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By F. Fadi. Wheelock College.

The tube is advanced by manipulation through the entire distended bowel to the obstructed segment order discount erectafil line. The obstructed point can be located by following distended bowel distally unit collapsed intestine is found cheap erectafil master card. Manipulation of distended bowel is easier if the intestine has been decompressed preoperatively order cheap erectafil on line. During op­ eration an intestinal tube may be passed into the distended bowel and aspiration through this should be done. The approach to colon obstruction is somewhere different from small bowel obstruction. If there is ob­ structive lesion of the right colon, right colectomy with ileotransverse colostomy or if resection is not possible a simple ileotransverse colostomy is performed to give a chance of later elective resection of the right colon. The simple bypass operation is reserved for poor-risk patients and in those where the growth is irremovable. In case of obstruction of the left colon three stages operation is performed — (i) proximal defunctioning colostomy, (ii) removal of the diseased segmental colon and anastomosis and (iii) closure of the colostomy when healing of the anastomosis is complete. There are two nerve plexuses in the wall of the intestine — myenteric plexus between longitudinal and circular muscle layers and one in the submucous coat which is known as submucous plexus or Meissner’s plexus. This failure of transmission of peristaltic waves leads to accumulation of intestinal fluid and gas inside the lumen which results in abdominal distension. The main feature of this condition is absence of bowel sounds, which is loud and high piched in case of mechanical obstruction. Vomiting and absolute constipation alongwith abdominal distension are the features of this condition which is similar to those of mechanical obstruction. Only during presence of peritonitis or metabolic abnormalities (hypoproteinaemia, hypokalaemia and uraemia) this stage may continue for quite sometime. Effortless vomiting, abdominal distension and no passage of flatus are the features almost similar to those found in mechanical obstruction. Straight X-ray of the abdomen shows gas-filled loops of intestine with multiple fluid levels. In some cases where there is too much distension, long intestinal tube should be used for intestinal decompression. If mechanical obstruction or intra-abdominal sepsis can be clearly ruled out, a parasympathomimatic drug such as neostigmine (prostigmin) may be used. If paralytic ileus continues for sometime after surgery, one must rule out two possibilities — (i) intra-abdominal sepsis and (ii) mechanical obstruction for which abdominal exploration may be necessary. But rarely the distal loop may invaginate into the proximal loop and this condition is called retrograde intussusception (e. Sometimes the mass of intussusception may again invaginate into the distal bowel and this condition is called com­ pound or double intussusception. Intussusception is usually single but very occasionally one may find more than one intussusception at different levels. Intussusception is usually acute, but rarely chronic intussusception may persist for months or years. Where there is definite cause of intussusception — Secondary intussusception and 2. Where there is no definite cause for intussusception — Primary or idiopathic intussusception. This type of intussusception, which is caused by some pathology, is known as secondary intussusception. Sometimes intussusception may occur in the early postoperative period due to inco-ordinale peristalsis in the small intestine. This type of intussusception usually occurs in children between 6 to 9 months of age. Some structural peculiarity of this part of the intestine may play some role — (a) mobile intestine terminating into immobile caecum, (b) oblique entrance of ileum into the caecum and (c) excessive lymphoid tissue. The constricted segment is pushed into the adjacent passive dilated loop of the gut and then by peristalsis intussusception occurs. This occurs as the inhibitory nervous mechanism appears late in children and at this age it starts appearing, so some aberrant contractions cause such intussusception. Hypertrophy of Peyer’s patches will be caused by (a) change in diet which will bring about a change in bacterial flora of the intestine and will cause inflammation of the Peyer’s patch, (b) Inflammation of Peyer’s patch may occur secondary to upper respiratory tract infection. Next common are ileo-ileo-colic and ileo-ileal and least common are colocolic and multiple intussusceptions. So it is ileo- ileal to start with and then passes through ileocaecal valve to make it ileocolic. The entering or inner tube and the returning tube are together called intussusceptum. It is the fixed point of intussusception and intussusception progresses at the cost of the ensheathing tube or the outer tube. The site where the retuning layer and the ensheathing layer meet is called the neck and this point varies as the intussusception progresses. Intussusception is a type of intestinal obstruction which often accompanies strangulation. As the intussusception progresses, the mesentery of the entering and returning tubes is dragged alongwith the gut through the neck of the intussusception. Gradually the mesentery becomes compressed between the entering and returning tubes. In the beginning the veins within the mesentery become constricted and severe venous engorgement and oedema of the wall of the intussusceptum occurs. Such oedema will also discharge blood and mucus from its wall and this will be discharged per rectum. Gradually the pull on the mesentery becomes sufficient enough to occlude the arteries. The onset of gangrene is dependent upon the tightness of the invagination and it often occurs in ileocolic intussusception as the ileocaecal valve exerts pressure on the mesentery. In rare instances gross adhesion may develop at the neck between intussusceptum and intussuscipiens. If gangrene develops in such case, the whole mass of intussusceptum becomes necrosed and sloughs out. But remember that vomiting is a late feature and usually does not appear before 24 hours of the onset of the disease. Absolute intestinal coils of small intestine obstruction occurs and death is the ultimate result from intestinal obstruction alone or peritonitis following gan­ grene and perforation. If the abdomen is carefully palpated between the attacks one may feel a lump under the right or left ju. This is due to the fact that the If terminal part of ileum and caecum do not remain m right iliac fossa, but arc involved in intussusception and arc tclcscopcd through the ascending colon, transverse colon and descending colon according to V the various stages. In majority of cases the apex of the H intussusception cannot be felt per rectum but the mm. S*oved finger will be smeared by blood-stained mu­ m cusThis will give a definite clue to the diagnosis. I X-ray of the abdomen shows absence of caecal gas shadow and incresed gas shadows in the small intestine.

