Suspect tropical sprue when there is a history of being in a tropical country discount combivir 300mg amex, and Whipple disease (very rare) if there is dementia (10%) buy cheap combivir on-line, arthralgia (80%) purchase combivir 300 mg, and ophthalmoplegia. In patients with IgA deficiency, IgA endomysial and transglutaminase antibodies are falsely normal. Work up celiac in a patient with thyroiditis who is not responding to high doses of levothyroxine. The first step with celiac disease is to test for the presence of antiendomysial and anti-transglutaminase antibodies. Even if the antibody tests confirm the diagnosis of celiac disease, the bowel biopsy should be done anyway to exclude small bowel lymphoma. Just removing gluten (wheat, rye, oats) from the diet is not an accurate way to establish the diagnosis because the circulating antibodies will continue to be present for weeks after stopping the ingestion of gluten. Tropical sprue and Whipple disease are diagnosed by finding organisms on a bowel-wall biopsy. Celiac disease is managed by adhering to a gluten-free diet (no wheat, oats, rye, or barley); nonadherence is the most common reason for failure. On diagnostic testing, her blood and stool tests were within normal limits except for a mild elevation in stool osmolality. The cause of diverticulosis is believed to a lack of fiber in the diet to give bulk to stool. There is a subsequent rise in intracolonic pressure, leading to outpocketing of the colon. When symptoms do exist, they are typically left lower quadrant abdominal pain that is colicky in nature. Diverticula are more common on the left in the sigmoid, but bleeding occurs more often from diverticula on the right because of thinner mucosa and more fragile blood vessels. Treatment is an increased-fiber diet, as is found in bran, bulking agents such as psyllium husks, and soluble fiber supplements. This can occur when the diverticular entrance in the colon becomes blocked, perhaps by nuts or corn. Diverticulitis is distinguished from uninfected diverticula by the presence of fever, tenderness, more intense pain, and elevated white blood cell count. Barium study and endoscopy are contraindicated because there is a slightly higher risk of perforation. Diverticulitis is treated with antibiotics such as ciprofloxacin and metronidazole. The other choices are ampicillin/sulbactam, piperacillin/tazobactam, or combined cefotetan or cefoxitin with gentamicin. Mild disease can be treated with oral antibiotics such as amoxicillin/clavulanic acid. She also has a history of diabetes with peripheral neuropathy, for which she takes amitriptyline. She has untreated hypothyroidism, but is treated for hypertension with nifedipine. Currently, she has constipation, and when the stool does pass, it is very dark in color, almost black. The most common cause of constipation is lack of dietary fiber and insufficient fluid intake. Calcium-channel blockers, oral ferrous sulfate, hypothyroidism, opiate analgesics, and medications with anticholinergic effects such as the tricyclic antidepressants all cause constipation. In the patient above, the most likely cause of the constipation is the ferrous sulfate. Very dark stool, as in this patient, occurs only with bleeding, bismuth subsalicylate ingestion, and iron replacement. Stop all medications that cause constipation; then make sure the patient stays well-hydrated and consumes 20–30 grams of daily fiber. Most cases occur sporadically, which is to say there is no clearly identified etiology. When the cancer is in the right side of the colon, patients present with heme- positive, brown stool and chronic anemia. When the cancer is in the left side or in the sigmoid colon, patients present with obstruction and narrowing of stool caliber. That is because the right side of the colon is wider than the left, and the stool is more liquid in that part of the bowel, making obstruction less likely on the right. Endocarditis by Streptococcus bovis and Clostridium septicum have a strong association with colon cancer. If the lesion is in the distal area then the sigmoidoscopy will be equally sensitive as colonoscopy, but only 60% of cancers occur there. In cases of family history of colon cancer, begin screening at age 40 or 10 years earlier than the family member got cancer, whichever is younger (also see Preventive Medicine chapter). By definition, the syndrome is defined as: Three family members in at least 2 generations with colon cancer One of these cases should be premature, i. As soon as polyps are found, perform a colectomy; a new rectum should be made from the terminal ileum. By contrast, juvenile polyposis syndrome confers about a 10% risk of colon cancer. There are only a few dozen polyps, as opposed to the thousands of polyps found in those with familial polyposis. In addition, the polyps of the juvenile polyposis syndrome are hamartomas, not adenomas. Cowden syndrome is another polyposis syndrome with hamartomas that gives only a slightly increased risk of cancer compared with the general population. Peutz-Jeghers syndrome is the association of hamartomatous polyps in the large and small intestine with hyperpigmented spots. Most common presentation is with abdominal pain due to intussusception/bowel obstruction. Turcot syndrome is simply the association of colon cancer with central nervous system malignancies. There is no recommendation for increased cancer screening for any of these syndromes; they are not common enough to warrant a clear recommendation for uniform early screening. There is an association of endocarditis from Streptococcus bovis with colon cancer, so if a patient has endocarditis from S. If there is a history of abdominal aortic aneurysm repair in the past 6 months to 1 year, consider aortoenteric fistula. This can happen if the volume of blood is so high that it is rapidly transported to the bowel without time for it to oxidize and turn black. Orthostasis is defined as a >10-point rise in pulse when the patient goes from the supine to the standing or sitting position.

