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CURSO DE INGLÊS EM NATAL

TURMAS REDUZIDAS OU AULAS PARTICULARES

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By Q. Rocko. University of Dubuque.

Pigmentation of the skin is venous return of the upper limb leading to excessive seen in moles order sildalis pills in toronto erectile dysfunction in diabetes type 1, naevi or after repeated oedema and wrist drop from nerve involvement buy cheapest sildalis and sildalis erectile dysfunction age 29. Presence of scar indicates either previous operation (when the scar is a linear one with suture marks) 120mg sildalis with visa youth erectile dysfunction treatment, injury (a regular scar) or previous suppuration (when the scar is puckered, broad and irregular). Presence of ulcer on the skin over the swelling is examined as discussed in the next Chapter. An axillary swelling with oedema of the upper limb means the swelling is probably arising from the lymph nodes. Wasting of the distal limb indicates the swelling to be a traumatic one and the wasting is due to either non-use of the limb or due to injury to the nerves. This should immediately give rise to suspicion of possibility of retro-sternal prolongation of the swelling, giving rise to venous obstruction. The students must be very methodical in this examination and follow a definite order, which is given below, so that they would not miss any important examination. The students should also be very gentle in palpation not to hurt the patients and a few swellings may be malignant and may well spread into the system due to reckless handling. This examination should be done first in palpation, as manipulation of the swelling during subsequent examinations may increase the temperature without any definite reason. To elicit tenderness, one should be very gentle and should not give too much pain to the patient. Inflammatory swellings are mostly tender, whereas neoplastic swellings are not tender. The vertical and horizontal dimensions of the swelling are also better clarified by palpation. It is a good practice to mention in cm the vertical and horizontal diameters and should be sketched on the history sheet clearly indicating the position of the swelling as well. If a portion of the swelling disappears behind a bone, it should be clearly mentioned and its importance cannot Fig. The surface of a swelling may be smooth (cyst), lobular with smooth bumps (lipoma), nodular (a mass of matted lymph nodes) or irregular and rough (carcinoma). Sometimes the surface of the lump may be varied according to variable consistency. Broadly speaking, neoplastic swellings and chronic inflammatory swellings have well-defined margins. Benign growths generally have smooth margins whereas malignant growths have irregular margins. The most important finding, which differentiates benign tumour like lipoma from the cyst is that the margin of the former slips away from the palpating finger, but does not yield to it, whereas the margin of the latter yields to the palpating Fig. The fingers and cannot slip away from the margin of a cyst yields to the palpating finger and does not examining finger (Slip sign in Fig. The consistencies, just described, are all solid except the cystic one, which contains liquid within it. It should be borne in mind that consistency of a solid swelling may also be soft as seen in case of a lipoma. The fingers of the hand ‘P’ finger but slips away from it; but in case of a cystic swelling the will remain passive and perceive the edge yields to the pressure of the palpating finger and does not movement of the fluid displaced by the slip away. While palpating for consistency, one must look for whether the swelling is getting moulded or not to pressure. So the swelling must be a sebaceous cyst or a dermoid cyst or even an abdominal (colonic) swelling containing faecal mass. This means that there is oedematous tissue and most often the swelling is an inflammatory one. This will increase pressure within the cavity of the swelling and will be transmitted equally at right angles to all parts of its wall. In the first figure it is shown how a small swelling may pressure within the swelling be displaced as a whole by the displacing finger (D) and it shifts towards passively. Very often fluctuation the watching finger (W) to elicit a false sense of fluctuation even when is elicited in this manner in case the swelling is a solid one. The second figure is the correct method of of hydrocele, (iv) In case of very eliciting fluctuation in case of a small swelling. Two fingers of the left small swelling, which cannot hand (watching fingers ‘W’) are placed on two sides of the swelling and the index finger of the right hand (displacing finger ‘D’) is pressed accommodate two fingers, this on the swelling to displace the fluid within the swelling. The swelling containing fluid, will be softer at the centre than its periphery, while a solid swelling will be firmer at the centre than its periphery. This test should be done in two planes at right angles to one another as the conventional method. The students should not try to perform traditional fluctuation test on a small