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Wegener’s granulomatosis Usually multiple thick-walled cavities with Cavitation eventually occurs in approximately half (Fig C 11-15) irregular inner linings (may eventually become of patients purchase line caverta erectile dysfunction market. Large cavity lesions (arrows) fluid levels (arrows) of squamous cell carcinoma on a film in the left lung of an intravenous drug abuser with septic obtained after two cycles of chemotherapy purchase generic caverta pills erectile dysfunction causes yahoo. Multiple cavitary nodules Fig C 11-15 throughout both lungs representing Nocardia septic emboli in Wegener’s granulomatosis. Traumatic lung cyst Single or several thin-walled cavities that may Typically occurs in a peripheral subpleural location contain air-fluid levels. Sarcoidosis Cystic lesions developing on a background of Very uncommon manifestation (should suggest diffuse reticulonodular pulmonary disease. Intralobar Thin- or thick-walled cystic mass that is often Almost invariably arises contiguous to the bronchopulmonary multilocular or multiple. Bronchogenic cyst Solitary thin-walled cystic mass that may Approximately 75% of bronchogenic cysts that are contain an air-fluid level. Congenital cystic Multiple air-containing cysts scattered ir- Expands the ipsilateral hemithorax (depresses the adenomatoid malformation regularly throughout a mass of soft-tissue hemidiaphragm and shifts the mediastinum to the (see Fig C 15-7) density. Large bullae in the right with air-fluid levels (arrows), predominantly involve the upper lung. Laryngeal papillomatosis is a common disease in (Fig C 11-19) children that infrequently seeds distally in the tracheobronchial tree to produce excavating lesions in the lung. Plombage Plastic (lucite) spheres appear radiographically Former therapy for pulmonary tuberculosis that (Fig C 11-20) as multiple perfectly round, cavity-like lucencies. The spheres are often not entirely watertight, so that a small amount of fluid may collect in each. On upright views, the resulting air- fluid levels can simulate cavitation and suggest the incorrect diagnosis of acute infection. Multiple small cysts super- Fig C 11-19 imposed on a diffuse, coarse, reticular pattern. The hilar nodes often calcify and are usually lymphadenopathy associated with ipsilateral parenchymal disease. In lymphangitic spread, there is (Fig C 12-3) generally a diffuse reticular or reticulonodular pattern. Lymphoma Primarily Hodgkin’s disease, which often produces asymmetric bilateral hilar adenopathy. The combination of a focal (open arrow), there is enlargement of anterior parenchymal lesion (arrows) and enlarged right hilar lymph mediastinal lymph nodes (closed arrows). Pulmonary embolism Result of vascular distention by bulk thrombus (not increased vascular resistance in the affected lung). Pulmonary artery coarctation Poststenotic dilatation of the affected pulmonary artery. Pulmonary arteriovenous Enlargement of hilar vessels is due to increased blood flow on the affected side. There is often evidence fistula of single or multiple parenchymal nodules with characteristic feeding arteries and draining veins. Normal variant Prominence of the left pulmonary artery occurs in adults younger than 30 (especially women). Also cyanotic admixture lesions (transposition of great vessels, persistent truncus arteriosus). Pulmonary arterial Bilateral enlargement of central pulmonary Primary or secondary to such conditions as wide- hypertension arteries with rapid tapering and small peripheral spread peripheral pulmonary emboli, Eisen- (Fig C 13-7) vessels. Also cardiac enlargement (especially menger’s syndrome (reversed left-to-right shunt), the right ventricle). Rare causes include metastases from trophoblastic neoplasms, immunologic disorders (Raynaud’s phenomenon, rheumatoid disease), schistosomiasis, multiple pulmonary artery stenoses or coarctations, and vasoconstrictive diseases. Fig C 13-3 Ossified metastases to hilar lymph nodes bilaterally from osteogenic sarcoma. Pulmonary venous Bilateral enlargement of central pulmonary Causes include left-sided heart failure and mitral hypertension veins associated with cardiomegaly and cephali- stenosis. Primary polycythemia Generalized bilateral increase in central and Increased blood volume produces prominence of peripheral pulmonary vascularity. Intravascular thrombosis may cause pulmonary infarctions that appear as focal consoli- dations or bands of fibrosis. Prominent bilateral hilar node calcification associated with bilateral adenopathy with a suggestion of enlarged perihilar masses. Frontal chest film in a patient with atrial septal defect and Eisenmenger’s physiology demonstrates a huge pulmonary outflow tract and central pulmonary arteries with abrupt tapering and sparse peripheral