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The fingers must not be held vertical and poke the abdominal wall as shown in the Fig purchase combivir on line amex. To avoid this (ii) the patient is asked to flex the hips and knees to release ■■■ ^e abdominal muscles 300 mg combivir fast delivery. For example purchase 300mg combivir otc, if the pain is located at the right iliac fossa, commence palpating the left hypochondrium and after palpating each quadrant in turn reach the affected area last of all. He may wince at palpation of a region where he did not complain of pain and this may give a valuable clue to the diagnosis, (x) For deep palpation the whole of the volar surfaces of the fingers should be used and gradually tilted towards the abdomen. While the upper hand puts more pressure, the lower hand remains passive to receive more information about the structures deep to this hand, (xi) In case of children who are not cooperative, their hands should be used for deep palpation. If the patient has complained of pain at the time of history-taking, ask him to point to its site so that you can begin palpation in a non-tender area and move towards the tender spot. This should be done by gently resting the hand on the abdomen and pressing lightly. If systematic light palpation over the whole abdomen elicits no pain, repeat the process pressing firmly and deeply to find out if there is deep tenderness. The degree of tenderness must be assessed — whether it is mildly tender, moderately tender (which initiates slight tightening of the abdominal muscles) or severely tender (when the muscular rigidity becomes obvious). In case of gastric idcer tender spot is usually situated in the midepigastrium below the xiphoid process. In duodenal ulcer it is about 1 Vi inches to the right of the midline on the transpyloric plane (See Fig. To elicit tenderness in cholecystitis one may place the right hand just below the right costal margin on the lateral border of the right rectus (the gallbladder point). Moderate pressure is exerted with the fingers to palpate the fundus of the gallbladder. The patient is now asked to take a deep breath in, the gallbladder descends and hurts the examining fingers. The fingers are hooked under the right costal margin at the lateral border of the rectus and the patient is asked to take deep breaths in. In cholecystitis the cartilage of the right 8th rib becomes tender (compare with the other side). This is obtained when there is a large amount of fluid in the peritoneal cavity either free or encysted. This is obtained by a gentle tap applied to one flank of the abdomen while the thrill is felt with the other hand placed on the other flank of the abdomen. The fluid thrill is also obtained in case of encysted fluid such as a large ovarian cyst which has touched both the abdominal flanks. Differentiation between these two conditions can be done by shifting dullness test. This is a valuable sign and even becomes positive when the quantity of fluid in the peritoneal cavity is comparatively small. Percussion is started from the midline and continued to any of the flanks till the percussion note becomes dull. The finger on the abdomen is kept as such and the patient is asked to turn to the opposite side. In the passing it may be mentioned that in surgical practice the common causes of ascites are portal hypertension, carcinomatosis peritonei and tuberculous peritonitis, but considering all cases including the medical conditions the commonest cause is congestive cardiac failure in which there will be engorgement of the neck veins also. If there is any history suggesting pyloric stenosis, one should look for visible peristalsis. Short, sudden, jerky movements with fingers are made over the stomach area or the patient is shaken. In case of suspicion the patient may be asked to take