While playing in the backyard of her south Texas home order erectafil no prescription, a 6-year-old girl is bitten by a rattlesnake buy erectafil 20 mg. The point of this vignette is to remind you that snake antivenin is one of the very few medicines for which the dose is not calculated on the basis of the size of the patient buy erectafil with paypal. The dose of antivenin depends on the amount of venom injected, regardless of the size and age of the victim. During a picnic outing, a young girl inadvertently bumps into a beehive and is stung repeatedly by angry bees. She is seen 20 minutes later and found to be wheezing, hypotensive, and madly scratching an urticarial rash. While rummaging around her attic, a woman is bitten by a spider that she describes as black, with a red hourglass mark in her belly. A patient seeks help for a very painful ulceration that he discovered in his forearm on arising this morning. Yesterday he spent several hours cleaning up the attic, and he thinks he may have been “bitten by a bug. No, nobody actually bit him—he did it by punching someone in the mouth and getting cut with the teeth that were smashed by his fist. The point of management is that human bites are bacteriologically the dirtiest that one can get and antibiotics are given. Rabies shots will not be needed, but surgical exploration by an orthopedic surgeon will be required as well as antibiotics. Physical examination of the hips reveals that one of them can be easily dislocated posteriorly with a jerk and a “click,” and returned to normal position with a “snapping. The physical examination should suffice, but if there is any doubt, do a sonogram. Abduction splinting with Pavlik harness A 6-year-old boy has insidious development of limping with decreased hip motion. In this age group, Legg-Calve-Perthes disease (avascular necrosis of the capital femoral epiphysis). A 13-year-old obese boy complains of pain in the groin (it could be the knee) and is noted by the family to be limping. He sits in the office with the sole of the foot on the affected side pointing toward the other foot. As the hip is flexed, the leg goes into external rotation and cannot be rotated internally. Forget the details: a bad hip in this age group is slipped capital femoral epiphysis, an orthopedic emergency. A young toddler has had the flu for several days, but until 2 days ago he was walking around normally. He is in pain and holds the leg with the hip flexed, in slight abduction and external rotation, and you cannot examine that hip—-he will not let you move it. Aspiration of the hip under general anesthesia to confirm the diagnosis, and open arthrotomy is performed for drainage. A child with a febrile illness but no history of trauma has persistent, severe localized pain in a bone. Although there is no swelling of the knee joint, he complains of persistent pain right over the tibial tubercle, which is aggravated by contraction of the quadriceps. This is another one with a fancy name: Osgood-Schlatter disease (osteochondrosis of the tibial tubercle). It is usually treated with immobilization of the knee in an extension or cylinder cast for 4–6 weeks, if more conservative management fails (rest, ice, compression, and elevation). Physical examination shows that there is plantar flexion of the ankle, inversion of the foot, adduction of the forefoot, and internal rotation of the tibia. This is the complex deformity known as club foot (fancy name: talipes equinovarus). The sequence of correction starts with the adducted forefoot, then the hindfoot varus, and finally the equinus. About 50% of patients respond completely and need no surgery; those who require surgery are operated on age >6–8 months, but <1–2 years. A 12-year-old girl is referred by the school nurse because of potential scoliosis. The thoracic spine is curved toward the right, and when the girl bends forward a “hump” is noted over her right thorax. This is too complicated for the exam, but the point is that scoliosis may progress until skeletal maturity is reached. At the onset of menses skeletal maturity is ~80%, so this patient still has a way to go. He is placed in a cast at the nearby “doc in the box,” and he is seen by his regular pediatrician 2 days later. Except for rotational deformities, children have such tremendous ability to heal and remodel broken bones that almost any reasonable alignment and immobilization will end up with a good result. In fact, fractures in children