Treatment of localised painful lesion is by external radiotherapy in order to relieve pain and to prevent further bone destruction order himcolin 30 gm fast delivery. Lytic bone metastasis in weight bearing bone such as the femur require careful evaluation to determine how extensive the cortical damage is discount 30gm himcolin visa, since some will benefit from prophylactic pinning followed by radiotherapy in order to prevent pathological fractures buy himcolin no prescription. There is evidence that subsequent progression of bone metastasis can be reduced with biphosphonates. Disodium dichloromethylene diphosphonate (clodronate) in the dose of 1600 mg/day when administered between 3 and 9 months there is considerable reduction in the incidence of hypercalcaemia and subsequent skeletal fractures in these patients. Thus there is a place for clodronate in the palliation of women with bone metastases. Presenting symptoms include headache, nausea and vomiting fits, paresis and incoordination. Clinical examinations may reveal evidence of papilloedema with localised central nervous system signs. Treatment is immediate reduction in cerebral oedema with steroids (dexamethasone 4 mg 4 times daily). Only in rare circumstances surgery may be needed in the form of removal of isolated cerebral metastasis. Carcinomatous meningitis may occasionally occur causing symptoms of confusion, headache, nerve root pain or cranial nerve palsy. These cases respond to radiotherapy, but the place of intrathecal chemotherapy is still controversial. Vertebral bone metastases may cause spinal cord compression giving rise to backache, girdle pain, limb weakness or even bladder dysfunction. Patients with pleural effusion usually complain of shortness of breath, sometimes associated with cough. Clinical examination reveals dullness on percussion and reduced air intake over the lung base on the affected side. Confirmation of diagnosis is made by needle thoracentesis taking enough fluid for cytological evaluation. Cytological evidence of malignant cells is noticed in approximately 60% of patients. If a pleural biopsy is performed about 7% to 8% more cases will be confirmed as having metastatic disease. Thoracoscopy may be of value in confirming the presence of metastasis with parenchymal deposits being identifical in upto 60% of patients with negative fluid cytology. Firstly the effusion should be drained to dryness, secondly an effective agent should be instilled (to achieve pleurodesis) and finally the parietal and visceral pleura must be apposed so that a fibrous reaction can occur. The agent which is most effective is the talc, which is insufflated after drainage under general anaesthesia and an intercostal drain is left in place for 5 days. If the patient is too ill to undergo general anaesthesia, tetracycline (500 mg) can be instilled under local anaesthesia. Only in extreme rare cases, where pleurodesis may fail due to presence of loculation of effusion, may be benefited from decortication, though it carries a mortality rate of 5%. Only in selected cases insertion of peri toneovenous shunt may help in relieving abdomi­ nal distension. If such agents cannot control the pain, morphine sulphate slow-release tablets should be given together with antiemetics. Diamorphin continuous infusion may be valuable in the terminal stages of the disease. Followings are the modes of treatment in various problems of advanced breast cancer — Problems Treatment Regional or local recurrence Local radiotherapy. Reconstruction using autologus tissue alone, either as a pedicle flap or a ‘free’ flap (e. The world-wide popularity of expanders implant reconstruction is related to the speed and apparent simplicity of this approach, which has no donor site morbidity and requires a short hospital stay and little convalescence. Following subpec­ toral placement of tissue expander, the breast mould is created by repeated outpatient expansion introduc­ ing saline through a remotely-sited or integral injection port. Modern breast implants are manufactured with an outer shell of polydimethylsiloxane (silicone) and contains a ‘filler’ material such as silicone gel which gives the implant its volume. A recent wave of adverse publicity that silicone is both immunogenic and carcinogenic are unfounded. Some small amounts of silicone gel ‘bleed’ through the shell of all implants into the surrounding tissues. The subcutaneous technique is often condemned as it frequently causes skin necrosis and extrusion. When inserting the implant subpectorally care must be taken to ensure that the prosthesis is in an appropriate position. There is a tendency of such implant to migrate superiorly, so it is necessary to divide the fascial bands between the insertion of pectoralis muscle and the rectus abdominis. The main problem is the formation of a capsule, which is unsightly and imparts hard texture to the breast. The Becker expander consists of an outer lumen filled with silicon gel and an inner chamber filled with saline with self­ sealing side port. This inner chamber with saline is gradually expanded to the desired