fluid before this test is Rg. Visible lump is more often a feature of congenital pyloric stenosis than adult acquired stenosis. Otherwise a palpable swelling of the stomach means either carcinoma or leaking perforation of a peptic ulcer. But one thing should be borne in mind that absence of a lump by no means excludes carcinoma of the stomach. To palpate for an enlarged liver one should place the hand on the right iliac fossa with the fingers pointing towards the left axilla (that means parallel to the right costal margin). Every time the patient expires, slide the hand a little towards the right costal margin. This is carried on till the edge of an enlarged liver strikes the lateral margin of the hand when the patient inspires. On this line 1 inch to the right of the continuous pressure towards midline is the duodenal point. As the patient inspires the liver descends and the lateral margin of the index finger will be felt to ride over the free edge of the liver. If the students want to palpate the liver straight away by placing the fingers below the costal margin, they may miss gross enlargement of the liver. Palpable liver may not be necessarily enlarged, as it may be dropped or pushed down by something from above. The right hand reaches upper limit of the liver it the costal margin at the tip of the 10th rib and the clinician’s left hand is put is necessary to percuss round the lower left rib cage and is pushed forward with each inspiration. A along the right mid-axillary slightly enlarged spleen may be thus lifted forward enough to line commencing from the make it palpable by the right hand. It must be noted in the passing that hydatid cyst or amoebic abscess often causes an upward hepatic enlargement. When the liver becomes palpable note the following points : (i) The extent of enlargement below the costal margin in inches or finger-breadths; (ii) The character of the edge — sharp or rounded; (iii) The surface — smooth, irregular or nodular with or without umbilication in the nodules; (iv) The consistency — soft, firm or stony hard and (v) Presence or absence of tenderness. A stony hard and irregular liver is suggestive of metastatic carcinomatous deposits in the liver. The spleen must be near two times larger than its normal size to be detected by clinical examination. Splenic swelling has a sharp anterior border where one or two notches can be felt. The method of palpation of the spleen is very much similar to that of the liver except that this is tried on the left side. There are four methods of palpation : (i) The right hand of the clinician is placed parallel to the left costal margin at the level of the umbilicus and the patient is asked to breathe in and out. During expirations the hand is gradually slided towards the left costal margin till the splenic swelling touches the lateral border of the index finger during inspiration, (ii) Some clinicians put their left hands on the left lower ribs and slide the skin downwards so that the right hand gets an extra bit of skin to insinuate beneath the left costal margin. By this method one can palpate a relatively smaller spleen which has not become big enough to reach below the level of the costal margin. Failure of palpation of an enlarged spleen is mostly due to palpating more medially than its actual position. This manoeuvre occasionally lifts a slightly enlarged spleen forwards enough to make it palpable, (iv) From above spleen may be conveniently palpated with two hands arching below the left costal margin while the patient is asked to take deep breath in and out slowly. The hands are moved further downwards and laterally with each expiration waiting for the enlarged spleen to knock at the fingers during inspiration while the fingers are kept static. It moves freely with respiration and its upper limit is continuous with the liver.