are no big deal—with a few exceptions that are illustrated in the next few vignettes. An 8-year-old boy falls on his right hand with the arm extended, and he breaks his elbow by hyperextension. This type of fracture is common in children, but it is important because it may produce vascular or nerve injuries—or both—and end up with a Volkmann contracture. Although it can usually be treated with appropriate casting or traction (and rarely needs surgery), the answer revolves around careful monitoring of vascular and nerve integrity, and vigilance regarding development of a compartment syndrome. A child sustains a fracture of a long bone, involving the epiphyses and growth plate. The epiphyses and growth plate are laterally displaced from the metaphyses, but they are in one piece, i. A child sustains a fracture of a long bone that extends through the joint, the epiphyses, the growth plate, and a piece of the metaphyses. In the first example, even though the dreaded growth plate is involved it has not been divided by the fracture. If appropriate (this case is), check the other bones that might be in the same line of force (here, the lumbar spine). The point of tenderness is at the junction of the middle and distal thirds of the clavicle. After a grand mal seizure, a 32-year-old epileptic notices pain in her right shoulder, and she cannot move it. She goes to the nearby “doc in a box,” where she has x-rays and is diagnosed as having a sprain and given pain medication. During a rowdy demonstration and police crackdown, a young man is hit with a nightstick on his outer forearm that he had raised to protect himself. He is found to have a diaphyseal fracture of the proximal ulna, with anterior dislocation of the radial head. The patient needs closed reduction of the radial head, and possible open reduction and internal fixation of the ulnar fracture.

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Necrosectomy is the best way to deal with necrotic pancreas order 20mg erectafil with amex, but timing is crucial discount erectafil 20mg mastercard. Most practitioners will wait as long as possible before necrosectomy is offered order 20mg erectafil amex, as it requires the dead tissue to delineate well and mature for dissection. Patients do far better by waiting at least 4 weeks before debridement of the dead pancreatic tissue. Many pancreatic abscesses are not amenable to percutaneous or open drainage and will require open drainage or debridement. Imaging studies done at that time will reveal the collection(s) of pus, and percutaneous drainage and imipenem or meropenem will be indicated. Pancreatic pseudocyst can be a late sequela of acute pancreatitis, or of pancreatic (upper abdominal) trauma, with unrecognized ductal injury. In either case, ~5 weeks elapses between the original problem and the discovery of the pseudocyst. There is a collection of pancreatic juice outside the pancreatic ducts (most commonly in the lesser sac), and the pressure symptoms thereof (early satiety, vague symptoms, discomfort, a deep palpable mass). Cysts ≤6 cm or those that have been present <6 weeks are not likely to have complications and can be observed for spontaneous resolution. Larger (>6 cm) or older cysts (>6 weeks) are more likely to cause obstruction, bleed, or get infected, and they need to be treated. People who have repeated episodes of pancreatitis (usually alcoholic) eventually develop calcified burned- out pancreas, steatorrhea, diabetes, and constant epigastric pain. The diabetes and steatorrhea can be controlled with insulin and pancreatic enzymes, but the pain is resistant to most modalities of therapy and can be incredibly debilitating. Exceptions include: Asymptomatic umbilical hernia in patients age <5 (they typically close spontaneously) Esophageal sliding hiatal hernias (not “true” hernias) Hernias that become irreducible need emergency surgery to prevent strangulation. Other risk factors for the development of breast cancer include first period at a young age, radiation exposure, later menopause, and never having been pregnant. Mammography is not a substitute for tissue diagnosis, but is an important adjunct to physical examination. A breast mass that might be missed by palpation may be seen on mammogram and the opposite can also be true. As a regular screening exam, mammography should be started between ages 40-50 (earlier if there is family history). Mammography is not as helpful in women age <30 (breast is too