swelling, as pressure exerted by one finger, will simply displace the swelling and fluctuation test cannot be performed, (v) For very large swelling more than one finger of each hand are used. Two or even three fingers may be used for providing pressure (displacing fingers) and palmar aspect of four fingers of the other hand may be used to perceive the movement of displaced fluid (watching fingers), (vi) Very soft swellings sometimes yield false positive sense in fluctuation test. The swellings which can be included in this list are : lipoma, myxoma, soft fibroma, vascular sarcoma etc. But if the students become careful while performing the fluctuation test, they will easily realise that these swellings yield to pressure, but fail to expand in other parts of the swelling like a true fluctuant swelling. In case of a big swelling, this can be demonstrated by tapping the swelling on one side with two fingers while the percussion wave is felt on the other side of the swelling with palmar aspect of the hand. In case of a small swelling, three fingers are placed on the swelling and the middle finger is tapped Fig. A swelling may be fluctuant as it contains fluid, but may not be translucent when it contains opaque fluid, such as blood or pultaceous material (dermoid or sebaceous cyst). In day time, this can be achieved by a roll of paper, which is held on one side of the swelling, while a torch light is held on the other side of the swelling. The torch light should not be kept on the surface of the swelling, but on one side of the swelling, while the roll of paper on the other side so that the whole swelling intervenes between the light and the roll of paper. The swellings, which are likely to give rise to impulse on coughing, are: (i) those, which are in continuity with the abdominal cavity (e. Due to coughing, pressure is increased within the abdominal, pleural, spinal and cranial cavities. This increase in pressure is transmitted to the swelling, where the impulse is felt. The compressible swellings may not have connections with the abdominal, pleural, spinal or cranial cavity. The most important differentiating feature between a compressible swelling and a reducible swelling is that in case of the latter, the swelling completely disappears as the contents are displaced into the cavities from where they have come out and may not come back until and unless an opposite force, such as coughing or gravity is applied. But in case of the former, the contents are not actually displaced, so the swelling immediately reappears as soon as the pressure is taken off. Two fingers, one from each hand, are placed on the swel­ ling as far apart as possible (Fig.

Rare causes of isolated tricuspid valve disease include carcinoid syndrome order 120mg sildalis overnight delivery erectile dysfunction protocol book pdf, endomyo- cardial fibrosis purchase sildalis with visa medication that causes erectile dysfunction, and right atrial myxoma discount 120 mg sildalis overnight delivery vasculogenic erectile dysfunction causes. Pulmonary stenosis or Enlargement of the right atrium and right Right atrial enlargement secondary to enlargement atresia ventricle; decreased pulmonary vascularity. Usually nary vascularity (usually some degree of a ventricular septal defect or patent ductus pulmonary stenosis). The smaller the shunt, the more marked the elevation of right atrial pressure and more striking the enlargement of this chamber. Decreased pulmonary vascularity; flat upper portion of the right ventricle is effectively or concave pulmonary outflow tract; narrow incorporated into the right atrium. Uhl’s disease Radiographic pattern identical to that in Focal or complete absence of the right ventricular Ebstein’s anomaly. Most common cause of cyanotic congenital heart disease beyond the immediate neonatal period. If there is severe pulmonary stenosis, blood flow from both ventricles is effectively forced into the aorta, causing pronounced bulging of the ascending aorta and prominence of the aortic knob. The overloading of this chamber; poststenotic stenosis is most common at the level of the dilatation of the pulmonary artery. Decreased left ventricular tension from transmitted increased pressure in output causes a small aortic knob. The right ventricular enlargement causes obliteration of the retrosternal air space, whereas left atrial enlargement produces a convexity of the upper left border of the heart (arrow, A). Rare causes include metastases from trophoblastic neoplasms, immunologic disease, schistosomiasis, multiple pulmonary artery stenoses or coarctations, and vasoconstrictive diseases. Chronic left heart failure Enlarged right ventricle associated with left May reflect a myocardiopathy or mitral insuffi- ventricular enlargement and pulmonary venous ciency. Tricuspid insufficiency Right ventricular enlargement that may be Usually functional and secondary to marked obscured by the often extreme enlargement of dilatation of the failing right ventricle. Right ventricular enlargement has obliterated the retrosternal air space on the lateral view. Pseudotruncus arteriosus Enlargement of the right ventricle; decreased Single