Parathyroid tumor Typically a small rounded mass that enhances (Fig C 24-11) more than muscle or lymph nodes but less than the great vessels order 300mg combivir visa. Bilobed purchase combivir with visa, homogeneous soft-tissue lesion (arrows) in a patient with Graves’ disease buy combivir 300 mg without prescription. Cystic teratomas often demonstrate fat-fluid interfaces and may contain calcifications and soft-tissue nodules in the mass. Lymphoma Involvement of anterior mediastinal lymph nodes (Fig C 24-13) lying ventral to the aorta and superior vena cava. The presence of enlarged nodes in this region is a differential point from sarcoidosis that also affects hilar nodes (as does lymphoma) but not nodes in the anterior compartment. Mediastinitis/abscess Suggested by the presence of bubbles of gas or a discrete cavity with a thick, shaggy wall. Morgagni’s hernia A hernia containing fluid-filled bowel or part of the liver produces a mass of soft-tissue density. Mediastinal Uniform, symmetric widening of the mediastinum hemorrhage/hematoma (especially the superior portion) in a patient with a history of trauma, surgery, or dissecting aneurysm. Note that the lung interfaces with the hilar vessels (arrow) and aorta (arrowhead) are well preserved. Thus, on plain radiog- Fig C 24-12 raphs these middle mediastinal structures were clearly seen Mixed germ cell tumor. Contrast scan shows a huge tumor through the mass (hilum overlay sign), indicating that the that is primarily solid, thought there is a relatively large cystic lesion was either in the anterior or posterior portion of the component (arrow). Although often idiopathic, many cases are thought to be the result of an abnormal immunologic response Histoplasma capsulatum infection. Aneurysm of aorta or Various patterns depending on the location of Transverse arch aneurysms typically obliterate the major branch the aneurysm. Medias- tinal masses may also be caused by pseudocoarc- tation of the aorta and by dilatation of the superior vena cava or azygos vein. Mediastinitis Generalized widening of the mediastinum, Acute mediastinitis is most often due to esophageal (Figs C 25-6 and C 25-7) usually most evident superiorly. A lobulated rupture and may be associated with mediastinal paratracheal mass predominantly projecting to air. Chronic mediastinitis (granulomatous or sclero- the right may develop in chronic disease. Pleuropericardial Round, oval, or teardrop mass with smooth Fluid-filled cyst that is almost always asymptomatic (mesothelial) cyst margins. Intrapericardial hernia Gas-filled loops of bowel that lie alongside the Extremely rare congenital or posttraumatic lesion (Fig C 25-8) heart and remain in conformity with the heart that can contain (in decreasing order of fre- border on multiple projections (including quency) omentum, colon, small bowel, liver, or decubitus views). Although often asymptomatic for long periods, most patients eventually present with cardiorespiratory or gastrointestinal complaints. Rare condition that most often involves the (Castleman’s disease) posterior mediastinum. Frontal chest radiograph taken imme- Plain radiograph demonstrates linear lucent shadows diately after trauma demonstrates mediastinal widening, (arrows) that represent localized mediastinal emphysema obscuration of the aorta, deviation of the trachea to the right, 51 and correspond to the fascial planes of the mediastinal and downward displacement of the left main-stem bronchus. Pericardial lipoma Localized collection of fat-density tissue (lipo- mas occur more commonly in the anterior mediastinum). Diffuse fatty lesion with a mass effect on the superior vena cava and azygos vein. Malleable lesion that may change shape when the patient is scanned in the prone or decubitus position. Easily differentiated from prominent epicardial fat pads or lipomas, which also present as cardiophrenic angle masses. Bronchogenic cyst Smooth, round, homogeneous mass that usually (Fig C 26-4) has a thin, imperceptible rim and does not show any change in attenuation after infusion of contrast material. May contain viscous mucoid or proteinaceous material that produces a higher attenuation in the range of a solid neoplasm. The cyst had a uniform appearance and near-water density and extended vertically from the lower pole of the thyroid gland to the carina. Mediastinitis/abscess Suggested by the presence of bubbles of gas or a discrete cavity with a thick, shaggy wall. The enlarged nodes (arrow) aortopulmonary window and subcarinal space, a finding obliterate the air-soft tissue interface between the consistent with metastatic lymphadenopathy. There is also right lung and the tracheal wall (right paratracheal lymphadenopathy in the paratracheal region, which produced stripe). Calcification in the affected hilar nodes suggests a normal concave border of the interface between the prolonged clinical course. Note the simultaneous presence of left lung and the mediastinum constituting the aorti- huge subcarinal