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Besides the fact that this will help to give a clue to the present illness or in the subsequent treatment generic aurogra 100 mg with amex, it has tremendous importance from anaesthetic point of view buy aurogra with a mastercard. Special enquiry should be made about steroids aurogra 100 mg discount, insulin, antihypertensives, diuretics, ergot derivatives, monoamine oxidase inhibitors, hormone replacement therapy, contraceptive pills etc. This is very important and should not be missed under any circumstances, while taking history of a patient. The patient should be asked whether he or she is allergic to any medicine or diet. The students should make it a practice and they will definitely find that this valuable practice will save many catastrophies. It is also enquired about the marital status of the individual — whether married or single, a widow or a widower. In women, the menstrual history must be- recorded perfectly — whether the patient is having regular menstruation or not, the days of menstruation, whether any pain is associated with menstruation or not and last date of menstruation. The number of pregnancies and miscarriages are noted with their dates, — whether the deliveries were normal or not, whether the patient had Caesarean section or not and if so, for what reason. The patient is also asked whether there is any white discharge per vaginam or not. Haemophilia, tuberculosis, diabetes, essential hypertension, peptic ulcer, majority of the cancers particularly the breast cancer and certain other diseases like fissure-in-ano, piles etc. So the students must not forget to enquire about other members of the family, such as about the parents if they are still alive. For complete examination, the patient should be asked to take off all his clothes and covered by only a dressing gown. In case of severely ill patients, one should cut down the wastage of time to know other less important findings. The doctor should hasten into the treatment after rapidly going through the local examination to come to a probable diagnosis and to find out those signs which may help him to institute proper treatment. An intelligent patient will give a very good history on which the doctor can rely. On the other hand the doctor should not rely wholly on the history from the patient with very low intelligence. There are 5 stages of level of consciousness — (a) Fully conscious with perfect orientation of time, space and person, (b) Fully conscious with lack of orientation of time and space, (c) Semiconsciousness (drowsy) but can be awakened, (d) Unconscious (stupor), but responding to painful stimuli, (e) Unconscious (coma) and not responding to painful stimuli. As for example, a cachectic patient suffering from an abdominal discomfort with a lump, is probably suffering from carcinoma of some part of the G. Patients with pain due to peritonitis lie still, whereas patients with colicky pain become restless and toss on the bed. An old patient after a fall, when lies helplessly with an everted leg, possibility of fracture of the neck of the femur becomes obvious. Abnormal gait occurs due to various reasons — (a) Pain; (b) Bone and joint abnormalities; (c) Muscle and neurological diseases; (d) Structural abnormalities and (e) Psychiatric diseases. Just looking at the face good clinician can assess the depth of the disease and effect of his treatment. One should look at the lower palpebral conjunctiva, mucous membrane of the lips and cheeks, nail beds and palmar creases for pallor. It may be either due to poor perfusion of these vessels (peripheral cyanosis) or due to reduction in the oxygen saturation of arterial blood (central cyanosis). For cyanosis to be observed, there must be a minimum of 5 g/dl of reduced haemoglobin in the blood perfusing the skin. Peripheral cyanosis is due to excessive reduction of oxyhaemoglobin in the capillaries when the blood flow is slowed down. It is also seen in patients with reduced cardiac output when differential vasoconstriction diverts blood flow from the skin to other more important organs e. Peripheral cyanosis is looked for in the nail bed, tip of the nose, skin of the palm and toes. This may be due to diseases in the lungs or due to some congenital abnormalities of the heart where venous blood by-passes the lung and is shunted into the systemic circulation. For central cyanosis one should look at the tongue and other places as mentioned above. This is due to the presence of excess of lipid-soluble yellow pigments (mostly the bile pjgments) in the plasma. The places where one should look for jaundice are — (i) sclera of the eyeball — for this the patient is asked to look at his feet when the surgeon keeps the palpebral fissure wide open by pulling up the eyelid, (ii) nail bed, (iii) lobule of the ear, (iv) tip of the nose, (v) under-surface of the tongue etc. When the jaundice is deep and long standing, a distinct greenish colour becomes evident in the sclerae and in the skin due to the development of appreciable quantities of biliverdin. Scratch marks may be prominent in the skin in obstructive jaundice as a result of pruritus which is believed to be due to retention of bile acids. Such hypercarotinaemia may occur occasionally in vegetarians and in those who eat excessive quantities of raw carrot. They may be due to capillary naevi or erythemas which disappear on pressure, whereas purpuric macules do not blanch when pressed. Vesicles — are elevations of horny layer of the epidermis by collection of transparent or milky fluid within them. Pustules — are similar elevations of the skin as vesicles, but these contain pus instead of fluid within them. Wheal — is a flat oedematous elevation of the skin frequently accompanied by itching. It is the typical lesion of urticaria and may be seen in sensitive persons provoked by irritation of the skin. Pulse gives a good indication as to the severity of acute appendicitis and thyrotoxicosis. Generally it gives a good indication of the cardio-vascular condition of the patient. Shock, fever and thyrotoxicosis are a few conditions, which are well reflected in pulse. Following points are particularly noted in pulse :— (a) Rate — fast or slow, (b) Rhythm — regular or irregular, (c) Tension and force which indicate diastolic and systolic blood pressure respectively, (d) Volume which indicates pulse pressure, (e) Character e. Water-hammer pulse of aortic regurgitation or thyrotoxicosis, pulsus paradoxus of pericardial effusion etc. Tachypnoea (fast breathing) is seen in fever, shock, hypoxia, cerebral disturbances, metabolic acidosis, tetany, hysteria etc. In Cheyne-Stokes respiration there is gradual deepening of respiration or overventilation alternating with short periods of apnoea. Fever or high temperature is come across in various conditions, which the students will be more conversant in medical ward. But broadly, the students should know that there are three types of fever — the continued, the remittent and the intermittent.

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The answer to this postoperative death buy 100 mg aurogra mastercard, now a relatively rare event following question depends somewhat on the surgeon’s attitude toward bariatric surgery proven aurogra 100mg. Preoperative cardiac assessment should be traindicated if liver or peritoneal disease is extensive buy cheap aurogra 100mg on line. Intraoperative testing of gastric anastomo- Laparoscopy helps avoid a major unnecessary operation in sis or staple lines is routine. Finally, it is clear that in experi- Each bariatric operation has a specific set of possible long- enced hands, laparoscopic radical gastrectomy for gastric term complications, nutritional and otherwise. Lap-band slippage can be a surgical emergency since gastric necrosis may ensue, but band erosion into the stomach typi- Operation for Morbid Obesity cally is handled with elective band removal and drainage. Duodenal switch and biliopancreatic ered for bariatric surgery and referral to a multidisciplinary diversion are not commonly performed bariatric procedures. For interstitial cells of Cajal, and though they may occur any- safe application, it is important to adhere to certain principles. There are three histologic sub- dividing stomach or duodenum if the staples are too types: spindle cell (70 %), epithelioid (20 %), and mixed big, excessive staple-line bleeding can occur or rarely (10 %). If the staples are too small, they will not go patients with completely resected nonmetastatic disease, full thickness through both walls and the staples will prognosis is related to (inter alia) tumor size and mitotic not form correctly. It is probably better to use a staple size that kinase blocker imatinib (Gleevec). There may be a role for preoperative imatinib for pany’s stapler for 10 years cannot assume that she knows very large tumors that appear marginally resectable on exactly how to use the other company’s similar stapler. Patients who experience disease familiar with the new instrument before using it in the progression or