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Assessment: Pain in the medial joint cavity suggests meniscus dam- age (usually a lesion of the posterior horn) purchase 250mg keppra with amex. Moving the knee back and forth causes the injured portion of the meniscus to be drawn into the joint and then spring back out with a snap when the joint cavity is distended. With the knee maximally flexed, the lower leg is externally rotated as far as possible. Then with the knee in slight adduction (varus stress), the leg is flexed further in the direction of the contralateral hip. Assessment: Pain in the posterior medial joint cavity suggests damage to the medial meniscus (most often the posterior horn is involved, which is compressed by this maneuver). The posterior horn of the lateral meniscus can be similarly examined with the knee internally rotated and abducted (valgus stress). The examiner then forcefully rotates the lower leg in various degrees of knee flexion. Assessment: Pain in the medial joint cavity in forced external rotation suggests damage to the medial meniscus; pain in the lateral joint cavity in internal rotation suggests damage to the lateral meniscus. Because the localization of the tear can vary, the test for the Steinmann I sign should be performed with the knee in varying degrees of flexion. The tenderness to palpation in the joint cavity migrates medially and posteriorly during flexion and slight external rotation of the knee; it then migrates back anteriorly as the knee is extended. Where a meniscus injury is suspected and the lower leg is placed in internal rotation, the tenderness to palpation will migrate anteriorly as the knee is extended and posteriorly as it is flexed. Note: Although this test can also be used for an injury to the lateral meniscus, its primary purpose is to help evaluate medial meniscus lesions.
Spas- livery (nitroglycerin patch) also avoids modic constriction of larger coronary presystemic elimination order keppra 250mg visa. Organic nitrates are used through membranes, is more stable chiefly in angina pectoris (p. ISDN Continuous intake of higher doses with can also be applied sublingually; how- maintenance of steady plasma levels ever, it is mainly administered orally in leads to loss of efficacy, inasmuch as the order to achieve a prolonged effect. This “nitrate tolerance” can because of its higher polarity and slower be avoided if a daily “nitrate-free inter- rate of absorption. Af- of a throbbing headache, probably ter oral intake, it is slowly converted caused by dilation of cephalic vessels. Apparently, This effect also exhibits tolerance, even there is little likelihood of "nitrate tole- when daily “nitrate pauses” are kept. Excessive dosages give rise to hypoten- Sodium nitroprusside contains a sion, reflex tachycardia, and circulatory nitroso (-NO) group, but is not an ester. It is administered by infusion to tion in vascular smooth muscle tone is achieve controlled hypotension under presumably due to activation of guany- continuous close monitoring. Cyanide late cyclase and elevation of cyclic GMP ions liberated from nitroprusside can be levels. The causative agent is most likely inactivated with sodium thiosulfate nitric oxide (NO) generated from the or- (Na2S2O3) (p. NO is a physiological mes- senger molecule that endothelial cells release onto subjacent smooth muscle cells (“endothelium-derived relaxing factor,” EDRF). Organic nitrates would thus utilize a pre-existing pathway, hence their high efficacy. The genera- tion of NO within the smooth muscle cell depends on a supply of free sulfhy- dryl (-SH) groups; “nitrate-tolerance” Lüllmann, Color Atlas of Pharmacology © 2000 Thieme All rights reserved. Vasodilators 121 Preload Afterload O2-supply O2-demand Blood pressure Venous blood return Prevention of Peripheral to heart coronary artery resistance spasm Venous bed “Nitrate- Arterial bed tolerance” Route: Route: e. Vasodilators: Nitrates Lüllmann, Color Atlas of Pharmacology © 2000 Thieme All rights reserved.