nodes (arrowheads), an unusual finding in copulmonary window. Although often idiopathic, many cases are thought to be due to an abnormal immunologic response to Histoplasma capsulatum infection. Fibrosing mediastinitis most commonly involves the middle mediastinum, primarily in young patients, and presents with signs symptoms of obstruction or compression of the superior vena cava, pulmonary veins or arteries, central airways, or esophagus. Vascular/enhancing Ectatic vessels, aneurysms, dissections, and con- (Figs C 26-11 to C 26-15) genital vascular anomalies. Large right paratracheal mass (arrow) with diffuse osteopenia from primary hyperpara- thyroidism. There is a subcarinal mass (M), encasement of the left main coronary artery (arrow), and narrowing of the left superior pulmonary vein (S). Contrast- enhanced scan shows the large aneurysm partially filled with thrombus (t). This vascular structure (arrow) (A) and slightly below (B) the aortic arch after the caused loss of the normal right paratracheal stripe on plain intravenous injection of contrast material demonstrate 52 radiographs. Enlargement of the azygos vein (arrow) that widened the inferior margin of the right paratracheal stripe on plain radiographs. Chemodectomas (any mediastinal com- partment) and pheochromocytomas are extremely rare. There may be associated rib or vertebral erosion, calcification, and a dumbbell appearance (part of the tumor is inside and part outside the spinal canal). Spinal neoplasm Rounded paravertebral mass with associated Tumors include osteochondroma, aneurysmal bone destruction. Extramedullary Single or multiple (often bilateral), lobulated or Usually associated with congenital hemolytic hematopoiesis smooth mass that generally occurs in the anemia. Splenomegaly (or a history of splenec- paravertebral region in the lower half of the tomy) is common. Aneurysm of Smooth or lobulated mass that typically pro- Frequently calcified and may become large enough descending aorta jects from the posterolateral aspect of the aorta to erode the vertebral column. Hiatal hernia Retrocardiac mass of variable size that usually Diagnosis confirmed by esophagram. Megaesophagus Broad vertical opacity on the right side of the Causes of marked dilatation of the esophagus (Fig C 27-4) mediastinum that often contains an air-fluid include achalasia, scleroderma, carcinoma, Chagas’ level (especially in achalasia). Lateral chest film in a patient with achalasia shows a mixture of fluid and air density in the dilated esophagus (arrows).

This fact can be verified by drawing a line which is drawn downwards along the anterior surface of the humerus which divides the circular trochlea into anterior l/3rd and posterior 2/3rd in the lateral X-ray film purchase combivir with american express. The following conditions are to be considered in injury around the elbow :— 1) Supracondylar fracture discount 300mg combivir free shipping. This is due to the fact that the lower epiphysis of the humerus after it has fused with the shaft is bent 8) Fracture of the olecranon process buy 300mg combivir otc. Note also the position and shape of the epiphysis 9) Posterior dislocation of the elbow forming the olecranon. This must not be mistaken for a with or without fracture of the coronoid fracture which usually occurs at the base of the olecranon process. The mechanism of backward supracondylar fracture is a fall on the hand with bent elbow, when the distal fragment is pushed backwards and twisted inwards as the forearm is usually full pronated. The displacement of the distal fragment is backwards, upwards, backward angulation with a slight internal rotation. The victims are usually children and present with a gross swelling at the elbow which is supported by the patient with his other hand. On examination there may be bruising and the posterior prominence of the elbow which requires differentiation from the posterior dislocation of the elbow. The possibility of an injury to the brachial artery as well as three main nerves should be foreseen and properly examined to exclude such possibility. An immediate reduction of the displaced fracture is essential and the elbow joint is kept flexed in collar and cuff in such a position as the radial pulse is well palpated. The mechanism of forward supracondylar fracture which is very much rarer than its previous counterpart is caused by a fall on the stretched hand with fully extended elbow so that the lower fragment is tilted forward. The patient presents with a more extended elbow than its previous counterpart and swelling around the elbow. The lower fragment is displaced laterally for a considerable distance which is obvious in anteroposterior film. The centre of ossifcation for the capitulum is likely to be mistaken for that of the head of the radius in anteroposterior view but not in the lateral view. In fact the centre of ossification for the head of the radius has not yet appeared. The elbow remains slightly flexed supported by the other