volume over a number of weeks. Once expansion is complete the saline chamber is aspirated to allow creation of a reconstructed breast of similar volume to that of the opposite side alongwith providing some ptosis. The most commonly adopted technique has been the pedicled lattissimus dorsi myocutaneous flap due to its proximity and good blood supply. A few surgeons even use free transverse rectus abdominis flap with microvascular anastomosis between epigastric and thoracodorsal vessls. Unfortunately it is time-consuming proce­ dure which requires specific expertise with microvascular anastomosis. In contrast to prosthesis reconstruction, these autologus techniques are complex and more expensive procedures which require comprehensive training and experience. Lattissimus dorsi myocutaneous flap is used mainly in pedicle form and often used due to its proximity and good blood supply. Complications are mainly related to donor site morbidity including pain, seroma formation and scarring. Rectus muscle is taken with each pedicle to improve the circu­ lation and reduce the likelihood of flap necrosis. Excellent cosmetic results are achieved at the expense of 5 to 7 days hospital stay, a 4 to 6 weeks convalescent period and an overall complication rate of 16% to 28%. Major complications include abdominal weakness, abdominal herniation and flap loss. After separating the flap from its native blood supply and transpo­ sition into the empty breast pocket, circulation of the flap is re-established by performing a microvascular anastomosis between the inferior epigastric and the thoracodorsal or internal mammary vessels.

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Sometimes the operation should be performed under local anaesthesia in old and cardiac patients discount 30 gm himcolin fast delivery. So patients with these conditions generic himcolin 30 gm mastercard, if operated on trusted 30gm himcolin, will definitely come back with recurrence of hernia. At the same time, the surgeon should look for the tone of the abdominal muscles to determine whether herniorrhaphy or hernioplasty will give the best result. Similarly cancer of the breast, if shows secondary metastases in bones and lungs, is considered to be in the last stage. Upper limbs I) General examination of the arms and hand with particular reference to their vascular supply and nerve supply (Power, tone, reflexes and sensations). Lower limbs 1) General Examination of legs and feet — with particular reference to the vascular supply and nerve supply (Power, tone, reflexes and sensation). Examination of the external genitalia Sputum, vomit, urine, stool should be examined by naked eye and under microscope, if required. He will now require a few investigations to come to the proper clinical diagnosis. The students should know how to diagnose common diseases first and then he should think for possibility of rare diseases. By this we mean that not only the ailing organ is identified, but the type of pathological process at work and its extent in different directions is also understood. As for example, in carcinoma of the breast, one should mention under this heading the clinical stage of the disease and the various structures involved in metastasis. Similarly in case of inguinal hernia, the clinician should not only mention that whether it is direct or indirect, reducible or irreducible, but also should mention its content — either the intestine or omentum or a portion of urinary bladder. While writing medical treatment the students should clearly mention the drugs given to the patient, their doses and duration of the treatment. In surgical treatment they should clearly mention the type of anaesthesia given and type of operation performed. Students should also mention if any investigation performed during the postoperative period, the dressings done during the period, condition of the wound etc. The students should learn how to make a discharge certificate mentioning in nutshell the diagnosis, special investigations performed, the treatment received and the postoperative advice. He should also mention the date when the patient should report to the outpatient clinic to let the surgeon know his progress and his complaints. Now the students should make a record of the days the patient came for follow-up and the advice given by the surgeon. In case of death, the student should mention the cause of death and also make a note of the result of the postmortem examination, if carried out. Tenderness means pain which occurs in response to a stimulus given by somebody (usually from the doctor). This is located in a particular dermatome of the body supplied by the affected sensory nerve trunk or root. The pain sensation from the affected structure is conveyed to the brain either by somatic nerve or by the autonomic nervous system. The deep pain is vague compared to the superficial pain and may be one of the various types which are described below. The deep pain may be referred to some other area of the body due to common area of representation in the spinal cord (supplied by the same segment). The