vessel arising from the heart that is pulmonary vascularity; flat or concave pul- accompanied by a remnant of the atretic pulmo- monary outflow tract; right aortic arch in nary artery (essentially the same as tetralogy of approximately 40% of patients. Hypoplastic left heart Right ventricular and right atrial enlargement Consists of several conditions in which under- syndrome causes progressive globular cardiomegaly. Malformations obstructing Right ventricular enlargement associated with Congenital mitral stenosis; cor triatriatum pulmonary venous flow severe pulmonary venous congestion (increased (incomplete fibromuscular diaphragm dividing the pressure transmitted to the right side of the left atrium); congenital pulmonary vein stenosis or heart). Pulmonary atresia (with Right ventricular enlargement associated with May be an isolated anomaly or associated with tricuspid insufficiency) decreased pulmonary vascularity and a shallow transposition, atrial septal defect, or common or concave pulmonary artery segment. Obstruction of blood flow from nary arteries; normal-sized left ventricle; small the left atrium into the left ventricle during diastole aortic knob (decreased left ventricular output). Calcification of the mitral valve (best demonstrated by fluoroscopy) and pulmonary hemosiderosis may develop. In mitral insufficiency, the left atrium is usually considerably larger than in mitral stenosis, and pulmonary venous congestion is less frequent and less prominent. The and aorticopulmonary window are the most appearance of the right atrium, right ventricle, common causes. Myxoma of left atrium Normal heart size and pulmonary vascularity Most common primary cardiac tumor. Almost all until the tumor causes dysfunction of the arise in an atrium (particularly the left). The tumor mitral valve (radiographic pattern of mitral is usually pedunculated and causes intermittent stenosis). Pathognomonic calcification is seen obstruction or traumatic injury to the mitral (or on fluoroscopy in approximately 10% of cases. Right-to-left shunts and Various patterns, depending on the precise Tricuspid atresia, trilogy of Fallot, transposition of admixture lesions intracardiac anomaly. Common cause of cardiac failure during the first There may be dramatic left atrial enlargement year of life. Characterized by diffuse thickening of due to often-associated mitral insufficiency. Note the striking double-contour configuration (open arrows, A) and elevation of the left main bronchus (closed arrows, B), characteristic signs of left atrial enlargement. The aortic knob is normal in size, and there is no evidence of pulmonary venous congestion. Pleural effusion is common depend on the underlying heart disease (bilateral or right sided; unilateral left-sided effusion is rare and suggests another cause). Best seen with cardiac fluoroscopy (infrequently visualized on routine chest radiographs). Characteristic curvilinear calcification in the aneurysm wall and paradoxical or extremely limited pulsation on fluoroscopy. Eventually, continued strain leads indicate coarctation; paravertebral mass suggests to dilatation and enlargement of the left pheochromocytoma; erosion of the distal clavicle ventricle. Aortic tortuosity with prominence of suggests secondary hyperparathyroidism (renal the ascending portion often occurs. Dilatation of the ascending aorta disease; also caused by infective endocarditis, and aortic knob. As the left ventricle fails, syphilis, dissecting aneurysm, and Marfan’s pulmonary venous congestion develops along syndrome. Congenital aortic insufficiency is usually with left atrial enlargement (due to relative due to a bicuspid valve. Left valve), or may represent a degenerative process of ventricular failure and dilatation develop late aging (idiopathic calcific stenosis). An aortic valve and are often accompanied by left atrial disorder due to rheumatic heart disease is rarely enlargement, pulmonary venous congestion, isolated and is most commonly associated with a and prominence of the right ventricle and significant lesion of the mitral valve. Poststenotic dilatation of the calcification (best seen with fluoroscopy) is ascending aorta occurs with valvular stenosis. Frontal chest radio- view of the chest shows marked pro- graph shows left ventricular enlargement minence of the left ventricle (arrows). Note that the cardiac shadow extends below the dome of the A B left hemidiaphragm. The ascending aorta is strikingly dilated (arrows), suggesting some underlying aortic stenosis. There there is a long segment of narrowing lying proximal may be rib notching (usually involving the to the ductus (obligatory right-to-left shunt and posterior fourth to eighth ribs) but rarely early congestive heart failure). Generally normal pulmonary vascularity papillary muscle dysfunction, or severe left (there may be pulmonary venous congestion, ventricular dilatation (aortic valve disease, but it is less frequent and less prominent than congestive heart failure) distorting the mitral in mitral stenosis). The development of left ventricular glycogen storage disease, leukemia); endocrine failure produces pulmonary venous congestion.

