By V. Yorik. Drury University.

The swollen leg may become very much painful and is called phlegmasia alba dolens lamisil 250 mg mastercard. When all the deep veins become blocked discount lamisil 250 mg on line, the skin becomes congested and blue discount lamisil 250mg visa, which is called phlegmasia cerulea dolens. Gentle pressure directly on the calf muscles in the relaxed position will also elicit pain. Care must be taken to be gentle in manipulation lest it may dislodge a clot and cause pulmonary embolism. Squeezing of the relaxed calf muscles from side-to-side is also painful as the thrombosed deep veins in the calf are always tender and this test is known as Moses’ sign. Direct palpation of the deep veins such as femoral or popliteal vein may become painful if they are thrombosed. Only about l/4th of cases of the foot (Homan’s Sign) and (b) directly by produce symptoms and signs. If the patient has pulmonary embolism he may complain of breathlessness, haemoptysis and pleuritic pain. This swelling may affect the thigh if the thrombosis is in the iliac vein or just around the ankle if the thrombosis is confined to the calf. Change in the texture of the muscle is more important than tenderness, as there are many conditions which make muscles tender, but there are very few conditions which make the muscle stiff and hard. Forcible dorsiflexion of the foot which stretches the calf muscles will produce pain, which goes by the name of ‘Homan’s sign’ (Fig. When thrombosis of the veinr obstruct outflow of blood from the limbs, the superficial veins dilate and the leg feels hot. With obstruction of all the main veins the skin becomes congested and blue, which is known as phlegmasia cerulea dolens. The resulting thrombus is firmly attached to the vein, so incidence of pulmonary embolism is very much less in comparison to phlebothrombosis. Even if the patient has varicose veins, he should be thoroughly examined to exclude any occult cancer. To the contrary there may be extensive involvement of veins by the thrombotic process without clinical signs. In these cases destruction of venous valves with the sequelae of varicose veins, varicose eczema, ulceration and other trophic changes may result. Radioactive fibrinogen test and ascending functional phlebography have gone a long distance to diagnose deep vein thrombosis in rather early stage. The thyroid gland is firstly blocked by sodium iodide (100 mg) given orally 24 hours before the intravenous injection of 100 microcuries of 125I-labelled fibrinogen. The scintillation counter is first placed over the precordial region and the radioactivity over the heart is measured. The legs are elevated on an adjustable stand to decrease venous pooling and to give access to the calf for the scintillation counter. Preoperative counting can be compared with the postoperative counting on J the 1st, 3rd and 6th days after operation. A pneumatic cuff just above the ankle directs the contrast medium into the deep veins. The amount and rate of injection of the contrast medium is controlled by the filling of the veins as viewed on the television screen. The patient is asked to dorsiflex and plantarflex his foot thus propelling the contrast medium into the tibial veins. At the end of the procedure the contrast medium is washed off the leg veins by injecting 100 ml of normal saline containing heparin. Ascending functional cinephlebography can be obtained by continuous observation of the flow of the contrast medium on the television screen as it progresses through the tibial veins. The valvular function is considered to be normal when both the valve cusps are seen to open and close with onward flow of blood and no retrograde flow occurs even with the Valsalva manoeuvre. If the calf is squeezed or the calf muscles contract, it changes hum into a roar due to increased blood flow. If there is deep vein thrombosis (femoral or popliteal) between the calf and the groin, the roar does not occur. At first clinical features of the diseases of the lymph nodes will be described followed by diseases of the lymphatics. Primary malignant lymphomas occur at young age, though secondary malignant lymphadenopathy occurs in old age. The nodes are painful in both acute and chronic lymphadenitis, but are painless in syphilis, primary malignant lymphomas and secondary carcinoma. In filaria a periodic fever (especially during the full or new moon) is very common. An insignificant abrasion or inflammation in the drainage area may lead to lymphadenitis. Patient may complain of swelling of face and neck due to venous and lymphatic obstruction by the enlarged superior mediastinal group of lymph nodes or lymph nodes at the root of the neck. Dyspnoea may be complained of in case of enlargement of mediastinal group of lymph nodes due to pressure on trachea or bronchus. Similarly a patient who presents with enlarged cervical group of lymph nodes may give a past history of tuberculosis and the diagnosis becomes easy without thorough clinical examination and costly special investigations. Sometimes a patient with penile cancer may present with lump in the abdomen, which is nothing but enlarged iliac group of lymph nodes. A patient with enlarged cervical lymph nodes may give history of previous lung tuberculosis if specifically asked for. Lymphosarcoma and other types of lymphomas have also shown a tendency to run in families. Of these the position is important, as it will not only give an idea as to which group of lymph nodes is affected, but also Fig. So far as an ulcer or a sinus is concerned, the students If the femoral vessels are involved by such are advised to examine them as described in chapter 4 & lymph nodes fatal haemorrhage may result. Oedema and swelling of the upper limb and lower limb may occur due to enlargement of axillary and inguinal groups of lymph nodes respectively. Swelling and venous engorgement of face and neck may occur due to pressure effect of lymph nodes at the root of the neck. Dyspnoea and dysphagia may be complained of due to pressure on the trachea and oesophagus respectively. This is evident by the fact that carefully palpated with palmar aspects of the 3 fingers. While when the tongue is protruded out the rolling the fingers against the swelling slight pressure is tip of the tongue is deviated towards maintained to know the actual consistency of the swelling.