vasculature. Bilateral involvement in approxi- chymal disease (may even obscure the lympha- mately 20% of cases. Histoplasmosis Unilateral or bilateral enlargement of hilar, Usually associated with parenchymal disease (often mediastinal, and, occasionally, intrapulmonary absent in children). Calcification of nodes is common and may even lead to erosion into the bronchial lumen. Coccidioidomycosis Unilateral or bilateral enlargement of hilar or There may be associated parenchymal disease. Mycoplasma pneumoniae Unilateral or bilateral enlargement of hilar Common in children, rare in adults. Psittacosis, infectious mononucleosis (also spleno- (Fig C 14-1; see Fig C 13-1) megaly), rubeola, echovirus, varicella. Unilateral in pertussis (whooping cough) and (Figs C 14-2 and C 14-3) tularemia (ipsilateral hilar enlargement in 25% to 50% of tularemic pneumonias); bilateral involve- ment in anthrax and plague. Diffuse, reticular interstitial infiltrate Fig C 14-2 with a focal area of consolidation in the right upper lobe. Air-space consolidation involving the Note the striking right hilar and mediastinal adenopathy right middle lobe and a portion of the right upper lobe. Presenting sign in up to one-third of patients (Fig C 14-4) (primary carcinoma arising in a major hilar bronchus or metastasis from a small primary tumor in adjacent or peripheral parenchyma). Prominent right mediastinal lymphadenopathy associated with an ill-defined primary malignant lesion (arrow). Pulmonary involvement or pleural asymmetric (unilateral node enlargement is effusion occurs in about 30%. Leukemia (Fig C 14-7) Symmetric enlargement of hilar and medias- Lymphadenopathy occurs more commonly in tinal nodes in approximately 25% of patients. Metastases (lymphangitic Unilateral or bilateral enlargement of hilar or Usually associated with a diffuse reticular or reti- spread) mediastinal nodes. Lateral view of the chest shows subtle Fig C 14-7 enlargement of a retrosternal (internal mammary) Leukemia. Typical Usually associated with a diffuse nodular or (see Fig C 13-5) eggshell calcification (in approximately 10% of reticulonodular pattern throughout both lungs.

In case of involvement of 1st sacral root cheap caverta online master card erectile dysfunction getting pregnant, there will be weakness of plantar flexors and flexor hallucis longus purchase caverta 50mg amex erectile dysfunction young causes, so there will be weakness in plantar flexion of the ankle and flexion of the great toe. In case of involvementof the 1st sacral root there will be very much diminished or absent ankle jerk. In case of involvement of the 5th lumbar root, sensory impairment is detected in the back of the thigh, most of the lateral aspect of the leg and dorsum of the foot. In case of involvement of 1st sacral root (which suggests protrusion of L5/S1 disc) sensory impairment is noticed on the sole and outer margin of the foot with loss of ankle jerk. In short, in case of L51S1 disc protrusion, usually the 1st sacral nerve root is involved and there will be sensory im­ pairment of the sole and outer margin of the foot and in the dorsum of the web between the great and the second toe with absence of the ankle jerk. In case of L4/5 disc protrusion, usually the 5th lumbar root is involved, in which there will be sensory impairment of the dorsum of the foot, lateral aspect of the leg and back of the thigh, there will be weak dorsiflexion of the ankle and great toe but no alteration of the ankle jerk. In case of upper iumbar disc(L3/4 or L2/3) prolapse, there will be sensory impair­ ment of the front of the lower thigh and side of the thigh and anteromedial aspect of the leg. First exclude that there is no compensatory lordosis by insinuating a hand beneath the lumbar spine. He should continue to raise the leg till he experiences pain as evidenced by watching his face. To be sure the test is repeated and as the angle is approached additional care is exercised to note when the pain starts. If the pain is evoked under 40° it suggests impingement of the protruding intervertebral disc on a nerve root. If the pain is evoked at an angle above 40° it indicates tension on nerve root that is abnormally sensitive from a cause not necessarily an intervertebral disc protrusion. At the angle when the patient experiences first twinge of pain, the ankle is passively dorsiflexed. It suggests irritation of one or more nerve roots either by disc protrusion or from some other space occupying lesion. This second part of the test is important to differentiate sciatica from diseases of the sacro-iliac joint. In the latter condition straight leg-raising test will be positive but there will be no aggravation of pain during passive dorsiflexion of the ankle. Pathological narrowing of the intervertebral space is noticed in X-ray in l/3rd of