The bone becomes sclerosed with lipping and osteophytes at the margins of the joint order 120 mg sildalis mastercard erectile dysfunction doctor seattle. The patient is first examined in the standing position both from front and behind order 120mg sildalis free shipping erectile dysfunction treatment online, secondly in the seated position order sildalis 120 mg erectile dysfunction treatment youtube, thirdly in the supine position and lastly in the prone position. During these examinations the hip is also examined, as very often a patient with the pathology in the hip will complain of pain in the knee. In case of locking the patient fails to extend the joint beyond a certain angle and the knee is kept in flexed position f ■ » A w i t h limping. This condition may be confused with superficial r cellulitis, but the latter will Fig. Extra-articular swellings are quite common l * H around the knee due to enlargement of the different bursae around the joint. The semimembranosus bursa is seen behind the knee on its medial aspect and slightly above the joint line. Infrapatellar bursa (lying deep to the ligamentum patellae), bicipital bursa (lying under the biceps tendon) may occasionally be enlarged. The suprapatellar bursa almost always communicates with the knee joint and becomes swollen in effusion of the joint. This condition also gives rise to a swelling on the posterior aspect of the knee joint in its middle and becomes prominent on extension and disappears on flexion of the joint. This condition is often associated with tuberculosis or osteoarthritis of the joint. But in affections of the knee joint if there be any muscular wasting, it is more obvious in the thigh. So far as the effusion of the joint is concerned, two important tests may be performed — fluctuation and "patellar tap". Fluctuation is demonstrated by pressing the --------- suprapatellar pouch with one hand and feeling the impulse with the thumb and the fingers of the other hand placed on either side of the patella or the ligamentum patellae. With the index finger of other hand the patella is pushed backwards towards the femoral condyles with a sharp and jerky movement. A moderate amount of fluid must be present in the joint to make this test positive. For demonstration of small amount of fluid in the knee joint two tests can be performed. The patient keeps standing and gentle pressure is applied over one of the obliterated hollows on either side of the ligamentum patellae (in order to displace fluid) and now the pressure is released. A thickened synovial membrane may also present a fluctuating swelling in the joint line, on either side of the patella and just above the patella. Its "spongy" or "boggy" feel and absence of patellar tap differentiate it from effusion of the joint. The edge of the thickened synovial membrane can be rolled under the finger as in Fig. When a swelling appears to be an enlarged bursa, its relation with the tendon (by making the appropriate tendon taut), its consistency, its mobility and translucency are ascertained. Any swelling in the popliteal fossa (particularly in the midline) should be examined for expansile pulsation. Transillumination test should always be performed in case of swellings around the knee joint. This test will be positive when swelling is an enlarged bursa or any cystic swelling e. In case of swellings containing blood (aneurysm) or pus, this test will be negative. It must be remembered that examination of the knee joint is incomplete without examination of the popliteal fossa. The knee joint is flexed and the popliteal fossa is palpated popliteal artery, the areolar tissue, the vein and nerves and the tendons in and around the Fig. Flexion of the knee greatly facilitates palpation of the tenderness, irregularity and swelling. If the click is associated with discomfort or pain, one should carefully examine to detect pathology. The patella is examined, particularly its margins and its mobility — whether this is giving rise to pain to the patients or not. Sometimes in childhood a painless click may occur as the patella moves over the condyle in a normal joint. Often the clinicians forget to examine the patella and the patello-femoral component of the knee joint and thus miss cardinal informations regarding intra-articular pathology and also the pathologies like chondromalacia patellae. For tibiofemoral component the joint line is thoroughly palpated to detect any tenderness or irregularity or swelling. Minor degrees of abduction, adduction and rotations may be permitted when the joint is partly flexed. During active or passive movement the palm of one hand is placed over the patella, crepitus will be felt if osteoarthritis has involved the patello-femoral joint. Though many a time it becomes obvious on inspection, yet measurement of the thigh along its circumference at a level same distance from the anterior superior iliac spine should be considered. But the students must remember that a line from the anterior superior iliac spine to the middle of the patella if extended downwards, strikes the medial malleolus. This of course cannot be the fact in case of genu valgum (abnormal abduction of the knee joint) or genu varum (abnormal adduction of the knee joint). In case of genu valgum or knock knee, the degree of deformity can be estimated by the intermalleolar separation present when the inner sides of the knees are kept in apposition. The popliteal lymph nodes are not very accessible to the examining fingers and may often be missed. So it is wiser to palpate the inguinal lymph nodes to detect arthritis of the knee joint. When the articular cartilages are damaged the joint space will be diminished and the joint line becomes irregular. In late cases, a triple deformity with flexion, posterior subluxation and lateral rotation of the tibia becomes evident with practically no joint space in between. In most of the pathologies of the knee joint X-ray fail to show any abnormality, as the cartilaginous pathologies out number the bony pathologies. Yet in all affections of the knee joint one should advise X-ray to exclude a minor fracture or loose bodies. Osteochondritis dissecans affecting the medial condyle of the femur becomes very much obvious in X-ray as a dense spot with a clear demarcating margin. Arthrography with contrast medium (Conray or Urografin) or air is particularly helpful in the knee joint to detect any internal derangement here.