Replacement 3 lipomatosis of the kidney is seen as a fatty mass at the renal pelvis with markedly atrophied renal parenchyma ( order discount lamisil on-line. Conn’s syndrome commonly arises due to adrenal adenoma (80 %) or adrenal hyperplasia (20 %) buy generic lamisil 250 mg online. Aldosterone facilitates sodium absorp- tion and facilitates potassium excretion in the kidney generic lamisil 250 mg online. Increased aldosterone secretion can occur in some condi- tions that are not related to a true pathology such as anxiety, adaptation to hot weather, high potassium intake, low sodium intake, and pregnancy (second and third trimesters). Diferential Diagnoses and Related Diseases 5 Liddle syndrome is a rare autosomal dominant pediatric disorder characterized by failure to thrive, hypertension, metabolic alkalosis, hypokalemia, and an abnormally decreased rate of aldosterone and renin secretion. Children with Liddle syndrome present he developed pituitary adenoma in 2006 classically with a triad of hypertension, hypokalemia, and metabolic alkalosis. Death usually hyperkalemia, hyperchloremia, and normal renal occurs within the first year of life. Inconstant features include 5 Allgrove syndrome ( triple A syndrome) is a rare short stature and muscle weakness. The basic disease characterized by adrenal hypoplasia and abnormality is related to excessive renal sodium insufficiency, achalasia, and alacrima (lacks of retention, causing suppression of renin and teardrops). In contrast, symptoms of achalasia hyperaldosteronism, metabolic alkalosis, severe start from the early 6 months of age or early hypokalemia, and normal blood pressure. Diferential Diagnoses and Related Diseases 5 Wolman’s disease is a rare neonatal, autosomal recessive, lysosomal storage disorder that. Liver 160 Chapter 3 · Endocrinology and Metabolism Pheochromocytoma 5 Bladder paraganglioma is detected usually as a Pheochromocytoma is an adrenal medullary tumor that single mass with well-defined or lobulated border arises from chromafn cells of the sympathetic system with that may show cystic necrosis and circumferential increase secretion of catecholamine. It is usually suspected in a young patient (<30 years) with history of hypertension. Classic pheochromocytoma symptoms are summarized by 5 Ps: high blood pressure, pain (abdomen or heart), perspiration, p alpi- tation, and p anic attacks. Pheochromocytoma has a classical “rule of 10%”: 10% bilateral, 10 % inherited as autosomal dominant, 10 % extra- adrenal (paragangliomas), and 10% occurring with von Hippel–Lindau syndrome. Extra-adrenal intra-abdominal pheochromocytoma is usually detected in the para-aortic area at the level of the celiac axis and the renal hilum, paracaval area at the level of the renal hilum, and the retrocaval area. Patients present with signs of pheochromocytoma during micturition due to catecholamine release during micturition. Although most cases of with pheochromocytoma shows large mass in the area of the adrenal gland with multiple cystic changes inside the mass bladder paragangliomas are sporadic, they can be associated with phakomatosis (e. The mass contrast enhancement after contrast injection can show internal calcifications or cystic changes (. As the disease progresses, the temporal and frontal areas Neuroblastoma is a pediatric malignant tumor that arises are afected too. When the tumor histopathologically con- years of age with progressive disturbance of gait, disturbance tains mature ganglion cells, it is called ganglioneuroblastoma. Te most common complaint is pain or abdominal 5 Low-density white matter afecting mainly the fullness. Other uncommon symptoms include Horner’s syn- occipital lobes and corpus callosum (almost