cases of disc prolapse. Various other bone deformities may be detected by X- ray which are the causes of backache. Myelography is of tremendous impor­ tance in excluding a tumour of cauda equina to be differentiated from disc prolapse. It must be remembered that negative myelo­ graphy does not rule out presence of disc prolapse. Where facilities of this investigation are available, this has certainly surpassed the previous investigations so far as its diagnostic efficacy is concerned (See Fig. If the attack is less severe, the patient may get out of the bed earlier and a corset is worn. Immobilisation in plaster of Paris jacket may be recommended after a few days rest in bed when pain has subsided considerably. The traction may have opened up the disc spaces to cause reduc­ tion of the prolapse. Injection of 2 mg of chymopapaine into the disc space has also been claimed to reduce prolapse. Operation is only indicated if the symptoms persist or neurological signs develop. The muscles are stripped off from the outer surfaces of the laminae with a wide chisel. The nerve root and the duramater are gently retracted to expose the intervertebral disc. The disc above must be inspected even when the prolapse has already been detected and removed. An interlaminar approach with excision of the ligamentum flavum and little, if any, of parts of the adjacent lamillae. Many orthopaedic surgeons recommend immediate spinal fusion in every case operated for prolapse intervertebral disc. This is because they are concerned with the mechanical aspects of the spinal column after removal of the intervertebral disc. But an intelligent compromise is to chalk out a few indications for spinal fusion. The indications for spinal fusion are :— (i) Presence of osteoarthritis ; (ii) Instability is anticipated (when pain is not relieved by rest, particularly at night, as the patient wakes up when he turns over in the bed); (iii) In case of heavy manual workers; (iv) When associated with congenital malformations or spondylolisthesis. A bone graft from the superficial cortex of the posterior part of the ileum is removed and is notched at either end to receive the spinous process above and below. The area to be fused is stripped off its cortical bone and the two spinous processes are cut flush with the laminae. The graft is inserted with the patient in flexion and the spinous processes separated. The lumbar spine is then extended and the graft is automatically fixed between the spinous processes. It is a degenerative condition of the lower cervical region and is characterised by :— (i) Degeneration of the intervertebral disc with extrusion of the disc material; (ii) Surrounding fibrosis which may spread to the nerve roots ; (iii) The edges of the vertebral bodies hypertrophy,which is known as ‘lipping’; (iv) There is also degeneration of the neurocentral joints of Luschka with the formation of osteophytes which project into the intervertebral foramen producing neurological symptoms. Examination for sensory loss, motor weakness and of tendon reflexes should be performed. Angiography—may reveal restriction of movement of vertebral and basilar arteries with the movement of the neck. This occurs due to fibrosis from spondylosis which engulfs the arteries and restricts their movements as also cause constriction in those arteries. Spinal fusion is the main operative treatment, but it should be added with removal of osteophytes which press on the nerve roots and removal of bony ridges if they are detected pressing on the anterior surface of the cord. Though he considered it to be chiefly affecting women, yet later on orthopaedic surgeons have discovered that this condition affects males more often than females. This is a deformity of the lumbosacral region produced by gradual slipping forward of the lumbar spine on the sacrum. The main pathology is a separa­ tion of the body of the vertebra from its posterior articulation, lamina and spinous process due to de­ fect in the pedicles. The pedicles are concerned with holding the vertebral body in front with the laminae and spinous process behind. Due to the defect in the pedicle (pars interarticularis), the laminae with the spinous process are left in their normal position, whereas the vertebral body moves forward alongwith the spinal column. The condition is usually revealed later in life, probably due to continuous stresses. It is the pars interarticularis which is the part of the pedicle between the superior and inferior articular facets. When the pars interarticularis is in two pieces, the gap is occupied by fibrous tissue, then the vertebra is divided into two parts—a posterior part which consists of the spinous process, laminae and inferior articular facets and an anterior part which consists of the vertebral body and the superior articular facets.

