Surgical drainage if fever and tenderness persist after 24 hrs of appropriate antibiotic therapy and pus is present discount 5mg provera otc women's health clinic tralee. Clinical Features Infection may remain quiescent purchase provera 10mg otc women's health issues and physical therapy, with acute or sub−acute exacerbations which manifest as discharging sinuses discount provera 10mg without prescription menstrual cramps. X−ray features include; periosteal reaction and new bone formation, dead−bone (sequestrum), bone abscesses, rarefaction of bone. Management • Antibiotic therapy; as per culture/sensitivity results • Refer for surgical drainage, sequestrectomy and irrigation. This tumor presents with pain, noticeable swelling, tenderness or pathological fractures. Aetiology • Haematogenous spread from a primary focus elsewhere in the body • Direct penetrating injuries into the joint • Extension from a compound fracture of the neighbouring bone The commonest causative organisms are staphylococcus, streptococcus, haemophilus influenzae and to a lesser extent salmonella. Clinical Features • Fever, chills and irritability • Swollen, warm, very tender joint • Pseudoparalysis of the joint • Multiple joints may be affected. Investigations • Haemogram − anaemia and leucocytosis present • Pus for C&S • X−ray of the affected joint shows increased joint space, synovial thickening and later rarefaction of the adjacent bone surfaces. Refer If • The fever persists for more than 7 days of full treatment • The joint swelling does not subside within 3 weeks • New joints get involved while on treatment 263 • The affected joint starts to discharge pus spontaneously • Shortening of the limb occurs • There is persistent deformity of the joint • Loss of function related to the infection. Overdose refers to excessive amounts of a substance or drug normally intended for therapeutic use. Self poisoning with pesticides, drugs or parasuicide are the commonest causes of emergency admission in adults whereas in children it is accidental or intentional. Diagnosis • History: To include time, route, duration and circumstances of exposure, name and amount of drug or chemical, medical and psychiatric history. These should be performed in specialised centres • Antidotes administration [see table on common poisons and treatment in the next page] • Prevent re−exposure: − adult education − child−proofing − psychiatric referral 21. Causes include rhino−, influenza, parainfluenza, respiratory syncytial, corona adeno− and caucasic viruses. Clinical Features Nasal obstruction, watery rhinorrhoea, sneezing, sore throat, cough, watery red eyes, headache and general malaise. Common cold can be complicated by bacteria like staphylococcus, streptococcus, klebsiella and should be treated with antibiotics e. Clinical Features Sore throat, painful swallowing, general malaise, fever, body aches, rhinitis, tender cervical or submandibular lymph nodes. Refer For • Drainage of retropharyngeal abscess • Tonsillectomy If peritonsillar abscess recurs with the current illness. Admit If • Patient deteriorates or goes on to develop peritonsillar or retropharyngeal abscess. Complications Streptococcal infection include otitis media, rheumatic fever with or without carditis. It is the size of the mass relative to the nasopharyngeal space that is important; not the absolute size. Clinical Features Nasal obstruction leading to mouth−breathing, difficulty in breathing and eating, drooling, snoring and toneless voice. Other features are nasal discharge, postnasal drip, cough, cervical adenitis and inflammatory process in the nose, sinuses, and ears. Mental dullness and the apathy may be marked due to poor breathing, bad posture or deafness. Diagnosis Is based on history and narrowing of the nasopharyngeal air space on lateral soft tissue x−ray of the nasophynx. Refer For • Failure of treatment, the onset of complications, suspected malignancy or need for surgical intervention. Infection through the respiratory tract extends downwards to produce a supraglottic cellulitis with marked inflammation. Deep suprasternal, supraclavicular, intercostal and subcostal inspiratory retractions. Management • Admit immediately if the diagnosis is suspected clinically • Direct visualisation of the epiglottis by a designated trained person may reveal a beefy red, stiff and oedematous epiglottis. Infection produces inflammation of larynx, trachea, bronchi, bronchioles and lung parenchyma. Obstruction caused by swelling and inflammatory exudate is most severe in the subglottic region and leads to increased work of breathing, hypercapnia and at times atelectasis. Respiratory distress, tachypnoea, supraclavicular, suprasternal, substernal and intercostal inspiratory retractions. Some expiratory rhonchi and wheezes, and diminished breath sounds if atelectasis is present. The illness lasts 3−4 days and during this period may improve in the morning and worsen at night. Management • Admit to hospital and