always). A fuid–fuid level within the cystic changes indicates hemorrhage within the tumor. Demyelinating diseases are characterized by the formation of normal myelin, and then the myelin is destroyed. In contrast, dysmyelinating diseases are characterized by the formation of abnormal nonfunctioning myelin. In congenital ticular tumor of adrenogenital syndrome (adrenal rests of adrenal hyperplasia, neonates present with bilateral testicular both testes): a case report and review of the literature. Characteristic imaging fndings in Wolman’s dis- hypoechoic masses within the testes. Testicular adrenal rest tumors and intensity lesions with marked contrast enhancement Leydig and Sertoli cell function in boys with classical con- after contrast injection (. Radiology can help establish the diagnosis of many endo- Precocious puberty is a condition characterized by prema- crinal pathological conditions that are related to abnormal ture development of secondary sexual characteristics before levels of estrogen and androgen when combined with the 8. Delayed female clinical history, clinical examination, and laboratory investi- puberty is defned as a girl who shows no signs of secondary gations. In contrast, delayed male puberty is defned as a male who shows no signs of secondary sexual Polycystic Ovary Disease (Stein–Leventhal characteristics by the age of 14. Te girl exhibits all features of of the central stroma is an important sign diferentiating true puberty. Maturation is incomplete with usually only one type of sexual characteristic developing early. In girls, if ovar- ian estrogen secretion predominates, breast development is the major manifestation of precocious puberty (premature thelarche). In contrast, if adrenal steroid secretion and early and rogenization predominate, pubic hair development in the absence of virilization is the major manifestation of pre- cocious puberty (premature adrenarche). Radiological evaluation of a child with precocious puberty should include bone age assessment, ultrasound for. The lesion has 3 low T1 and high T2 signal intensities and does not enhance after contrast administration (because they are normal cells but disorganized) (. Signs on Plain Radiographs Bone age determination is an important step in evaluating a precocious puberty patient. Children with premature adrenarche or thelarche often show normal or slightly advanced bone age. The ovarian volume is the largest among all types of causes of precocious puberty (e. Te third is seen in patients aged 50–80 cystic ovarian mass due to hyperraction luteinaris years old. Pathological gynecomastia is related to increased serum level of estrogen in males or reduced serum androgen level. Causes of pathological gynecomastia can be idiopathic (25%), drug related in 15% of cases (e. Stromal tumors make cysts that mimic cystic neoplastic disease up approximately 5% of testicular tumors and may arise (. In contrast, neoplastic cysts are from Leydig, Sertoli, theca, granulosa, or lutein cells. Tey form a junction with one another forming a 5 The anterior pituitary gland may show convex blood–testis barrier. Sertoli cells are located within the semi- upper surface due to hypertrophy in the absence niferous tubules in males. Leydig cell tumors constitute approximately 2% of tes- ticular tumors and commonly seen in male children between 3 and 6 years old, as well as adults between 30 and 50 years of age. Patients present with painless scrotal swelling, and the tumors are hormonally active in up to 30% of cases. Serum androgen or estrogen levels are high causing precocious puberty, gynecomastia, or impotence. Testicular Sertoli cell tumors are rare, and they lead to feminization and gynecomastia in males.

