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However erectile dysfunction causes mnemonic purchase 80mg super levitra visa, in both conditions impotence at 18 generic super levitra 80 mg, a detailed history will indicate that the evolution of symptoms was gradual; if it was saltatory erectile dysfunction treatment by acupuncture purchase super levitra with a mastercard, seizures will usually have occurred erectile dysfunction doctors knoxville tn buy discount super levitra. The chest film frequently discloses a primary or secondary tumor, and an increased blood sedimentation rate suggests that a concealed systemic disease process is at hand. A lack of detailed history may also be responsible for the opposite diagnostic error, i. Dementia of the Alzheimer type is often ascribed, on insufficient and conceptually incorrect grounds, to the occurrence of multiple small strokes. If vascular lesions are responsible, evidence of an apoplectic episode or episodes and of focal neurologic deficit to account for at least part of the syndrome will almost invariably be disclosed by history and examination. In the absence of a history of episodic development or of focal neurologic signs, it is unwarranted to attribute senile dementia to cerebrovascular disease- in particular to small strokes in silent areas. Cerebral arteriosclerosis is another term that has often been used carelessly to explain such mental changes, the implication (incorrect) being that arteriosclerosis itself causes ischemic damage to the nervous system, producing loss of intellectual function but no other neurologic deficit. If cerebral arteriosclerosis (atherosclerosis) is actually responsible, there should be evidence of it in the form of strokes at some time in the course of the illness and often in the heart (myocardial infarction, angina pectoris) or legs (intermittent claudication, loss of pulses). Frequently the lesions of both vascular and Alzheimer disease are present, in which case there may be difficulty in determining to what extent each of them is responsible for the neurologic deficit. Several studies have shown an increased incidence or an acceleration of Alzheimer dementia if there are concurrent vascular lesions, but further studies are needed to confirm this notion. Recurrent seizures as the result of a previous stroke occur in up to 10 percent of cases (postinfarction epilepsy, page 740). Contrariwise, certain manifestations of stroke may be incorrectly interpreted as evidence of some other neurologic disorder. In lateral medullary infarction, dysphagia may be the outstanding feature; if the syndrome is not kept in mind, a fruitless radiologic search for a local esophageal or pharyngeal cause may be undertaken. Similarly, facial pain or a burning sensation due to involvement of the trigeminal spinal nucleus in lateral medullary stroke may be misattributed to sinus disease. A strikingly focal monoplegia of cerebral origin, causing only weakness of the hand or arm or foot drop, is not infrequently misdiagnosed as a peripheral neuropathy. In the presence of coma, the differentiation of vascular from other neurologic diseases offers special problems. If the patient is comatose when first seen and an adequate history is not available, cerebrovascular lesions must be differentiated from all the other causes of coma described in Chap. Patients below approximately age 65 who are "lone fibrillators" (have no other cardiac or systemic disease) need not receive anticoagulation unless there has been a previous embolism. Whether younger patients who have additional vascular risk factors, such as diabetes or hypertension, benefit from anticoagulation is not known. If warfarin is to be discontinued for a necessary surgical procedure, it should be reinstated as soon as the surgeon deems it safe, since this is a time of increased stroke vulnerability. It has been the sense of many cardiologists that intermittent atrial fibrillation and fibrillation-flutter tachycardias also represent a risk of cerebral embolism, but there are no adequate studies to confirm this. The Patient with a Recent Stroke That May Not Be Complete Here the basic problem is whether a thrombotic infarction (venous or arterial) will spread and involve more brain tissue; or if embolic, whether the ischemic tissue will become hemorrhagic or another embolus will occur; or if there is an arterial dissection, whether it will give rise to emboli. In some centers it is the practice to try to prevent propagation of a thrombus by administering heparin (or low-molecular-weight heparin) followed by warfarin, as discussed earlier. Thrombolytic agents are an alternative if the stroke has occurred within the previous 2 or 3 h and is not too large. Except perhaps in cases of recent myocardial infarction, atrial fibrillation, or carotid disease, it is not imperative to begin heparin immediately while awaiting the effects of warfarin. The Inevident or Misconstrued Syndromes of Cerebrovascular Disease Although hemiplegia is the classic type of stroke, cerebrovascular disease may manifest itself by signs that spare the motor pathways but have the same serious diagnostic and therapeutic implications. Sometimes disregarded is a leaking aneurysm presenting as a sudden and intense generalized headache lasting hours or days and unlike any headache in the past. Examination may disclose no abnormality except for a slightly stiff neck and raised blood pressure. A second unobvious stroke is one caused by occlusion of the posterior cerebral artery, usually embolic. This may not be recognized unless the visual fields are routinely tested at the bedside.