deep pain may cause involuntary spasm of the skeletal muscles supplied by the same spinal cord segment. A careful history must be taken about pain so that it may help to reach the diagnosis. If careful history is not taken about pain, it may frequently confuse the clinician to make wrong diagnosis. The followings are the various points which must be asked to know the cause of pain. So exact localization may not be possible particularly in case of deep pain originating in thoracic or abdominal viscus. A patient with acute appendicitis when brought to the surgeon may locate pain at the right iliac fossa. This simple history is highly important to come to the diagnosis of acute appendicitis and this history only differentiates this condition from many others. A long continued pain with insidious onset indicates chronic nature of the disease e. Whereas recent onset of pain with sudden arrival indicates acute nature of the disease e. On the other hand patients may find it very difficult to describe the nature of their pain. Burning pain is typically experienced in case of peptic ulcer or reflux oesophagitis. As if pins and needles are being pricked in that area of the skin supplied by the affected sensory nerve. Secondly the pain is of griping nature, may not be very excruciating and it is often associated with vomiting and sweating. Usually four types of colics are seen in surgical practice—ureteric colic, biliary colic, intestinal colic and appendicular colic. Such sensation is often felt in case of volvulus of intestine, torsion of testis or ovarian cyst. Characteristically the griping pain of intestinal colic is felt for less than a minute. The pain of angina of effort ceases within 5 minutes of resting, whereas that of a myocardial infarct may continue for hours. The pain in the epigastrium remains but at the same time the pain spreads or radiates to the back. Irritation or inflammation of the diaphragm causes pain at the tip of the shoulder. Referred pain occurs when the central nervous system fails to differentiate between visceral and somatic sensory impulses from the same segment. In this case diaphragm is supplied by phrenic nerve (C3, 4 and 5) and the cutaneous supply of the shoulder is also C4 and C5. Diseases of the hip joint may be referred to the knee joint as both these joints are supplied by the articulate branches of the femoral nerve, obturator nerve and sciatic nerve. This occurs when an abdominal viscus becomes diseased, the original pain is experienced at the site of distribution of the same somatic segment. But when the parietal peritoneum overlying the viscus is involved with the disease, the pain is experienced at the local site of the viscus. In case of acute appendicitis pain is first felt at the umbilical region which is also supplied by the T9 and 10 as the appendix, but later on pain is felt in the right iliac fossa when the parietal peritoneum above the appendix becomes inflamed. Often patients with acute appendicitis give history that they feel pain on waking up in the morning, in fact pain awakens the patient.

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Up to 50 mL of fluid is necessary to tumor cells (malignant pleural efusion) himcolin 30 gm discount, or lymph obliterate the posterior costophrenic angle buy himcolin without prescription, and (chylothorax) cheap 30gm himcolin visa. Silhouette sign effusion that occurs below the lungs at the is a term used to describe any opacity within the diaphragmatic surface. It occurs usually at the right lung’s minor fissure, and it has biconvex contour mimicking a mass (. Very rarely, a benign form of mesothelioma can grow along the major or minor fissures mimicking encysted pleural effusion, a condition known as pseudotumor. Almost 30 % of patients with pneumonia develop pleural effusion and usually resolve with antibiotic therapy. In contrast, Pseudo - Meigs ’ syndrome is defned as absence of the peripheral vasculature laterally and ascites, pleural efusion, and ovarian tumor other than lung tissue with possible increased density due to the ones mentioned previously. Lung apices are cells from the ascites or the pleural efusion is mandatory the best sites checked for early detection of for the diagnosis of Meigs’ syndrome. Te disease is commonly accompanied by idiopathic pleural efusion, chronic bronchiectasis, chronic sinusitis, and lymphedema of the face. Yellow nail syndrome may be accompanied by rheumatoid arthritis or thyroid disease. Te disease is believed to be caused by hypoplasia, atresia, or varicosity of the lymphatics. Pneumothorax Pneumothorax is a condition characterized by the presence of air between the parietal and visceral pleura. Tere are three types of pneumothoraces: 5 Primary (spontaneous) pneumothorax: this type occurs without a defned cause and mainly seen in young males. Primary pneumothorax nails of the yellow nail syndrome is attributed to rupture of subpleuritic blebs at lung apices according to some investigators. Pneumomediasti- num is characterized by the presence of air around the mediastinal structures. Always correlate