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The presence of a clear discharge suggests cerebral spinal fluid rhinorrhea and senile rhinorrhea purchase cheap caverta on-line erectile dysfunction psychological causes, especially if the patient is older buy discount caverta 100 mg line female erectile dysfunction treatment. If there is unilateral face pain, one should consider cluster headache or migraine. The presence of pain with fever or purulent discharge certainly suggests acute sinusitis. However, when there is pain with a clear discharge, one should think of cluster headache or migraine. The presence of sneezing or an allergic history should suggest allergic rhinitis and sinusitis. However, allergic rhinitis and sinusitis may also occur without sneezing or an allergic history. If the discharge is chronic and mucoid or clear, one should do a nasal smear for eosinophils and serum IgE level to look for allergic rhinitis. If there is still diagnostic confusion after the above tests have been done, referral to an ear, nose, and throat specialist or an allergist is indicated. The presence of chronic nasal obstruction, particularly if it is unilateral, would suggest sinusitis, foreign bodies, neoplasm, deviated septum, polyps, Wegener’s granulomatosis, mucormycosis, and nasal gumma. If it is bilateral, it would suggest allergic rhinitis, vasomotor rhinitis, adenoid enlargement, rhinitis medicamentosa, and ingestion of drugs such as reserpine. The presence of unilateral nasal obstruction suggests acute purulent sinusitis, foreign body, neoplasm, mucormycosis, Wegener’s granulomatosis, polyps, and neoplasms. The presence of fever with unilateral nasal obstruction would suggest acute sinusitis. Nasal diphtheria may occasionally present with this picture, even in modern times. If allergy is suspected, a nasal smear for eosinophils and serum IgE antibodies should be done. If there is still confusion regarding the diagnosis at this point, a referral to an ear, nose, and throat specialist or allergist would be indicated. Alcohol and many drugs, such as digitalis, aspirin, nonsteroidal anti-inflammatory agents, antihypertensives, and antibiotics may cause gastric irritation or gastritis. Fever may point to a localized abdominal condition such as acute cholecystitis or acute appendicitis, as well as a systemic condition, such as tuberculosis, brucellosis, yellow fever, and other febrile illnesses. Abdominal pain suggests the possibility of acute cholecystitis, acute appendicitis, pyelonephritis, pancreatitis, renal calculus, and peritonitis. The presence of an abdominal mass suggests pyloric or intestinal obstruction, a pancreatic neoplasm, acute cholecystitis, Crohn’s disease, perinephric abscess, diverticulitis, and other abscesses and neoplasms. The clinician should remember that inner ear diseases such as Ménière’s disease and labyrinthitis may be associated with vomiting, and sometimes the patient does not mention vertigo. Migraine, concussion, cerebral tumors or other space-occupying lesions, meningitis, and subarachnoid hemorrhage are associated with headaches, nausea, and vomiting. However, appendicitis, pancreatitis, and cholecystitis must always be kept in mind as does botulism. If there is fever, febrile agglutinins and a heterophile antibody titer should be done. When there is persistent vomiting with abdominal pain, an exploratory laparotomy may need to be considered. However, before ordering expensive diagnostic tests, a general surgeon or gastroenterologist ought to be consulted. Laparoscopy, gastroscopy, esophagoscopy, duodenoscopy, and colonoscopy all need to be considered in the workup. Gastroparesis and intestinal pseudo- obstruction can be ruled out by radioisotope studies and manometry of the stomach and small intestine. The finding of radiation of the pain to one or both upper extremities would suggest a space-occupying lesion, such as a herniated disk, spinal cord tumor, fracture, or cervical spondylosis. The presence of focal neurologic findings makes a space-occupying lesion even more likely and the conditions that should be considered are fracture, herniated disk, spinal cord tumor, and cervical spondylosis. At this point, it is best to observe the results of conservative treatment before an expensive workup is begun. It is wise to consult a neurologist or neurosurgeon before ordering these expensive tests. If there is nuchal rigidity, meningitis or subarachnoid hemorrhage would be high on the list of possibilities. If there is chronic neck stiffness, one should consider rheumatoid arthritis, cervical spondylosis, and idiopathic torticollis. With a history of trauma, the possibility of flexion–extension injury and fracture