dense) or during lactation (increased parenchymal density). Fibroadenoma is primarily seen in young women (late teens, 20s, or 30s) as a firm, rubbery mass that moves easily with palpation. Giant juvenile fibroadenoma is seen in very young adolescents, where it has very rapid growth. Cystosarcoma phyllodes tumors are most common in women in their 30s and 40s, but women of any age can have them. They can become very large, distorting the entire breast, yet not invading or becoming fixed. Mammary dysplasia (fibrocystic disease, cystic mastitis)is most common in women of childbearing age, but can affect women of any age. It often presents with bilateral tenderness related to the menstrual cycle and multiple lumps (cysts) that seem to come and go (they are cysts) also following the menstrual cycle. U/S can be used to evaluate breast complaints and is also diagnostic for simple cysts. Any dominant or persistent mass of concern should be worked-up, including a mammogram and biopsy if appropriate. Mammogram is needed to exclude other potential lesions, but it will not show the papilloma (they are tiny). However, any patient with a bloody nipple discharge is cancer until proven otherwise. Mastitis and breast abscesses are most commonly seen in lactating women; what appears to be a breast abscess at other times is cancer until proven otherwise. Mastitis is treated with oral antibiotics alone, whereas ultrasound- guided fine needle aspiration or incision and drainage are needed to drain a true abscess. Breast cancer should be suspected in any woman with a palpable breast mass, and the index of suspicion increases with the patient’s age. Other strong indicators of cancer include: Ill-defined fixed mass Retraction of overlying skin Recent retraction of the nipple Eczematoid lesions of the areola Reddish orange peel skin over the mass (so called “inflammatory cancer,” with skin edema due to extensive lymph node involvement by tumor) Palpable axillary nodes A history of trauma does not rule out cancer. Breast cancer during pregnancy is diagnosed exactly as if pregnancy did not exist, and is treated the same way with the following exceptions: no radiotherapy during the pregnancy and no chemotherapy during the first trimester. The radiologic appearance of breast cancer on mammogram includes an irregular, spiculated mass, asymmetric density, architectural distortion or fine microcalcifications that were not there in a previous study. Treatment of resectable breast cancer starts with lumpectomy (partial mastectomy) plus post-op radiation or total mastectomy; either way, axillary sentinel lymph node sampling is performed simultaneously. The sentinel node biopsy is performed only when nodes are not palpable on physical exam. Infiltrating (or invasive) ductal carcinoma is the common standard form of breast cancer. Other variants (lobular, medullary, tubular, mucinous ) tend to have slightly better prognosis and are treated the same way as the standard infiltrating ductal. The surgery for inflammatory breast cancer is almost always a modified radical mastectomy. Inflammatory breast cancer is also one of the few times where radiation is added following a total mastectomy. It mimics mastitis but is not an infectious process, and antibiotics do not play a role in treatment. Since it is confined to the ducts, it cannot metastasize (thus no axillary sampling is needed). Total mastectomy is recommended for multicentric lesions throughout the breast, many practitioners add a sentinel node biopsy in those patients, in the event that invasive cancer is found following the mastectomy, as a sentinel node cannot be identified after the breast has been removed. Lumpectomy with or without radiation is used if the lesion(s) are confined to a limited portion of the breast. Inoperable cancer of the breast is breast cancer that is not amenable to surgical resection. Treatment for inoperable breast cancer can include any combination of chemotherapy, hormone therapy (if hormone receptor positive), or radiation, and is often considered palliative. Anti- estrogen hormonal therapy is an option for adjuvant systemic therapy if the tumor is estrogen receptor-positive. Premenopausal women receive tamoxifen Postmenopausal women receive an aromatase-inhibitor (e. Large Calcification Located within a Case of Overt Breast Cancer Noted on Mammography visualsonline. The need for further surgery is determined by the histologic diagnosis given from a frozen section.