the radiological findings with the patient history and current status. Unilateral pleural calcifcation occurs usually as a late com- 5 Asbestos-related diffuse pleural thickening is a plication of empyema, hemothorax, fungal infection, or bilateral thickening involving at least 25 % of the tuberculosis. Bilateral pleural calcifcation is commonly chest or 50 % if unilateral, plus pleural thickness caused by asbestosis >5 mm at any site. The diffuse pleural thickening Asbestosis is a pathological condition that results from can affect the visceral layer and the parenchyma previous exposure to asbestos. Tey are com- (3–5 cm) that abuts over the pleura with a posed of focal areas of parietal pleural thickening with dense hyaline collagen. Mesothelioma is an uncommon primary tumor of the serosal lining of the pleura or peritoneum. Bronchogenic carcinoma develops in 25% of cases of asbestosis, and it is the main cause of death. Signs on Chest Radiographs 5 Pleural plaques are seen as smoothly demarcated, well-defined opacities (in profile) or faint, ill-defined plaques (en face), in a bilateral fashion. Unilateral pleural plaques may be seen in 25 % of cases and usually located on the left side. The most common pleural thickening (94 %) that commonly involves manifestation of malignant mesothelioma is a the lung bases (50 %) (. Diaphragmatic involvement (80 %), pleural calcification (20 %), and pleural effusion (80 %) are other common features. Notice the nodular mass that follows the pleural distribution in (b) (arrowhead ) Further Reading Goyal M, et al. Spontaneous pneumothorax in children: Noncardiogenic pulmonary edema has the same radio- when is invasive treatment indicated? Pneumomediastinum and pneumothorax as nitis is a pulmonary edema that occurs due to inhalation of presenting signs in severe Mycoplasma pneumoniae noxious chemical substance such as ammonia, smoking pneumonia. Te mechanism of pulmonary edema is the result of one of the three mechanisms: irritation of the tracheobronchial 7. Drug-induced and transfusion reac- Alveolar diseases are characterized by flling of the alveoli tions pulmonary edema arise due to anaphylactic lupus-like with materials that impede its normal physiological function reaction formation. Names of the conditions depend upon the content of ingestion or recent transfusion reaction. Negative pressure pulmonary edema is a term used to describe noncardiogenic edema that arises due to acute Types of Alveolar Lung Diseases airway obstruction (type 1) or afer the relief of chronic air- way obstruction (type 2). Usually, pulmonary edema 5 Alveoli flled with malignant cells: bronchoalveolar causes homogenous opacities, but sometimes carcinoma they can cause nodular or blotchy opacities. Pulmonary Edema 5 Kerley lines represent thickening of the interlobar T e alveoli are the main units for respiratory–blood ventila- septae. Lung lymphatics and veins run in the tion and oxygenation and normally are full of air on inspira- interstitium, leakage of the veins (edema), or tion. You can think of the alveoli as an empty cup, and any tumor infiltration of the lymphatics (lymphangitis pathological condition that flls this cup will form a patho- carcinomatosis) can result in thickening of the logical condition according to the cup content. Kerley A lines are long lines located near the lung Pulmonary edema can be either due to cardiac disease hilum and extend obliquely near the (cardiogenic) or other conditions (noncardiogenic). It starts as an interstitial edema before it turns C lines are a mixture between the two lines into alveolar edema, because the pulmonary veins lie in the resulting in a reticular pattern. As the hydrostatic pressure within the veins rises, 5 Air-bronchogram sign is a sign seen when the they leak into the interstitium frst and then progress to fll the alveoli are filled with fluid and the terminal alveoli. This process is rapid, and only very early edema can be seen as a pure interstitial linear pattern in chest radiographs. The bronchioles appear as radiolucent Pulmonary edema, pulmonary hemorrhage, lines within whitish radio-opaque opacities pneumonia, and alveolar carcinoma all look (. The medical history plays a very important role in differentiating these a conditions because the radiographic signs can be nonspecific. In cases of cardiac diseases and pulmonary hypertension, the upper lobe vessels will be as wide as the lower lobe vessels in upright radiographs. Note that the upper lobe vessels can be seen dilated normally in supine (lying) chest radiographs (e. Silhouette sign refers to a patchy, ill-defined radio-opaque shadow that obscures part of the normal mediastinal configuration. Lobar pneumonia is central, whereas cardiogenic edema typically starts from characterized by an “air-bronchogram sign. This type is seen Pneumonia with Staphylococcus aureus, Haemophilus infuenza, and Pneumonia is a condition characterized by an infectious Mycoplasma pneumonias. Pneumonia can be caused by bacteria infection that involves the interstitial septa and giving (e.

G. Temmy. Mount Mercy College.