is more likely. The presence of nuchal rigidity or fever should make one think of meningitis, subarachnoid hemorrhage, or meningismus due to some systemic infectious disease. The presence of congenital stiffness of the neck should make one think of congenital torticollis or Klippel– Feil syndrome. Chronic acquired neck stiffness should make one think of cervical spondylosis, Parkinson’s disease, idiopathic torticollis, rheumatoid arthritis, tuberculosis, fractures of the spine, flexion– extension injuries, and inflammation of the lymph nodes. Plain films of the cervical spine will often reveal cervical spondylosis, fractures, and tuberculosis. However, one should not jump to the conclusion that this is the cause of the condition. If there is no nuchal rigidity or fever, plain films of the cervical spine are a good place to start the diagnostic workup. A neurologic specialist should be consulted before ordering expensive diagnostic tests. Focal masses or swellings may be thyroglossal cyst, branchial cleft cyst, aneurysm, an enlarged lymph node due to Hodgkin’s disease, metastatic carcinoma, sarcoidosis, a cystic hygroma, carotid body tumor, Riedel’s struma, and thyroid adenomas and carcinomas. Diffuse masses would be Graves’ disease, subacute thyroiditis, nontoxic goiter, venous distention of congestive heart failure or superior vena cava syndrome, and subcutaneous emphysema. An acute diffuse neck swelling must be considered Ludwig’s angina (neck extension of an abscessed tooth) until proven otherwise. Midline masses are thyroglossal cysts, adenoma of the thyroid, Riedel’s struma, and thyroid cyst. Lateral masses include a pharyngeal pouch, bronchial cyst, pulsion diverticulum, stone of Wharton’s duct, Virchow’s node, cervical rib, metastatic lymph nodes or Hodgkin’s lymphoma, metastatic carcinoma, cystic hygroma, carotid body tumor, and some thyroid masses. The presence of an intermittent swelling suggests a pulsion diverticulum, venous distention of congestive heart failure, a bronchial cyst, a stone of Wharton’s duct, and aneurysms. The presence of tremor or tachycardia would make one think of Graves’ disease and subacute thyroiditis. A radioactive iodine uptake and scan will help differentiate thyroid tumors and enlargements. Ultrasound and needle aspiration will be needed in differentiating cystic adenomas. A lymph node biopsy will be useful in 453 diagnosing sarcoidosis, lymphomas, and metastatic carcinoma. The presence of acute nightmares should make one think of the possibility of infectious disease, acute situational maladjustment, or a head injury.

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On the other hand cardiac arrest in an otherwise healthy individual can be managed effectively as mentioned above purchase caverta 100mg on line impotence trials france. Precise cardiac surgery has been made possible by detail informations of the diseased heart through various special investigations cheap caverta 50 mg mastercard erectile dysfunction treatment pdf. A few special views from different angles may indicate enlargement of a particular chamber of the heart e. This has been described in details under special investigation of various cardiac conditions later in this chapter. Certain amounts of functions of the cardiac chambers may also be assessed with this investigation. Conditions like coarctation of aorta, calcified valves may be detected through this investigation. With this technique important anatomical examination regarding size and shape of the different heart chambers, presence of a shunt or septal defects and function of different valves can be obtained. The aorta and the pulmonary artery and its branches are also visualised in detail. Selective angiocardiography is possible to delineate the anatomy of the coronary arteries in patients with angina. Atherosclerotic plaque in the artery, its correct size and extent and collateral circulation can be well assessed using Neopam 370 with a dose of 4 to 6 ml per selected coronary artery. In the 3rd period catheterisation techniques were modified and extended to allow the angiographer to treat cardiac disease as well as to diagnose it Access to the vena cava and right heart chambers can be attained either percutaneously or by surgical venotomy. Percutaneous right heart cannulation is usually done via the femoral vein, whereas venotomy is performed at the antecubital fossa. Right heart catheterisation can also be done from the internal or external jugular or subclavian veins. Cannulation of the left heart is performed percutaneously from the femoral artery or by surgical cut down on the brachial artery. Occasionally the left heart chambers are approached from the right atrium