prepare equipment for intubation and/or tracheostomy • Administer humidified O2 (at 30−40% concentration) • Nasotraeheal intubation if signs of severe obstruction occur: Severe chest indrawing, agitation, anxiety (air−hunger) and cyanosis • Tracheostomy may be done if intubation is impossible. Early diagnosis and proper treatment of pneumonia is essential to reduce mortality. Assessment of cough or difficult breathing in children is described in this section. Examination − The child must be calm: • Count breaths in one minute • Look for chest indrawing • Look and listen for stridor • Look and listen for wheeze. Danger signs to look for • Age 2 months up to 5 years: Is the child able to drink? Avoid cotrimoxazole in infants less than one month of age who are premature or jaundiced. Suspect these conditions if any of the following are present in an infant under 2 months: Stopped feeding well (if feeding well before). Continue for 3 days after child is well • If meningitis suspected: Treat for at least 14 days. Ampicillin plus gentamicin may be more effective than penicillin plus gentamicin • Chloramphenicol can be substituted for first choice drug 12. Clinical Features Breathlessness, cough with or without sputum which may be rust coloured, fever, pleuritic chest pain. Bronchial breathing, reduced chest movements, reduced breath sounds, tachypnoea, crackles and percussion dullness. Classification Primary: Occurring in a previously healthy person living in the community. It is almost always caused by viral infection (due to respiratory syncytial virus, influenza virus, para−influenza virus, or rhinovirus). Bronchitis is usually associated with an upper respiratory infection (a cold) in young children. Clinical Features • Productive cough without cyanosis, chest indrawing, wheezing, or fast breathing. Management • Treatment is the same as for cold without pneumonia • If wheezing for the first time and child has respiratory distress then antibiotics as for pneumonia and wheezing treatment. Wheezing may or may not be complicated by pneumonia of bacterial or viral aetiology.

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Blunt trauma to a muscle results in a it extends partly or completely through the meniscus) 2.5 mg provera overnight delivery pregnancy 4 months, contusion purchase provera 5mg amex menstrual like cramps at 38 weeks. The radiologist should also note the presence of dis- out from the point of contact in the muscle belly order provera 2.5mg with mastercard pregnancy over 35. Around the knee, muscle trauma affects the distal When the abnormality is also present on a T2-weighted hamstrings, distal quadriceps, proximal gastrocnemius, image, when there is a displaced fragment, or when a tear soleus, popliteus, and plantaris muscles. The patellar, examination, the presence of injected contrast within the quadriceps, and semimembranosus tendons are most fre- substance of a repaired meniscus is diagnostic of a quently involved around the knee. Sonographically, a degen- a partial meniscectomy; in these cases both the meniscal erated tendon appears enlarged, with loss of the normal shape and internal signal are unreliable signs of recurrent parallel fiber architecture, and often with focal hypoe- meniscal tear. A gap between the tendon noninvasive test for recurrent meniscal tears following fibers indicates that the process has progressed to partial partial meniscectomy [75]. In those cases in which T2-weighted images show a focus of high signal intensi- T2-weighted images demonstrate ruptures of the cruciate, ty, surgical excision of the abnormal focus can hasten collateral, and patellar ligaments. When macroscopic tearing is present, the radiolo- tion of the ligament fibers [76]. While edema surround- gist should also examine the corresponding muscle belly ing a ligament is typically seen in acute tears, edema sur- for fatty atrophy (which indicates chronicity) or edema rounding an intact ligament is a nonspecific finding, (suggesting a more acute rupture). If the tear is complete, which can be seen in bursitis or other soft tissue injuries, the retracted stump should be located on the images as in addition to ligament tears [77]. Synovium Secondary findings of ligament tears, such as bone con- tusions or subluxations, are useful when present, but do While radiographs can show medium and large knee ef- not supplant the primary findings, and do not reliably dis- fusions, other modalities better demonstrate specific syn- tinguish acute from chronic injuries, nor partial from ovial processes. In the knee, the anterior cruciate liga- hanced through-transmission on ultrasound images. At least 11 other named bursae occur around will be placed on the detection of clinically suspected or the knee. The most commonly diseased ones are proba- occult soft-tissue and bone abnormalities that could be bly the prepatellar, superficial infrapatellar, medial col- exacerbated by repeat trauma or could lead to chronic in- lateral