There is a narrowing of large and small airways caused by hypertrophy and spasm of bronchial smooth muscle sildalis 120 mg lowest price erectile dysfunction remedies fruits, edema and inflammation of the bronchial mucosa cheap sildalis 120mg overnight delivery impotence from diabetes, and production of viscous mucus buy sildalis online pills impotence mayo clinic. The cells thought to play an important role in the inflammatory response are the mast cells, lymphocytes, and eosinophils. In a mild attack, slight tachypnea, tachycardia (increased respiratory rate), prolonged expirations, and mild, diffuse wheezing are seen. In a severe attack, use of accessory muscles of respiration, diminished breath sounds, loud wheezing, hyper-resonance (increased vocal fremitus), and intercostal retraction are noted. Poor prognostic factors include fatigue, diaphoresis, pulsus paradoxus (>20 mm Hg), inaudible breath sounds, decreased wheezing, cyanosis, and bradycardia. Variants of asthma include asthma presenting primarily with nocturnal cough and exercise-induced asthma (both presentations of asthma are commonly tested). The chest x-ray may be helpful in ruling out acute infection as the cause of an acute attack. Salmeterol is a long-lasting (12 h) type of albuterol that is effective in nocturnal cough variant and exercise-induced asthma. Other adrenergic stimulant drugs like the catecholamines (isoproterenol, epinephrine, and isoetharine) are given orally or intravenously and are not routinely used. Aminophylline (ethylenediamine salt of theophylline) and theophylline are only modest bronchodilators. They are sometimes of benefit in chronic management, especially in patients with nocturnal cough. Their mechanism of action is by improving contractility of the diaphragm as well as other respiratory muscles. Generally, aminophylline and theophylline are not routinely used in asthma because they appear to add no benefit to optimal inhaled beta-agonist therapy. Anticholinergic drugs (ipratropium bromide and tiotropium) have particular benefit in patients with heart disease, in whom the use of β-adrenergic agonists and theophylline may be dangerous. Their major disadvantages are that they take significant time to achieve maximal bronchodilation (~90 min) and they are only of medium potency. Supplemental oxygen, by nasal cannula or mask, should be given immediately when a patient presents with acute asthma exacerbation. The use of “routine” antibiotic treatment in asthma exacerbation has not been established. Antibiotic treatment should be considered in patients with symptoms (purulent sputum) and chest x-ray findings (infiltrates) consistent with bacterial pneumonia. Treatment of asthma in the outpatient setting (chronic management) consists of looking for and removing environmental irritants and allergens. The goal is to remove or minimize contact with precipitating factors of asthma (such as pets). Inhaled corticosteroids have been shown in studies to reduce asthma exacerbations and hospitalizations. Side effects of inhaled corticosteroids include oral candidiasis, glaucoma, cataracts, diabetes, muscle weakness, and osteoporosis. Appropriate technique in use of inhalers should be reviewed with the patient, as well as the use of spacers and/or mouth-rinsing to avoid oral candidiasis. Systemic steroids are used only in acute exacerbations (for 10–14 days) and in the treatment of chronic severe asthma. Inhaled short-acting beta 2 agonists such as albuterol are the mainstays of treatment of chronic asthma and are usually used in conjunction with inhaled corticosteroids. Use of short-acting beta-2 agonists for 3 days/week indicates poor control of symptoms, and treatment should be intensified. Inhaled long-acting beta 2 agonists like salmeterol and formoterol have a sustained effect on bronchial smooth muscle relaxation. They are indicated for the treatment of moderate to severe persistent asthma (after initial therapy with short-acting beta 2 agonist plus inhaled corticosteroids), especially with a significant nocturnal component. They are approved for severe asthma resistant to maximum doses of inhaled corticosteroids and as a last resort before using chronic systemic corticosteroids. For chronic asthma, use only as a possible adjunct to inhaled corticosteroids for difficult-to- control asthma. For an acute exacerbation of asthma, a long-acting beta agonist plus inhaled corticosteroids is more effective. In terms of preventing asthma exacerbations and reducing inflammation in adults, they are not as