hand and movement is extremely painful and restricted. Swollen elbow and tenderness on the lateral condyle are the usual clinical features. The mechanism of injury is usually a severe abduction force and young children between ten and fifteen years of age are the usual victims (before the medial epicondylar epiphysis fuses with the shaft). The peculiar feature of this fracture is that besides slight rotational displacement the medial epicondyle may be included into the joint by the forced abduction which momentarily opens up the medial side of the joint and thus sucks in the fractured medial epicondyle. The anterior half of the capitulum and the trochlea are broken off and displaced proximally. It is actually an epiphyseal separation with a triangular metaphysis attached to it. There is tenderness at the upper end of the radius with a lateral projection of the head of the radius which can be palpated. X-ray shows fracture of the neck of the radius with the head tilted forwards, outwards and distally. On examination there will be localized tenderness on the head of the radius and rotation of the forearm i. X-ray will confirm the diagnosis by showing either a vertical split in the radial head or a lateral major fragment of the head broken off and displaced laterally or a comminuted fracture with multiple fragments. The fracture line is at the narrowest point of the olecranon almost where it joins with the shaft of the ulna and must not be confused with the epiphysial line which lies near the tip of the olecranon process. If the triceps muscle goes in action during the injury a gap is expected between the two fragments of the olecranon process. If there is just a crack fracture, slight swelling, bruising, localized bony tenderness and bony irregularity will be the clinical features. Whereas in more severe injury with separation of fragments there will be more swelling, oedema and bruising at the fracture site. X-ray examination is obligatory not only to know the details of the fracture and displacement but also to assess the type of treatment which would be best suited for the particular case. The mechanism of posterior dislocation is a fall on the outstretched hand with the elbow in slightly flexed position. The coronoid process may pass posteriorly below the distal end of the humerus intact or may be fractured by the thrust against this part of the humerus. Very often the posterior dislocation is associated with lateral displacement of varying range. Clinically this condition may mimic the supracondylar fracture and the differentiating points between these two conditions should be borne in mind. Generally such a history can be elicited and the patient presents with a complaint of pain at the elbow. The elbow is more or less fixed in slight flexion and pronation; more flexion of the elbow and supination become painful and limited. On palpation one may find the head of the radius a little below and lateral to its normal position. When the displacement of the ulnar fracture is anteriorly and the head of the radius is dislocated anteriorly — this is known as Monteggia fracture-dislocation. When the displacement of the ulnar fracture is posteriorly and the head of the radius also dislocates backwards — this is known as reversed Monteggia. Mechanism is usually a fall on the hand and the body twists at the moment of impact thus forcibly pronating the forearm. A careful palpation will reveal radial dislocation besides rather easy detection of ulnar fracture-displacement. Movement of the elbow joint is completely restricted — both extension and flexion as well as supination and pronation. But two points deserve mentioning — (i) that the dorsal prominence is not at the level of the wrist but about one inch above it and (ii) that there is also a slight radial deviation which makes the head of the ulna more prominent. When the patient is asked to make a fist, the line of knuckles may not be on the normal line. In "mallet finger", which is caused by rupture of the extensor tendon at its insertion at the base of terminal phalanx, there is persistent flexion of the terminal phalanx. It must be remembered that normally the lower third of the radius is smoothly concave in front. In this case squeezing of the upper part of the radius and ulna together will elicit pain at the site of fracture. In order to demonstrate this, the clinician uses his two index fingers to locate the tips of the styloid processes in pronated forearm of the patient. The dotted line scaphoid bone is most important as very often fracture of the represents the horizontal level at the scaphoid is misdiagnosed as simple sprain and the patient tip of the ulnar styloid process. Moreover fracture of the scaphoid requires prolonged immobilization as this fracture is notorious for non-union and avascular necrosis of the proximal fragment. The scaphoid is palpated at the anatomical snuff-box with the wrist bent medially to expose the bone for palpation.

S. Gelford. Emmanuel College.