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Barium enema is contraindicated and straight X-ray of the abdomen is only required to establish the diagnosis buy generic lamisil 250mg on line. If the condition of the patient does not allow such operation exteriorization of the involved segment should be performed discount lamisil 250 mg otc. After ingestion of cyst through contaminated food or drink purchase discount lamisil online, the cyst passes through the stomach into the small intestine. The cyst wall is resistant to the action of the gastric juice but is digested by the action of trypsin inthe intestine. Excystation occurs in the lower part of the ileumand each cyst liberates a single amoeba with four nuclei (tetranucleate amoeba) which divides and forms eight trophozoites by the division of four nuclei. The trophozoite phase is responsible for producing the characteristic lesion of amoebiasis. Cutaneous amoebiasis may be found over the region adjoining a visceral lesion such as in the area of drainage of liver abscess or colostomy wound, in the sites of ruptured appendicular and peri­ colic abscesses. Extensive necrosis and sloughing of the skin and subcutaneous tissues are caused by the trophozoites of E. Besides this granulomatous ulceration, a granulomatous mass simulating an epithelioma may be seen in the perianal region. Though the whole large gut may be involved, yet there are mainly two places which show predilection to such ulcer formation — these are the caecum and the sigmoid colon. Amoebic ulcers are ragged undermined ulcers, which are flask-shaped on vertical section. These ulcers are usually round or oval and become transverse when these ulcers coalesce. Usually perforation occurs in a confined place where adhesions have previously formed. So local peritonitis develops followed by abscess formation, which eventually needs draining. Healing of extensive ulcers may lead to stricture formation and intestinal obstruction may result. An uncommon complication of chronic amoebic colitis is the amoeboma, a mass of granulation tissue in the colon. Granulomas are most frequent in the caecum which may be confused with carcinoma, tuberculosis or actinomycosis. Onset is abrupt with high fever, abdominal cramps and profuse bloody diarrhoea and tenesmus. This condition must be differentiated from ulcerative colitis and Crohn’s colitis. Period of relapse is followed by a period of remission lasting for many weeks or months. Diagnosis may be difficult as cyst or trophozoite may not be detected in the stool. Alternatively emetine-and tetracycline injection should be given initially to control symptoms followed by a course of metronidazole. Chronic amoebic dysentery may be treated by diiodohydroxyquin 650 mg 3 times daily for 20 days. Diloxanide furoate 500 mg 3 times daily for 10 days is also successful in cases where the previous drug is not so effective. These reside in the mouth and invade whenever there is a breach in the mucous membrane. The cervico-facial area is the most commonly involved site followed by thoracic and abdominal involvement. This fungus normally remains quiescent, after trauma it becomes virulent and infection results. At any stage of the disease if pus is collected and allowed to trickle down the side of a test tube, sulphur granules may be discovered. Actinomycosis rarely gives rise to obstructive symptoms as the intestinal lumen is not narrowed. A prolonged intensive course of penicillin (10 megaunits daily) is quite effective. Angiodysplasias occur mainly on the right side of the colon particularly in the ascending colon and caecum. Actual pathology lies in the vessels which are thin walled, distorted and with scanty muscles in their walls. The lesions may be seen on careful inspection, as of a few millimetres in size and reddish raised areas. It is even more difficult to diagnose at laparotomy as these cannot be felt nor seen from outside of the colon. It must be remembered that the common finding however is obscure gastrointestinal bleeding and these are diagnosed when investigated for occult bleeding. The percentage of the cases presented with occult bleeding is almost 50% or even more. Before the advent of these two investigating armamenterium, this condition was not known. The most reliable technique for demonstrating these lesions is undoubtedly the selective mesenteric angiography. In case of failure one can try using technetium-99m ("Tc) — labelled red cells, which will confirm the diagnosis. When the bleeding is brisk, a catheter is introduced through the appendix stump and the colon is irrigated with saline. Electrocautary laser ablasion, injection sclerotherpy or argon beam ablation may be used to stop acute haemorrhage. When the lesion is a big one or there are multiple lesions in a localised part of the colon, that part of the colon has to be resected with end-to-end anastomosis to maintain continuity of the bowel. If there are multiple lesions involving other parts of the colon or it is still not clear exactly which segment of the colon is involved, the treatment is total colectomy with ileorectal anastomosis. We shall now discuss multiple false diverticula of the colon which is known as diverticulosis coli. Diverticula tend to occur in rows on either side of the colon between mesenteric and the respective antimesenteric taeniae. The proximity of this vessel presumably accounts for the propensity of diverticula to bleed. The followings are usually incriminated — (a) Abnormal contraction rings form in the sigmoid colon. With contraction of the colonic muscles intraluminal pressure goes upto at least 90 mm Hg.