intolerable side effects on imatinib are operating room. This is why when stapling across an existing antrum and pylorus, resulting in gastric stasis. When feasible, staple lines in the stomach and duodenum mosis and Roux duodenojejunostomy. Instillation 28 Concepts in Surgery of the Stomach and Duodenum 277 of methylene blue and intraoperative endoscopy are other Pancreatitis useful methods to confirm staple-line integrity. Staple-line bleeding into the lumen can be problematic Pancreatitis following gastroduodenal operation is generally and rarely can be life threatening. Either of the papillae can be injured during aggres- rhage and bleeders controlled. More com- gastrojejunostomy, intraoperative endoscopy should monly, the more proximal minor papilla is occluded or be performed if excessive staple-line hemorrhage is transected. The problems are interrelated in that infection predisposes to the other two complications, and all Postoperative Complications three share risk factors. Wound infection is related to intra- operative contamination, which is more significant in the set- Pulmonary Problems ting of acid suppression, gastric cancer, and obstruction. Appropriate use of prophylactic antibiotics and good surgical Atelectasis is probably the most common complication technique are important preventative measures. Adequate analgesia, incentive spi- disease, abdominal distension, obesity, infection, malnutri- rometry, and early ambulation help minimize this prob- tion, and steroid therapy have all been shown to increase the lem. Pulmonary embolism is unusual with current prophylactic practices but should be considered Early Gastric Stasis in any postoperative patient with acute shortness of breath, chest pain, or unexplained fever and tachycardia. Occasionally in the hospitalized patient who is recovering from gastric surgery, the nasogastric tube “cannot be removed” because of persistent nausea and vomiting. Alternative methods of gastric intubation and alimentation Following a gastric or duodenal operation, any suture line are preferable to a major reoperation during the first 6 weeks may leak and create a potentially fatal situation. These prob- postoperatively when the inflammatory response in the sur- lems manifest by the fifth or sixth postoperative day and are gical field may be intense. Reoperation during this early associated with increasing abdominal pain, fever, distension, postoperative period is often difficult, hazardous, and usually and leukocytosis. In patients and drainage of the peritoneal cavity, decompression of the with a small gastric remnant where a Stamm gastrostomy leaking segment (e. If the initial Witzel technique), and another (distal) tube may be placed operation was laparoscopic, sometimes an adequate reopera- antegrade as a Witzel feeding jejunostomy. Reoperation should thus usually be delayed for patients with postvagotomy diarrhea respond to cholestyr- 3–6 months after the first operation unless a high-grade or amine, and in others codeine or loperamide is useful. Following ablation or resection of the pylorus, most patients have bile in the stomach on endoscopic examination along with some degree of gross or microscopic gastric inflamma- Dumping Syndrome tion (Malagelada et al. Attributing post- operative symptoms to bile reflux is therefore problematic, Clinically significant dumping occurs in 5–10 % of patients as most asymptomatic patients also have bile reflux. It is usually epigastric pain, and quantitative evidence of excess entero- due to ablation of the pylorus, but decreased gastric compli- gastric reflux. Curiously, symptoms often develop months or ance with accelerated emptying of liquids (e. Medical therapy for early dumping syndrome consists of Remedial operation eliminates the bile from the vomitus dietary management and if necessary somatostatin analog and may improve the epigastric pain, but it is quite unusual to (octreotide). Bile reflux gastritis after distal It is the rare patient with dumping symptoms who requires gastric resection may be treated by Roux-en-Y gastrojejunos- an operation. To eliminate bile reflux, the Roux results of remedial operation for dumping are variable and limb or Henley loop should be at least 45 cm long, and a unpredictable. A variety of surgical approaches have been Braun enteroenterostomy should be placed a similar distance described, none of which works consistently well. Excessively long jejunal limbs may be include simple takedown of the gastrojejunostomy if the associated with obstruction or