effective as inhaled corticosteroids. Cromolyn and Nedocromil are used extensively in the chronic treatment of pediatric asthma. Clinical guidelines have classified asthma in 4 categories, based on frequency, severity of symptoms, and requirements for medication. Mild intermittent Mild persistent Moderate Severe Treatment of asthma in the inpatient setting (acute exacerbation) requires a different approach. Referring to the case presented earlier, the patient is likely having an acute exacerbation of asthma. If, 3 days after hospitalization the patient is improving and you decide to send her home, her drug regimen would likely be oral prednisone taper, albuterol inhaler, steroid inhaler. For testing purposes, the guidelines are simplified into the following classifications. In some people, the effects of the allergic reaction combine with the effects of the fungus to damage the airways and lungs further. The fungus does not actually invade the lung tissue and directly destroy it; rather, it colonizes the mucus in the airways of patients with asthma or cystic fibrosis (both of whom have increased amounts of mucus) and causes recurrent allergic inflammation in the lung. The first indications of allergic bronchopulmonary aspergillosis are usually progressive symptoms of asthma, such as wheezing and shortness of breath, and mild fever. Repeated chest x- rays show areas that look like pneumonia, but they appear to persist or migrate to new areas of the lung (most often the upper parts). The fungus itself, along with excess eosinophils, may be seen when a sputum sample is examined under a microscope. Skin testing can determine if the person is allergic to Aspergillus, though it does not distinguish between allergic bronchopulmonary aspergillosis and a simple allergy to Aspergillus. You note an increased anteroposterior diameter, distant heart sounds, and expiratory wheezing. Patients with chronic bronchitis have productive cough for most days of a 3- month period for at least 2 consecutive years. Patients with emphysema have abnormal permanent dilation of air spaces distal to the terminal bronchioles with destruction of air space walls. After long-term exposure to cigarette smoke, inflammatory cells are recruited in the lung. These inflammatory cells in turn secrete proteinases, which may lead to air space destruction and permanent enlargement. Eventually, decreased elastic recoil (mainly in emphysema) and increased airway resistance (mainly with chronic bronchitis) occur. In chronic bronchitis, there may be evidence of rhonchi and wheezes to auscultation.

It usually presents as a cluster of flat 120 mg sildalis with amex impotence at 75, pink purchase sildalis 120mg without a prescription impotent rage random encounter, papular patches which are covered with crust order sildalis mastercard erectile dysfunction psychogenic causes. If chronic infection stimulates the capillary loops to grow too vigorously a protruding mass develops covered with epithelium. It is dull red, soft or firm and more or less pedunculated nodule which grows rapidly to about 2 cm in diameter. The patient usually complains of a rapidly growing swelling on the skin which bleeds easily and discharges serous or purulent fluid. Pyogenic granuloma can occur anywhere in the skin but is most commonly seen on the face, the fingers and the toes, the parts which are likely to be injured. It grows rapidly and attains a full size of approximately 2 cm in diameter within a few weeks. The lesion may be curetted and silver nitrate may be applied to the crater for cure. Note the best treatment is of raised margin and central umbiiication which are the typical features of this condition. It may either follow molecular death of the surface epithelium or its traumatic removal. An ulcer has a margin or edge which takes characteristic shape in a particular form of ulcer. It has a floor which means the exposed surface of the ulcer and it has a base on which the ulcer rests. In a spreading ulcer, the edge is inflamed and oedematous whereas in a healing ulcer the edge, if traced from the red granulation tissue in the centre towards periphery, will show a blue zone (due to thin growing epithelium) and a white zone (due to fibrosis of the scar). Five common types of ulcer edge seen in surgical practice are;— (i) Undermined edge — is mostly seen in tuberculosis. The disease causing the ulcer spreads in and destroys the subcutaneous tissue faster than it destroys the skin. Every healing ulcer has a sloping edge, which is reddish purple in colour