Patients with unbalanced psychic condition is seen in case of primary thyrotoxicosis generic erectafil 20 mg without a prescription. Certain areas are particularly known to have low iodine content in the water and food cheap 20mg erectafil amex. Residents of these areas often suffer from iodine deficiency endemic simple goitre cheap erectafil 20 mg overnight delivery. Such goitre is also probably more common in Southern India than in Northern India. Endemic goitre is also found in low land areas where the soil lacks iodides or the water supply comes from far away mountain ranges e. In the mountains of Bulgaria arises the river Struma, which flows into the Aegean Sea. Calcium is also goitrogenic and areas producing chalk or lime stone are also goitrogenic areas e. In secondary thyrotoxicosis the brunt of the attack falls more on the cardiovascular system, whereas in primary thyrotoxicosis the brunt of attack falls more on the nervous system. While simple goitre grows very slowly or may remain of same size for quite sometime, multinodular goitre or solitary nodular goitre or colloid goitre increases in size though extremely slowly for year. A special feature of papillary and follicular carcinoma of the thyroid is their slow growth. Malignant diseases of the thyroid gland are painless to start with, but become painful in late stages. Anaplastic carcinoma is more known to infiltrate the surrounding structures and the nerves to cause pain. It must be remembered that thyroid swellings can rarely obstruct the oesophagus as it is a muscular tube and can be easily stretched or pushed aside. As in the first stage of deglutition the thyroid gland moves up, so an enlarged thyroid gland makes swallowing uncomfortable but usually this is not true dysphagia. An enlarged thyroid may compress on the trachea or deviate it to one side or the other to cause difficulty in breathing. When air rushes through a narrowed trachea, a whistling sound is produced which is called stridor. Hoarseness is usually due to paralysis of one recurrent laryngeal nerve and anaplastic carcinoma infiltrating the nerve is often the cause. Preference for cold and intolerance to heat and excessive sweating are the next symptoms. Nervous excitability, irritability, insomnia, tremor of hands and weakness of muscles are the symptoms of involvement of nervous system which are the main features of primary thyrotoxicosis. Cardiovascular symptoms are not so pronounce as seen in secondary thyrotoxicosis, but even then palpitation, tachycardia (rise in sleeping pulse) and dyspnoea on exertion are symptoms of this disease. The patient may complain of staring or protruding eyes and difficulty in closing her eye lids. Oedema or swelling of the conjunctiva (chemosis) is seen in very late cases of exophthalmos alongwith persistent primary thyrotoxicosis. As mentioned above the brunt of the attack falls more on the cardiovascular system than on the nervous system. Palpitations, ectopic beats, cardiac arrhythmias, dyspnoea on exertion and chest pain are the usual symptoms. Muscle fatigue and lethergy are important symptoms with failing memory and mild hoarseness due to oedema of vocal cords. In case of thyroglossal fistula there may be a previous history of an abscess (an inflamed thyroglossal cyst) which was incised or burst spontaneously. Persons who are in the habit of taking a kind of sea fish which has particularly low iodine content, may present with goitre. Similarly enzyme deficiency within the thyroid gland which are concerned in the synthesis of thyroid hormones are also seen to run in families. The patient sweats a lot with wasting of muscles and in hypothyroidism the patient is obese and overweight. Not only the pulse rate becomes rapid, but it becomes irregular in thyrotoxicosis. Particularly sleeping pulse rate is a very useful index to determine the degree of thyrotoxicosis. In case of mild thyrotoxicosis, it should be below 90, whereas in case of moderate or severe thyrotoxicosis it should be between 90 to 110 and above 110 respectively. The clinician while feeling for the pulse should take the opportunity to touch the hand as well. In case of obese and short-necked individual inspection of the thyroid gland becomes more difficult. Rarely a swelling on the lateral side of the neck is not due to enlargement of an aberrant thyroid gland but is caused by metastasis in lymph nodes from hidden carcinoma of the thyroid gland. Ask the patient to sivalloiv and watch for the most important physical sign — a thyroid swelling moves upwards on deglutition. Other swellings which may move on deglutition are thyroglossal cysts, subhyoid bursitis and prelaryngeal or pretracheal lymph nodes fixed to the larynx or trachea. Such movement of the thyroid _ becomes greatly limited when it is fixed by inflammation or malignant infiltration. In retrosternal goitre, pressure on the great veins » r at the thoracic inlet gives rise to dilatation of the subcutaneous veins over the upper anterior part of the thorax. When these are present, ask the patient to swallow and determine, on inspection, the lower border of the swelling as it moves up on deglutition. Congestion of face and distress become evident in case of retrosternal goitre due to obstruction of the great veins at the thoracic inlet. But the pathognomonic feature is that it moves upwards with protrusion ol the tongue since the thyroglossal duct extends downwards from the foramen caecum of the tongue to the isthmus of thyroid gland. The opening of the fistula is indrawn and overlaid by a crescentic fold of skin (See Fig. The patient should be sitted on a stool and the clinician stands behind the patient. The thumbs of both the hands are placed behind the neck and the other four fingers of each hand are placed on each lobe and the isthmus (See Figs. The first figure shows inspection in normal position and the 2nd figure thyroid gland is shows Pizzillo’s technique, important, particularly the lower margin. Additional information about one lobe may be jp obtained bv relaxing the sternomastoid muscle of that side by flexing and rotating the face to the *B1| same side. To palpate the left lobe properly, the thyroid gland is pushed to the left from the right side by the left hand of the examiner. This makes the left lobe more prominent so that the examiner can palpate it thoroughly with his right hand. During palpation the patient should be asked to swallow in order to settle the diagnosis of the thyroid swelling. Slight enlargement of the thyroid gland or presence of nodules in its substance can be appreciated by simply placing the thumb on the thyroid gland while the patient swallows. During palpation the following points should be noted :— (i) Whether the whole thyroid gland is enlarged?

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