malabsorption. Whether Roux-en-Y proximal a previous operation, the Roux or Braun operations may be duodenojejunostomy (i. The benefits of decreased acid secretion would benefit the rare patient with disabling dumping fol- following total gastric vagotomy may be outweighed by lowing pyloroplasty is unclear. The Roux operation may be associ- Diarrhea ated with an increased risk of emptying problems compared to the other two options, but controlled data are lacking. Truncal vagotomy is associated with clinically significant Primary bile reflux gastritis (i. It occurs soon after operation is rare and may be treated with duodenal switch operation, and is usually not associated with other symptoms, a fact that essentially an end-to-end Roux-en-Y to the proximal duo- helps distinguish it from dumping (see above). The Achilles’ heel of this operation is, not surpris- may be a daily occurrence or it may be more sporadic and ingly, marginal ulceration. Possible mechanisms include intestinal dys- with proximal gastric vagotomy and/or chronic acid motility and accelerated transit, bile acid malabsorption, suppressive medication. Gastric stasis following operation on the stomach may be due to gastric motor dysfunction or mechanical obstruction (Speicher et al. The gas- Metabolic Problems tric motility abnormality may have been preexistent and unrecognized by the operating surgeon. Weight loss is common in patients who have be secondary to deliberate or unintentional vagotomy or undergone vagotomy or gastric resection (or both) (Harju 1990). An obstruction The degree of weight loss tends to parallel the magnitude of the may be mechanical (e. It may be insignificant in the large person or devastat- ulcer, efferent limb kink from adhesions or constricting ing in the asthenic female patient.

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When a child comes with bleeding per anum purchase aurogra 100 mg mastercard, a diagnosis of rectal polyp should be made until this is excluded by rectal examination purchase 100mg aurogra free shipping. Enquiry should also be made whether it is the blood alone or blood with mucus or blood mixed with stool or blood streaked on stool purchase cheap aurogra on-line. Soiling of clothes with purulent discharge coming from a sinus is the constant complaint of a patient with fistula-in-ano. In ulcerative carcinoma of the rectum the patient often passes considerable quantity of blood stained, purulent and offensive discharge at the time of defaecation. While pain is very much associated with fissure-in-ano particularly the chronic type as also perianal abscess, pain is absent in haemorrhage from carcinomatous conditions and polyps. In case of intussuscep­ tion there may be emptiness in the right iliac fossa which is known as sign-dc-dance. So careful abdominal examination is necessary to find out cause of bleeding per anum. All anal, perianal and majority of rectal conditions can be diagnosed through this examination. The key to pleasant and successful colonoscopy lies in achieving a clean bowel before hand. Colonoscopy is never performed under general anaesthesia, but may be carried out after satisfactory analgesia by injecting intravenous diazepam 5 to 20 mg and pethidine 25 to 75 mg. It must be remembered that presence of anorectal or distal colonic lesions do not necessarily rule out the presence of a more proximal source of bleeding. The diagnostic accuracy of the barium enema has also been greatly increased by the use of the double contrast technique provided the bowel has been adequately prepared. Particularly in intussusception the role of barium enema is immense and this has been described in the section of ‘intussusception’. When colonoscopy is non-diagnostic and barium enema has not been informative, the small bowel lesion should be considered and a small bowel barium meal follow-through is necessary. The long intravascular half-life of labelled red cells allows repeat scanning and increases the probability of isolating those lesions that bleed intermittently. The advantages of this technique are accuracy, safety, its non-invasive character, freedom from contrast-related problems and its low cost. At present radioisotope scanning is limited to screening prior to angiography, but it has no therapeutic value. Selective angiography is necessary through superior mesenteric or inferior mesenteric artery. The site of bleeding is revealed by extravasated contrast medium remaining in the bowel in the late films of angiographic series. Haemorrhage can also be controlled by