ligament, and semimembranosus-tibial collateral stability and joint degeneration unless treated. Power Doppler ultrasound or the use of ultrasound contrast agent may in- Kinematic laws dictate normal joint motion and the bio- crease sensitivity for active synovitis [86]. Although the knee moves pri- amination, thickening of the usually imperceptibly thin marily as a hinge joint in the sagittal plane, it is also de- synovial membrane and enhancement of the synovium signed for internal-external rotation and abduction-ad- following intravenous contrast administration indicates duction. The signal intensities of the bodies logical, but the menisci must shift with the contact points vary depending on their composition. Diffuse pigmented to avoid entrapment and crush injury by the femoral villonodular synovitis and focal nodular synovitis demon- condyles. Paired cruciate and collateral ligaments func- strate nodular, thickened synovium, which enhances fol- tion collectively with the menisci to maintain joint con- lowing contrast administration. In external rota- echo images – is an important, though inconstant, clue to tion, for example, the cruciate ligaments are lax whereas the diagnosis [89]. Conversely, in internal rotation, the collateral lig- aments are lax whereas the cruciates become twisted Biomechanical Approach to Knee Trauma around each other, pulling the joint surfaces together and resisting varus or valgus rocking. Within the physiological Knee trauma often produces predictable groupings of lig- range of motion, the knee ligaments perform extremely amentous and meniscal injuries [90]. In both contact and non-contact sports, ture is disrupted, synergistic structures are jeopardized. Valgus force is directed at and osseous injury all provide clues about the mechanism the lateral aspect of the joint, and varus force is directed of injury. The lateral compartment normality in one structure should lead to a directed is distracted during varus stress, tearing the lateral collat- search for subtle abnormalities involving anatomically or eral ligament. In the weight-bearing knee, valgus force al- functionally related structures, thereby improving diag- so creates compressive load across the lateral compart- nostic confidence. The medial compartment is images are interpreted with an understanding that struc- compressed during varus stress, leading to impaction of tures with strong functional or anatomical relationships the medial femoral condyle against the tibia. By deducing the traumatic the most common traumatic mechanisms combine valgus mechanism, it is possible to improve diagnostic accuracy force with axial load. Therefore, compression with im- by taking a directed search for subtle, surgically relevant paction injury usually occurs in the lateral compartment, abnormalities that might otherwise go undetected. It may whereas tension with distraction injury occurs in the me- also be possible to communicate more knowledgeably dial compartment. Trauma-re- Acute ligamentous injuries are graded clinically into lated medial meniscal tears tend to be located at the pos- three degrees of severity. In mild sprain (stretch injury), teromedial corner (posterior to the medial collateral liga- the ligament is continuous but lax. The ligament can re- ment) because the capsule is more organized and thick- turn to normal function with appropriate conservative ened in this location, and its meniscal attachment is tight- treatment. In moderate sprain (partial tear), some but not all Although the posterior oblique ligament can be dissected fibers are discontinuous. Remaining intact fibers may not free in most cadaver knees, it is only rarely identified on be sufficient to stabilize the joint. Degenerative (attrition) tears of the medial bundles hang loosely, and intact fibers are overstretched meniscus also predominate posteromedially, but they in- with marked edematous swelling and ecchymosis. In severe sprain (rupture), the liga- a vertical orientation that can extend across the full thick- ment is incompetent. At operation, torn fiber bundles ness of the meniscus (from superior to inferior surface), hang loosely and can be moved easily. Once established, this vertical tear can propagate over time following the normal fiber architecture of the menis- cus. Propagation to the free margin creates a flap, or par- Meniscal Injury rot-beak, configuration. If the tear propagates longitudi- nally into the anterior and posterior meniscal thirds, the Why are most trauma-related medial meniscal tears pe- unstable inner fragment can become displaced into the in- ripheral in location and longitudinally orientated, where- tercondylar notch (bucket handle tear). When a distractive force sepa- dists recognize an association between longitudinal tears rates the femorotibial joint, tensile stress is transmitted and mechanical symptoms, and may decide to repair or across the joint capsule to the meniscocapsular junction, resect the inner meniscal fragment