expresses the intent) of dehumanizing the other (Bollas, 1995). Although it is likely that all individu- als with sadistic personality disorder are sadistic in their preferred expressions of sexu- ality, many people whose sexual fantasies or enactments involve sadistic themes are not sadistic generally and so cannot be considered to have the personality syndrome. Professionals interviewing sadistic individuals typically report feelings of visceral disturbance, vague uneasiness, intimidation, “creepiness,” and being overwhelmed by strong negative feelings. Meloy (1997) mentions goose bumps, the feeling of one’s hair standing on end, and other atavistic reactions to a predator–prey situation. Because sadistic individuals are mendacious (Stone, 1993) and may enjoy tormenting their interviewers by lying or by withholding verbal descriptions of their sadistic preoccu- pations, such countertransferences may be a prime indication of underlying sadism. A therapist should always take seriously disturbing reactions of this sort, as indicating the need for more thorough assessment and a treatment plan that takes into account the person’s possible dangerousness. Stone (1993, 2009), who has carefully analyzed biographical accounts of murderers, considers the sadistic individuals he has studied to be beyond the reach of therapy. The attachment deficit manifested by treating other beings as objects to toy with rather than subjects to respect may preclude developing the capacity for a therapeutic alli- ance. In addition, the pleasure in sadistic acts, especially orgiastic pleasure in sexual sadism, may be so reinforcing that efforts to reduce the sadistic pattern are futile. Still, accurate diagnosis of sadistic personality has significant implications for making recommendations to judicial officers, reducing opportunities for harm, helping people affected by sadistic persons, and allocating resources realistically. Characteristic pathogenic belief about self: “I am entitled to hurt and humiliate others. In attachment research, scholars have identified a relevant disorganized/disori- ented or “type D” insecure attachment style (e. This pat- tern is characterized by chronic, long-term difficulties in tolerating and regulating affect, and involves regarding attachment figures (such as therapists) as both objects of safety and objects of fear, causing them to be treated with confusing combinations of desperate clinging, hostile attack, and dissociative-like states of detachment. Neuro- scientific research (Fertuck, Lenzenweger, Hoermann, & Stanley, 2006; van der Kolk, 2003) indicates that early trauma can damage the capacities for executive control (and thus affective regulation). Efforts to understand the psychologies of people with borderline personalities span decades and have been undertaken from many perspectives. Scholars have viewed borderline personality in terms of reliance on splitting, projective identification, and other highly costly defenses (Kernberg, 1967, 1984); problems in psychiatric management (Gunderson & Singer, 1975; Main, 1957; Skodol, Gunderson, et al. In regard to etiology, there is evidence for a genetic vulnerability (Kernberg & Caligor, 2005; Paris, 1993; Siever & Davis, 1991; Stone, 1980; Torgersen, 2000), for origins in an early attachment disorder (Guidano & Liotti, 1983), for developmen- tal arrest (Bateman & Fonagy, 2004; Fonagy et al. Individuals with border- line personality disorder are notoriously difficult patients, partly because they may challenge ordinary therapeutic limits and evoke intense countertransference reactions, and partly because they require modification of the treatment models in which many therapists are trained. Patients with borderline personality disorder feel emotions that easily spiral out of control and reach extremes of intensity, compromising their capacity for adaptive functioning. They tend to catastrophize, and they consequently require the presence of another person to help regulate their affect and be soothed. When the relationship with this other person becomes closer, however, they feel easily controlled or engulfed, and at the same time feel a deep fear of being rejected and abandoned.
Approach to the Diagnosis The clinical picture will help to determine the diagnosis in many cases purchase toprol xl 25mg otc blood pressure ranges for infants. For example generic toprol xl 25mg online blood pressure chart low bp, a neck mass with hemoptysis suggests carcinoma of the lung with metastasis to the lymph node cheap 50 mg toprol xl arteria radialis. If the mass increases in size after swallowing food or liquid purchase on line toprol xl blood pressure medication video, an esophageal diverticulum is likely. If the mass is suspected to be an enlarged lymph node, exploration and biopsy may be appropriate. One can 616 now see that the diagnostic workup can be developed by visualizing the anatomy of the area. First, the anatomic components are distinguished, then the various etiologies are 618 applied to each (Table 48). Moving from the skin to the spinal cord layer by layer, we encounter the fascia, muscles, arteries, veins, brachial and cervical plexus, and lymph nodes. Finally, there is the cervical spine encircling the spinal cord and meninges and designed to allow uninfringed exit of the cervical nerve roots. The skin may be involved by herpes zoster, cellulitis, contusions, and lacerations. In the muscle and fascia, one encounters fibromyositis, dermatomyositis, and trichinosis as well as traumatic contusions and pulled or torn ligaments (strains). Remember Ludwig angina, which is a painful swelling under the chin caused by the spread of a dental abscess to the neck! The muscles may be involved by tension headache, poor posture, and occasionally by epidemic myalgia. Torticollis causes painful spasms, but the