selective infusion of vasopressin or by deliberate injection of embolic material as described in detail in upper G. Preoperative localisation of bleeding may facilitate minimal access surgery — for example laparoscopically assisted colectomy or Meckel’s diverticolectomy. General management includes the measures to resuscitate the patient from shock and at the same time to give blood transfusion to replenish the blood loss. Only one condition is to be discussed here and that is angiodysplasia (see page 1049). Approximately 15% of patients are amenable to colonoscopic treatment as mentioned above. Colonoscopic therapy is often not a definitive treatment modality, it merely tides over the critical period so that definitive surgical treatment can be undertaken when the patient is in a relatively stable condition. Treatment alongwith the use of angiography (as mentioned above) is on the rise in the management of lower G. Haemostasis can be achieved with embolisation in about 70% of patients and only in 10% the bleeding cannot be controlled. Vasopressin therapy has not been compared with embolisation, though angiographic embolisation is usually for patients with continuing bleeding prior to a surgical intervention so as to allow the patients to be in a better general condition. Surgery is reserved for those who continue to bleed or rebleed after initial cessation. At operation the identifiable lesions such as carcinoma or Meckel’s diverticulum should be resected. For patients with continuing bleeding from an unidentified source, a blind subtotal colectomy should be performed. Sometimes ‘rebleed’ cases may require surgery which may be segmental or subtotal colectomy. An approach being advocated recently, is the use of anticoagulants, vasodilators or thrombolytic agents to reactivate or augment the bleeding followed by a nuclear scan or angiography. Only a very small number of cases may even bleed inspite of multiple attempts at preoperative localisation have failed. The formation of the tail fold carries the connecting stalk on to the ventral aspect of the embryo, so that it now assumes the permanent position of the umbilical cord. Prior to the formation of the tail fold a diverticulum arises from the dorsicaudal portion of the yolk sac and grows into the mesoderm of the connecting stalk. Gradually the proximal part of this diverticulum becomes incorporated in the hind gut and its distal portion persists as the allantoic canal or the allantois, which then communicates directly with the ventral surface of the hind gut. The portion of the hind gut which lies caudal to this communication forms the entodermal cloaca. Between the head fold and the tail fold the embryo becomes constricted by right and left lateral folds. The intervening dorsal portion of the yolk sac which these folds threaten to cut off constitutes the midgut. At first the midgut communicates freely on its ventral surface with the rest of yolk sac, but the continued growth of the folds results in narrowing ofthe connection, which becomes drawn out as the vitello- intestinal duct. As a consequence of the continued expansion of the amnion, the extra-embryonic coelom which was surrounding the embryo is gradually obliterated. The mesoderm covered surfaces of the head, tail and lateral folds converge on the region of the connecting stalk and the vitello-intestinal duct. The mesoderm of the folds, mentioned earlier, which converge to form the umbilical cord. The umbilical cord consists of an outer covering of amnion, containing in its interior the vitello-intestinal duct, remains of the extra-embryonic coelom, the allantoic canal and umbilical vessels embedded in a mass of primary mesoderm. The part of the extra-embryonic coelom included in the umbilical cord acts as the sac for the physiological umbilical hermia which characterises the embryo between the 6th and the 10th weeks. After the disappearance of this hemia, the remains of the extra-embryonic coelom normally obliterate. The umbilical vessels, particularly the arteries are provided with a strong muscular coat, which when contracts produces thickening of the media, infolding of the interna and considerable narrowing of the lumen. The vitello-intestinal d uct may persist completely or partially to give rise 10 the following conditions. When it is patent althroughout, it gives rise to intestinal fistula, which discharges mucus and occasionally faeces (then it is termed faecal fistula). Sometimes the major part of the duct obliterates, only a small part near the umbilicus remains patent.