and consists of new healthy epithelium, (iv) Raised and pearly-white beaded edge — is a feature of rodent ulcer. This type of edge develops in invasive cellular disease and becomes necrotic at the centre, (v) Rolled out (Everted) edge — is a characteristic feature of squamous cell carcinoma or an ulcerated adenocarcinoma. This ulcer is caused by fast growing cellular disease, the growing portion at the edge of the ulcer heaps up and spills over the normal skin to produce an everted edge. Marked induration of the edge is a characteristic feature of a carcinoma be it a squamous cell carcinoma or adenocarcinoma. A certain degree of induration or thickness is expected in any chronic ulcer, whether it is atrophic ulcer, gummatous ulcer or a syphilitic ulcer. When floor is covered with red granulation tissue, the ulcer seems to be healthy and healing. Wash-leather slough (like wet chamois leather) on the floor of an ulcer is pathognomonic of gummatous ulcer. A trophic ulcer penetrates down even to the bone, which forms the floor in this case. If an attempt is made to pick up the ulcer between the thumb and the index finger, the base will be felt. Slight induration of the base is expected in any chronic ulcer but marked induration (hardness) of the base is an important feature of squamous cell carcinoma and Hunterian chancre. Ulcers associated with mal-nutrition, anaemia, avitaminosis and rheumatoid arthritis are also included in this group. But these ulcers occur more commonly where the skin is closely applied to bony prominences e. Occasionally, particularly in older people, a single ulcer confined to the lower leg is due to chronic staphylococcal infection. These ulcers heal quickly and do not become chronic unless supervened by infection or ischaemia, which may turn this ulcer to chronicity. These occur in those parts of the limbs which are subjected to repeated pressure and trauma. Prolonged pressure on one part of the foot causes ischaemic damage to the tissues and if the circulation is inadequate then the tissues cannot repair themselves and ischaemic ulcer develops. These ulcers are mostly due to peripheral arterial disease and poor peripheral circulation. Atherosclerosis of the peripheral arteries is the commonest cause of this condition. It is due to episodes of trauma and infection that destroy the skin which fails to heal because of poor arterial supply. These ulcers tend to occur on the anterior and lateral aspects of the leg, on the toes, dorsum of the foot or the heel (the parts exposed to trauma). These ulcers tend to be punched out and destroy the whole skin and the deep fascia (unlike the venous ulcer) and may expose the tendons in the floor of the ulcer. The basic cause of venous ulcer is abnormal venous hypertension in the lower-third of the leg, ankle and dorsum of the foot. The neurological conditions which predispose to formation of such ulcer include diabetes, alcoholic peripheral neuritis, tabes dorsalis, spina bifida, leprosy, peripheral nerve injury, paraplegia and syringomyelia. These ulcers are commonly seen on the heel and ball of the foot when the patient is ambulatory; on the buttock and on the back of the heel when the patient is non-ambulatory. Trophic ulcers are included in this group which are caused by various factors such as impairment of nutrition of the tissues, inadequate blood supply and neurological deficit. These ulcers have punched out edge with slough in the floor thus resembling a gummatous ulcer. These ulcers develop as the result of repeated trauma to insensitive part of the body. Syphilitic ulcers are classified under the heading of specific group of ulcers and are not included here. Every effort should be made to detect the cause behind the ulcer and to treat accordingly. Pain is an important symptom and this is often accompanied by acute lymphadenitis. Gradually pustules develop and burst in two or three days forming ulcers whose edges are undermined and raised. Copious serosanguineous discharge with considerable pain is the most important feature. Such lesion results from excessive vasoconstriction of the skin arterioles of the affected area. When any part of the body is exposed to wet cold below freezing point, ischaemic changes occur in the skin and subcutaneous tissues. Such ischaemic changes are due to arteriolar spasm followed by stasis of blood in the capillaries. This alongwith exposure of the tissues below freezing point will lead to freezing of tissues and denaturation of intracellular protein with destruction of enzyme systems.