before it becomes dis- creating traction and causing peripheral tear. Compressive placed and causes locking or a decreased range of mo- force entraps, splays and splits the free margin of menis- tion. If an unstable fragment detaches anteriorly or pos- cus due to axial load across the joint compartment. Since teriorly, it can pivot around the remaining attachment site the most common traumatic mechanisms in the knee in- and rotate into an intraarticular recess or the weight-bear- volve valgus rather than varus load, the medial femorotib- ing compartment. The identification and localization of a ial compartment is distracted whereas the lateral compart- displaced meniscal fragment can be important in the pre- ment is compressed. Lateral compression means sile stress can avulse the capsule away from the menis- that the lateral meniscus is at risk for entrapment and tear cus (meniscocapsular separation), with or without a along the free margin. Meniscocapsular injury avulsed at sites where they are fixed, but can escape in- may be an important cause of disability that can be jury in regions where they are mobile. Compared to the treated surgically by primary reattachment of the cap- lateral meniscus, the medial meniscus is more firmly at- sule.

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Hulda Regehr Clark began her studies in biology at the University of Saskatchewan discount provera 10 mg mastercard womens health diet plan, Canada provera 10mg visa menopause and fatigue, where she was awarded the Bachelor of Arts order provera 5mg pregnancy stretches, Magna Cum Laude, and the Master of Arts, with High Honors. After two years of study at McGill University, she attended the University of Minnesota, studying biophysics and cell physiology. In 1979 she left government funded research and began private consulting on a full time basis. Six years later she discovered an electronic technique for scanning the human body. No part of this publication may be reproduced or transmitted in any form or by any means, electronically or mechanically, including photocopying, recording or any information storage or retrieval system, without either prior permission in writing from the publisher or a licence permitting restricted copying. Whilst the advice and information in this book are believed to be true and accurate at the date of going to press, neither the author nor the publisher can accept any legal responsibility or liability for any errors or omissions that may be made. In particular (but without limiting the generality of the preceding disclaimer) every effort has been made to check drug dosages; however it is still possible that errors have been missed. Furthermore, dosage schedules are constantly being revised and new side-effects recognized. For these reasons the reader is strongly urged to consult the drug companies’ printed instructions before administering any of the drugs recommended in this book. These skills should form an essential part of the undergraduate cur- riculum because skin disorders are common and often extremely disabling in one way or another. Apart from the fact that all physicians will inevitably have to cope with patients with rashes, itches, skin ulcerations, inflamed papules, nodules and tumours at some point in their careers, skin disorders themselves are intrinsically fascinating. The fact that their progress both in development and in relapse can be closely observed, and their clinical appearance easily correlated with their path- ology, should enable the student or young physician to obtain a better overall view of the way disease processes affect tissues. The division of the material in this book into chapters has been pragmatic, combining both traditional clinical and ‘disease process’ categorization, and after much thought it seems to the author that no one classification is either universally applicable or completely acceptable. It is important that malfunction is seen as an extension of normal function rather than as an isolated and rather mysterious event. For this reason, basic struc- ture and function of the skin have been included, both in a separate chapter and where necessary in the descriptions of the various disorders. It is intended that the book fulfil both the educational needs of medical stu- dents and young doctors as well as being of assistance to general practitioners in their everyday professional lives. Hopefully it will also excite some who read it suf- ficiently to want to know more, so that they consult the appropriate monographs and larger, more specialized works. In this new edition of Roxburgh’s Common Skin Diseases account has been taken of recent advances both in the understanding of the pathogenesis of skin disease and in treatments for it. Please forgive any omissions as events move so fast it is really hard to catch up! It is a composite of several types of tissue that have evolved to work in harmony one with the other, each of which is modified regionally