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Data such as these assist in guiding societal resources to the cure of various conditions erectile dysfunction doctor seattle buy 80 mg super levitra otc, but they are somewhat less helpful in leading the physician to the correct diagnosis except insofar as they emphasize the oft stated dictum that "common conditions occur commonly" and therefore should not be overlooked (see discussion of Bayes theorem impotence trials cheap 80mg super levitra visa, further on erectile dysfunction in young males discount super levitra master card, under "Shortcomings of the Clinical Method") erectile dysfunction treatment penile injections discount 80 mg super levitra mastercard. And if the symptoms are in the sensory sphere, only the patient can tell what he* sees, hears, or feels. The practice of making notes at the bedside or in the office is particularly recommended. The following points about taking the neurologic history deserve further comment: 1. Special care must be taken to avoid suggesting to the patient the symptoms that one seeks. In the clinical interview, the *Throughout this text we follow the traditional English practice of using the pronoun he, his, or him in the generic sense whenever it is not intended to designate the gender of a specific individual. Since neurologic diseases often impair mental function, it is necessary, in every patient who might have cerebral disease, for the physician to decide, by an initial assessment of the mental status and the circumstances under which symptoms occurred, whether or not the patient is competent to give a history of the illness. In general, students (and some physicians as well) tend to be careless in estimating the mental capacities of their patients. The manner in which the patient tells the story of his illness may betray confusion or incoherence in thinking, impairment of memory or judgment, or difficulty in comprehending or expressing ideas. Observation of such matters is an integral part of the examination and provides information as to the adequacy of cerebral function. The physician should learn to obtain this type of information without embarrassment to the patient. A common error is to pass lightly over inconsistencies in history and inaccuracies about dates and symptoms, only to discover later that these flaws in memory were the essential features of the illness. Asking the patient to give his own interpretation of the possible meaning of symptoms may sometimes expose unnatural concern, anxiety, suspiciousness, or even delusional thinking. Errors and inconsistencies in the recorded history are as often the fault of the physician as of the patient. As a corollary, the patient should be discouraged from framing his symptom(s) in terms of a diagnosis that he may have heard; rather, he should be urged to give as accurate a description of the symptom as possible- being asked, for example, to choose a single word that best describes his pain and to describe precisely what he means by a particular term, such as dizziness, imbalance, or vertigo. The patient who is given to highly circumstantial and rambling accounts can be kept on the subject of his illness by discreet questions that draw out essential points. The setting in which the illness occurred, its mode of onset and evolution, and its course are of paramount importance. If such information cannot be supplied by the patient or his family, it may be necessary to judge the course of the illness by what the patient was able to do at different times. This is followed by an assessment of the function of sphincters and the autonomic nervous system and suppleness of the neck and spine (meningeal irritation). Gait and station (standing position) should be observed before or after the rest of the examination. In addition, it is often instructive to observe the patient in the course of his natural activities, such as walking or dressing; this may disclose subtle abnormalities of gait and movement that might not be evident in formal testing. When an abnormal finding is detected, whether cognitive, motor, or sensory, it becomes necessary to analyze the problem in a more elaborate fashion. Details of these more extensive examinations are to be found in appropriate chapters of the book (motor, Chaps. The neurologic examination is ideally performed and recorded in a sequential and uniform manner in order to avoid omissions and facilitate the subsequent analysis of case records. Some variation in the precise order of examination from physician to physician is permissible, but each examiner establishes an accustomed pattern. The thoroughness of the neurologic examination must of necessity be governed by the type of clinical problem presented by the patient. To spend a half hour or more testing cerebral, cerebellar, cranial nerve, and sensorimotor function in a patient seeking treatment for a simple compression palsy of an ulnar nerve is pointless and uneconomical. Obviously many parts of the examination cannot be carried out in a comatose patient; also, infants and small children as well as patients with psychiatric disease must be examined in special ways. Not to be neglected are certain portions of the general physical examination that may be particularly informative in the patient with neurologic disease. For example, examination of the pulse and blood pressure as well as carotid and cardiac auscultation are essential in a patient with stroke; likewise, the skin can reveal a number of conditions that pertain to congenital, metabolic, and infectious causes of neurologic disease; and so on.

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