But in general hospital it is better to provide continuous drainage through a fine Gibbon catheter discount lamisil 250 mg without prescription. Later on two types of incontinence may be seen:— (i) An automatic bladder which contracts reflexly when the bladder is full to certain extent and (ii) overflow incontinence where bladder continues to distend till it is manually emptied by suprapubic pressure or it is drained when it is extremely full buy lamisil 250 mg without a prescription. Such patients may require transurethral resection of the bladder neck or sphincterotomy cheap lamisil line. But these operations should be considered only when 3 full months of bladder training has been completed. The concerned joints should be moved passively through their full ranges at least twice daily. A portion of the bone which gives attachment to the concerned muscle becomes fractured and detached from the parent bone. Violent muscle contraction separates the apophyses which give attachment to these muscles. Usually three sites are affected:—(a) Anterior superior iliac spine avulsion due to contraction of the satorius muscle which is attached to that, (b) Anterior inferior iliac spine is avulsed due to violent contraction of rectus femoris attached to it. Normal activities can be resumed when pain disappears and the patient feels comfortable. Three types of fractures are usually seen in this group — (i) fracture of the ilium, (ii) fracture of the acetabulum with central dislocation of the hip and (iii) fracture of the pubic rami one or both on one side only. Only when there is acetabular fracture with large portion of the roof or posterior wall detached, open reduction and screw fixation become necessary. There is obviously considerable displacement and there is also chance of injury to the intrapelvic structures. One-half of the pelvis is usually affected and the symphysis pubis is forced apart in front whereas in the back there is usually fracture at the sacro-iliac region. The affected side of the pelvis fractures on two places, the pubis in front and the ilium behind. When pubic rami are fractured and there is considerable suprapubic tenderness one must be very careful to assess urogenital damage. The urinary bladder and urethra should be investigated properly to exclude any damage in those regions. In hinge fractures the gap may be felt in the symphysis which is abnormally large. In vertical force fractures there is a possibility of damage to the nerve roots and particularly the sciatic nerve. In hinge force fractures there is an abnormal gap at the symphysis pubis and there is a fracture near or subluxation at the sacro-iliac joint. In vertical force fractures the pubic rami and posterior portion of the ilium are fractured on same side with upward shift of the segment of pelvis between the fractures. This may also occur when the symphysis pubis is forced apart as in hinged type of injury. If he can pass urine and the urine is clear then nothing should be done except to keep watch on the patient particularly his subsequent urines. If the patient fails to pass urine, a soft rubber catheter should be passed through urethra. In this case soft rubber catheter cannot be passed through urethra into the bladder. By ‘rail-roading’ methods a self retaining catheter is introduced into the bladder. The suprapubic bladder drainage is continued alongwith a corrugated rubber drain to the retropubic space in front of the bladder which is known as Cave of Retzius. It must be remembered here that suturing of the rupture is required alongwith bladder drainage and a drain to the retropubic space (Cave of Retzius). During that period movement of the lower extremities particularly the hip joints should be performed. After 3 weeks when the patient is almost comfortable he can get up and walk normally. Weight-bearing is not harmful as there is no damage to the line of weight transmission. It must be remembered that this type of fracture is particularly liable to cause damage to the urethra and urinary bladder. A compression force is applied to the affected pelvis so that it gradually ‘closes’. After reduction that means after proper alignment of the pelvis, a firm binder or a lumbo­ sacral corset should be used. The wire is passed through drill holes or through obturator foramina to bring the two pubic bones together. This will bring down the fractured segment in line with the other side of the pelvis. Skeletal traction is applied and is continued for 6 weeks till the fracture unites. This is the most important complica­ tion and adequate attention should be given to this complication. A fall on the buttock usually causes fracture of the coccyx or sprain of the sacro-coccygeal joint. Tenderness is usually localised on the fractured site, but sometimes it may be generalised affecting the whole of middle of the buttock. Occasionally the roots of the sacral nerves may be damaged giving rise to neurological deficits in the areas of supply of the affected nerve roots. If the X-ray does not reveal any fracture, a sprain of the sacro-coccygeal joint should be the diagnosis. Sometimes the patient only complains of pain near the coccygeal region at the time of sitting. If the pain is not relieved with this measure injection of local anaesthetic to the tender spot or even excision of the coccyx should be considered. The connective tissue layer, which binds the skin to the galea aponeurotica, is also very dense and contains vessels and nerves. For this layer, the superficial 3 layers namely — skin, connective tissue and galea aponeurotica behave as one layer. From this layer, the scalp wounds bleed profusely and the bleeding does not stop by itself which is usual in case of bleedings any where in the body. This is because of the fact that the vessel walls are firmly anchored to the fibrous septa, which traverse through this layer and prevent the vessels from retraction. The galea aponeurotica is a dense aponeurosis, continuous in front with the frontalis muscle (which is not attached to the bone but is attached to the eye-brow and root of the nose), behind with the occipitalis muscle (which is attached to the occipital bone) and laterally with the temporal fascia (which is attached to the zygomatic arch). The loose areolar tissue is said to be ‘the dangerous layer of the scalp’, as the emissary veins, connecting the dural sinuses with the veins of the scalp, traverse this layer. The pericranium is like the periosteum, which is loosely attached to the skull except at the suture lines, where it is firmly attached. So any collection of fluid underneath the pericranium takes the shape of the bone concerned (cephal haematoma).

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