to serve a differ- ent function (Fig. This last point is compounded by the ready visibility of skin, so that minor deviations from normal give rise to a particular set of signs. However ‘healthy’ we think our skin is, it is likely that we will have suffered from some degree of acne and maybe one or other of the many common skin disorders. Atopic eczema and the other forms of eczema affect some 15 per cent of the population under the age of 12, psoriasis affects 1–2 per cent, and viral warts, seborrhoeic warts and solar keratoses affect large seg- ments of the population. It should be noted that 10–15 per cent of the general practitioner’s work is with skin disorders, and that skin disease is the second com- monest cause of loss of work. Although skin disease is not uncommon at any age, it is particularly frequent in the elderly. Skin disorders are not often dramatic, but cause considerable discomfort and much disability. The disability caused is physical, emotional and socioeconomic, and patients are much helped by an appreciation of this and attempts by their physician to relieve the various problems that arise. Skin structure and function It is difficult to understand abnormal skin and its vagaries of behaviour without some appreciation of how normal skin is put together and how it functions in health. Although, at first glance, skin may appear quite complicated to the uniniti- ated, a slightly deeper look shows that there is a kind of elegant logic about its architecture, which is directed to subserving vital functions. The limb and trunk skin is much the same from site to site, but the palms and soles, facial skin, scalp skin and genital skin differ some- what in structure and detail of function. The surface is thrown up into a number of intersecting ridges, which make rhomboidal patterns. At intervals, there are ‘pores’ opening onto the surface – these are the openings of the eccrine sweat glands (Fig. The diameter of these is approximately 25 m and there are approximately 150–350 duct openings per square centimetre (cm2). The hair follicle openings can also be seen at the skin surface and the diameter of these orifices and the numbers/cm2 vary greatly between anatomical regions. Close inspection of the follicular opening reveals a distinctive arrangement of the stratum corneum cells around the orifice. Corneocytes are approximately 35 m in diameter, 1 m thick and shield like in shape (Fig. The final step in differentiation is the dropping off of individual corneocytes in the process of desquamation seen in Figure 1. The horny layer is not well seen in routine formalin-fixed and paraffin-embedded sections. It is better observed in cryostat- sectioned skin in which the delicate structure is preserved (Fig. It will be noted that at most sites there are some 15 corneocytes stacked one on the other and that the arrangement does not appear haphazard, but is reminiscent of stacked coins. The corneocytes are joined together by the lipid and glycoprotein of the intercel- lular cement material and by special connecting structures known as desmosomes. On limb and trunk skin, the stratum corneum is some 15–20 cells thick and, as each corneocyte is about 1 m thick, it is about 15–20 m thick in absolute terms. The stratum corneum prevents water loss and when it is deranged, as, for example, in psoriasis or eczema, water loss is greatly increased so that severe dehy- dration can occur if enough skin is affected. It has been estimated that a patient with erythrodermic psoriasis may lose 6 L of water per day through the disordered stratum corneum, as opposed to 0. The stratum corneum also acts as a barrier to the penetration of chemical agents with which the skin comes into contact. It prevents systemic poisoning from skin contact, although it must be realized that it is not a complete barrier and percutaneous penetration of most agents does occur at a very slow rate. Those responsible for formulating drugs in topical formulations are well aware of this rate-limiting property for percutaneous penetration of the stratum corneum and try to find agents that accelerate the movement of drugs into the skin. The barrier properties are, of course, also of vital importance in the prevention of microbial life invading the skin – once again the barrier properties are not perfect, as the occasional pathogen gains entry via hair follicles or small cracks and fissures and causes infection. The structure is very extensible and compliant in health, permitting movement of the hands and feet, and is actually quite tough, so that it provides a degree of mechanical protection against minor penetrative injury. This cellular structure is some three to five cell layers thick – on average, 35–50 m thick in absolute terms (Fig. Not unexpectedly, the epidermis is about two to three times thicker on the hands and feet – particularly the palms and soles. The epidermis is indented by finger-like projections from the dermis known as the dermal papillae (Fig.