via the right femoral vein using a technique known as transseptal catheterisation. This procedure involves puncture of the interatrial septum with a special catheter. Most catheters are composed of Woven Dacron or nylon covered with a radio-opaque plastic coating. The normal haemodynamic values are — Right atrium — 0 to 8 mm Hg; Right ventricle — 5 to 30 mm Hg (systolic) and 0 to 8 mm Hg (diastolic). Pulmonary artery — 15 to 30 mm Hg (systolic); 5 to 15 mm Hg (diastolic); Pulmonary artery wedge — 1 to 12 mm Hg. Left ventricle — 90 to 140 mm Hg (systolic); 2 to 12 mm Hg (diastolic); Aorta — 90 to 140 mm Hg (systolic); 60 to 90 mm Hg (diastolic). A contrast cine angiogram of the left ventricle (contrast left ventriculography) is a routine part of most left heart catheterisation studies. It permits an evaluation of ventricular function and chamber size, segmental wall motion, wall thickness and presence and severity of mitral regurgitation. Angiographic assessment of the severity of a regurgitant vulvular lesion is an important step in determining the proper timing for valve replacement surgery. Coronary angiography is another investigation which may be performed by cardiac catheterisation and gives a clear delineation not only of the anatomy of the coronary arteries but also the presence of atherosclerotic plaque, its site and extent. Intracoronary administration of streptokinase is another part of the new and rapidly evolving field of interventional cardiac catheterisation. When these waves cross a boundary or interface, the waves will be reflected back to the transmiting source provided the reflecting surface is at right angles to the original beam. By placing the transmeter, the movements of various walls of the heart including various septa and leaflets of valves can be recorded with useful informations. Thickening, calcification and mobility of the valve cusps can be clearly demonstrated, so that necessary operation can be timed properly. It also indicates presence of any atrial tumour or pericardial effusion with certainty. Recent developments have included investigation of all forms of congenital heart disease by two dimensional and pulsed Doppler echocardiography. This investigation alone can find out various important informations of the diseased heart, so that cardiac catheterisation and angiocardiography can be dispensed with. If radioactive material is coupled with specific antimyocardial monoclonal antibodies, areas of heart damaged during heart attack can be defined. This is also proving useful in investigating cases with myocardial infarction, ventricular aneurysm, intracardiac thrombi and tumours. It also helps both in diagnosis and demonstrating the extent of dissecting aneurysm. The examples arepericardiectomy, resection of thoracic aortic aneurysms, systemic-pulmonary anastomosis, ligation of patient ductus and excision of coarctation of aorta. Mitral valvotomy is probably the only operation which is still performed as a closed intracardiac operation. If the heart is made motionless, blood supply to the various tissues will be stopped. So some alternative arrangement must be made to continue blood supply to the vital organs of the body, so long as the heart is operated on and kept without its function of pumping blood. This type of machine is now widely available in the market in many commercial models. Basically the machine consists of an oxygenator (alternative of lungs) and a pump (alternative of the heart). The circulating blood is diverted from the heart and lungs and is passed through this heart-lung machine, so that the surgeon can operate on the heart while it is not functioning. By this technique, majority of complicated congenital and acquired cardiac abnormalities are operated on. The ascending aorta is cannulated with a plastic tube through a purse-string suture placed in the coat of adventitia. So the deoxygenated blood from the venae cavae are coming to the heart-lung machine, where it is oxygenated and then pumped into the ascending aorta. This is the procedure, with which the heart and lungs of the patient are made inactivated for operation on the heart. Before starting the heart lung machine one must be sure that all air bubbles have been eliminated. After the operation is over, the cannulae are removed, the purse-string sutures are tightened and the heparin is counteracted with protamine (6 mg/kg body weight). A few of these are measurement of blood gases, determination of serum potassium and measuring urinary output. The surgeons prefer a motionless relaxed heart for a considerable period to operate on.

C. Rasul. University of Houston, Clear Lake. 2019.

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