jerking of the neck makes the condition obvious. Table 48 Neck Pain The arteries of the neck are infrequently tender or painful as are most aneurysms (aside from dissecting aneurysms) unless they compress 619 adjacent structures. Arteritis is unusual here, but a common carotid thrombosis may be tender and painful. As with the arteries, it is rare for the jugular veins and smaller veins of the neck to cause pain by thrombosis or rupture; however, it occasionally happens in superior vena cava obstruction. They are usually enlarged and tender in association with pharyngitis, otitis media, sinusitis, dental abscesses, and mediastinitis. The brachial plexus may be involved by a primary neuritis or by compression from a scalenus anticus syndrome, a Pancoast tumor, the clavicle (costoclavicular) syndrome, or a cervical rib. More often, the roots are compressed by diseases of the spine, such as a herniated disk, fracture, cervical spondylosis, tuberculous or nontuberculous osteomyelitis, and primary or metastatic tumors of the spine and spinal cord. In the case of the spinal cord, one should also remember the meninges as a cause of neck pain in meningitis, arachnoiditis, and subarachnoid hemorrhage. The esophagus is not usually a cause of neck pain, but pain may be referred to the neck from a hiatal hernia or subdiaphragmatic abscess. Pulsion diverticula of the esophagus may also compress adjacent structures and cause painful symptoms. Like the esophagus, the trachea is an infrequent source of neck pain, but occasionally acute laryngotracheitis will be the source of severe pain. Finally, subacute thyroiditis and inflammatory or obstructive lesions of the salivary glands may be the offenders in neck pain, even though the patient complains of a sore throat. Approach to the Diagnosis The patient who presents with neck pain most commonly has a cervical sprain or muscle contraction headache. However, we must rule out more serious pathology such as meningitis, subarachnoid hemorrhage, herniated disks, and neoplasms before we send the patient home with a collar and a bag of pills. This means checking for nuchal rigidity, doing a thorough neurologic examination, and checking for a thyroid or lymph node mass. If the neurologic examination is abnormal, referral to a neurologist or a neurosurgeon is indicated before ordering expensive diagnostic tests. If the neurologic examination is normal and there are no neck masses or other significant findings, conservative treatment may be initiated without ordering expensive diagnostic tests. However, most physicians consider it 620 wise to at least do plain films of the cervical spine. Careful and close follow-up is necessary so that something serious is not missed in these cases. Always keep in mind that the pain may be referred from the heart, lungs, esophagus, or gallbladder. Bone scan (osteomyelitis, metastasis, small fractures) Case Presentation #69 A 45-year-old Filipino female nurse complained of pain in the neck that began after turning a patient over in bed. Neurologic examination revealed loss of sensation to touch, pain in the right thumb, and diminished right biceps reflex. I—Inflammation prompts the recall of nightmares associated with systemic infections, and intoxication brings to mind the nightmares due to alcohol and drugs such as the benzodiazepines. Alcohol- or drug-induced nightmares may be diagnosed by the history and a drug screen. The history should also be useful in cases of head injury, especially when questioning the family or closely associated persons. If epilepsy is suspected, a wake-and-sleep electroencephalogram should be ordered; a trial of anticonvulsants may be necessary to rule out epilepsy. A pathophysiologic analysis of the symptoms would indicate that the patient is producing excessive urine at night, there is an obstruction to the output of urine so that the bladder cannot be emptied fully on one voiding, or there is an irritative focus in the urinary tract stimulating the patient to urinate more frequently. Excessive urine production at night: This category includes all the causes of polyuria: diabetes insipidus, diabetes mellitus, hyperthyroidism, diuretic drugs, nephrogenic diabetes insipidus, and chronic nephritis. In addition, the one condition that produces excessive urine output almost exclusively at night—congestive heart failure—must be considered. In heart failure, edema accumulates in the extremities during the day while the patient is in the upright position and is returned to the circulation and poured out through the kidneys at night while the patient is in the 622 recumbent position. Obstructive uropathy: Bladder neck obstruction by a calculus, enlarged or inflamed prostate, median bar hypertrophy, or urethral stricture is a condition to consider here. Neurogenic bladder from poliomyelitis, multiple sclerosis, and other spinal cord diseases must also be considered. Irritative focus in the urinary tract: Nocturia may result from inflammation of the bladder, prostate, urethra, and kidney on this basis. Inflammation of the vagina, fallopian tubes, and rectum are also occasionally responsible. Approach to the Diagnosis The workup of nocturia is essentially the same as the workup of polyuria and urinary frequency (see page 345). Venous pressure, circulation time, and pulmonary function studies to rule out congestive heart failure should be done if the urinary tract is clean. I—Inflammation prompts the recall of disorders that destroy the palate such as syphilis, leprosy, and tuberculosis. N—Neurologic disorders that paralyze the palate include poliomyelitis, Guillain–Barré syndrome, pseudobulbar palsy, brainstem tumors, and myasthenia gravis. T—Trauma should make one suspect palatal fenestration from gunshot wounds or surgery, posttonsillectomy weakness, and trauma to the brain stem.