A renal calculus has to be differentiated from (i) a gallstone order sildalis 120mg mastercard erectile dysfunction diabetes uk, (ii) calcified lymph nodes purchase sildalis with a mastercard injections for erectile dysfunction treatment, (iii) calcified costal cartilage buy sildalis 120mg cheap impotence natural home remedies, (iv) || phlebolith, (v) calcified aneurysm of the abdominal aorta or renal artery and (vi) small calcific bodies the substance a kidney as discussed above. A stone in the appendix or a faecolith in the colon may be confused with a stone in the ureter. It must be remembered that for the diagnosis of a stone either in the kidney, ureter or bladder, a straight film is all that r I is required, not a urogram. It is an imaginary line passing along the tips of the transverse processes of the lumbar vertebrae, over the sacro-iliac joint, down to the ischial spine from where this line deviates medially. A space-occupying lesion of the renal pelvis revealed in excretory urogram may show a faint opaque body compatible with stone but not tumour in the tomogram studies. If symptoms and signs of hypersensitivity appear during injection, it should be stopped immediately. Warning signs are respiratory difficulty, itching, urticaria, nausea, vomiting and fainting. Routine radiograms are taken at 10 seconds for nephrogram effect and at 5, 10 and 15 minutes with the patient in supine position. For hypertensive patients films should be taken 2 and 3 minutes after the beginning of the injection. Delayed concentration of dye in one kidney may suggest decreased renal blood flow and function. At 25 minutes a film is taken in erect posture to note the efficiency with which the renal pelvis and ureters drain, ureterograms and also the mobility of the kidneys. All films should include kidney, ureter and bladder areas, as fine changes in the ureters which imply the presence of vesico-ureteral reflux may be detected. It is advisable to inject additional radio-opaque medium if there is impaired concentration in the initial films. In infants and children the films should be taken at 3, 5, 8 and 12 minutes as their kidneys excrete the fluid more rapidly than do those of the adults. X-ray of the bladder region after voiding should be routine in all urologic patients. At the conclusion of the urographic study, the patient is instructed to pass urine and a film of the bladder area is taken immediately. Excretory urogram is contraindicated in (i) allergic patients, (ii) multiple myeloma (the dye makes insoluble complex with Bence-Jones protein and precipitate in the renal tubules), (iii) congenital adrenal hyperplasia, (iv) diabetes and (v) primary hyperparathyroidism. Excretory urogram is a physiological and as well as an anatomical test since it not only determines the function of the kidney but also clearly demonstrates the contour of the renal pelvis and calyces. About 2 ml per kg body weight of contrast medium in an equal volume of normal saline is infused in a subcutaneous vein slowly for over a period of 10 minutes. Diluted contrast medium is infused into the subcutaneous tissue alongwith hyaluronidase (hylase). If filling is not complete, more dye is instilled before further X-rays are taken. A stone may show some opacification, but a tumour will not, but both these will cause a filling defect in the pelvis or calyx in excretory urogram. Under fluoroscopic or ultrasonic control an 18-gauge needle, 15 cm long should be passed into a dilated calyx or pelvis. It is better to pass the needle into a dilated calyx rather than pelvis as there will be a better seal round the needle track and less danger of puncturing large hilar vessels. Temporary drainage can also be provided with by a small plastic catheter introduced through the needle, which will be subsequently removed. Inward directed calyces suggest congenital abnormality such as horese-shoe shaped kidney. The right pelvi-ureteric junction is situated opposite the transverse process of the second lumbar vertebra whereas the left is slightly higher up. The most important is the shape of the pelvis and the students must learn the normal shape of the pelvis. If the whole of the ureter is adenocarcinoma (T) outlined by seen there must be an obstruction further down. Also look at the position of the ureter, whether it is kinking or not and whether there is any congenital deformity or not. If these are not satisfied to delineate clearly the pathological conditions of the bladder, retrograde cystogram may be required. Besides these, this test has a diagnostic value in rupture of the bladder and recurrent infection (vesico-ureteral reflux is the commonest cause of perpetuation of infection). This will also reveal function of the bladder neck, presence of posterior urethral valves or urethral stricture. This investigation is of special value to know the length of the stricture, presence of diverticulum etc. Its importance also lies in revealing the dilated prostatic ducts in chronic or tuberculous prostatitis and bladder neck obstruction. Chromocystoscopy can be employed to find out the ureteric orifices as also the function of the kidney. Normally a blue jet will be seen to emerge from the ureteric orifices within 3 to 5 minutes. In case of haematuria, cystoscopy should be performed at the time of bleeding to detect which kidney is bleeding. But when bleeding is coming from the bladder, cystoscopy should be repeated when bleeding has ceased. Through this the membraneous part and the prostatic part of the urethra can be inspected. Verumontanum is an eminence on the posterior aspect of the prostatic urethra at the apex of which is the sinus pocularis on each side of which the two ejaculatory ducts open. Numerous prostatic ducts can be seen which will be enlarged and will be seen extruding pus. Space occupied by a cyst or abscess fails to opacify, whereas a malignant tumour shows a normal or increased opacification. A catheter is passed to the level of the renal arteries under fluoroscopic control. It is also possible to do the catheterisation through the brachial or axillary artery. Selective renal angiography is accomplished by passing a femoral catheter into one of the renal arteries under fluoroscopic control. About 8 ml of the contrast medium is injected and 16 exposures are taken within a few seconds. This technique gives detailed demonstration of the arterial pattern in the kidney and thus differentiates efficiently between renal cyst and tumour. If this technique also fails to differentiate in case of small lesion or gets obscured by overlying arteries, epinephrine can first be injected into the catheter followed by instillation of radio-opaque medium. Alternatively each hypogastric artery is selectively catheterized and 10 ml of radio-opaque fluid is injected.

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