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A 59-year-old quality 100mg aurogra, myopic gentleman reports “seeing flashes of light” at night when his eyes are closed generic aurogra 100 mg with visa. Further questioning reveals that he also sees “floaters” during the day generic aurogra 100mg with amex, that they number 10 or 20, and that he also sees a cloud at the top of his visual field. This is retinal detachment; 1–2 floaters would not mean that but >12 is an ominous sign. The “cloud” at the top of the visual field is hemorrhage settling at the bottom of the eye. The retina specialist will use laser treatment to “spot weld” the retina and prevent further detachment. If negative, this is an ophthalmologic emergency—although little can be done for the problem. It might help for him to take an aspirin and breathe into a paper bag en route, and have someone press hard on his eye and release it repeatedly. On questioning about eye symptoms, he reports that sometimes after a heavy dinner the television becomes blurry, and he has to squint to see it clearly. It takes 10–20 years for these to develop, but type 2 diabetes may be present that long before it is diagnosed. When the mass is palpated at the same time that the tongue is pulled, there seems to be a connection between the two. The mass has been present for at least 10 years, but only recently bothered the patient because it got infected. Sistrunk operation (removal of the mass and the track to the base of the tongue, along with the medial segment of the hyoid bone). Some people insist that the location of the normal thyroid must be ascertained first with radioisotope scanning. An 18-year-old woman has a 4-cm, fluctuant round mass on the side of her neck, just beneath and in front of the sternocleidomastoid. She reports that it has been there at least 10 years, although she thinks that it has become somewhat larger in the last year or two. A 6-year-old child has a mushy, fluid-filled mass at the base of the neck that has been noted for several years. The mass is ~6 cm in diameter, occupies most of the supraclavicular area and seems by physical examination to go deeper into the neck and chest. If the node has gone away by then, it was inflammatory and nothing further is needed. Three weeks of delay will not significantly impact the overall course of a neoplastic process. The node is in the jugular chain, measures ~2 cm, is firm, not tender, and was discovered by the patient 6 weeks ago. Physical examination reveals enlarged lymph nodes in both axillas and in the left groin. The patient has had a 20-pound weight loss in the past 2 months, but is otherwise asymptomatic. Malignant metastases to a supraclavicular node from a primary tumor below the neck (Virchow’s node). A 69-year-old man who smokes and drinks and has rotten teeth has a hard, fixed, 4-cm mass in his neck. The mass is just medial and in front of the sternocleidomastoid muscle, at the level of the upper notch of the thyroid cartilage. Metastatic squamous cell carcinoma to a jugular chain node, from a primary in the mucosa of the head and neck (oropharyngeal–laryngeal territory). Most patients get combined therapy that includes radiation, platinum-based chemotherapy, and surgery if possible. A 69-year-old man who smokes and drinks and has rotten teeth has a painless ulcer in the floor of the mouth that has been present for 6 weeks and has not healed. A 69-year-old man who smokes and drinks and has rotten teeth has a unilateral earache that has not gone away in 6 weeks. Physical examination shows serous otitis media on that side, but not on the other. These are all different ways for squamous cell carcinoma of the mucosa of the head and neck to show up. They all need triple endoscopy to find and biopsy the primary tumor and to look for synchronous second primaries. He does not engage in any activity (such as sport shooting) that would subject that ear to noise that spares the other side. Note that if the hearing loss had been conductive, a cerumen plug would be the obvious first diagnosis. A 56-year-old man develops slow, progressive paralysis of the facial nerve on one side. It took several weeks for the full-blown paralysis to become obvious, and it has been present now for 3 months. A 45-year-old man presents with a 2-cm firm mass in front of the left ear, which has been present for 4 months. Look for the option that offers referral to a head and neck surgeon for formal superficial parotidectomy which serves as a diagnostic and therapeutic tool. A 65-year-old man presents with a 4-cm hard mass in front of the left ear, which has been present for 6 months. He has constant pain in the area, and for the past 2 months has had gradual progression of left facial nerve paralysis. A 2-year-old has unilateral wheezing, and the lung on that side looks darker on x-rays (more air) than the other side. Appropriate x-rays, physical examination or endoscopies, and extraction are needed—obviously under anesthesia. Incision and drainage are needed, but intubation or tracheostomy may also be required. The latest trend is to start these patients right away on antiviral medication and steroids. Trauma to the temporal bone can certainly transect the facial nerve, but when that happens the nerve is paralyzed right there and then. Rodriguez, a middle-aged patient whom you have treated repeatedly over the years for episodes of sinusitis. In fact, 6 days ago you started her on decongestants and oral antibiotics for what you diagnosed as frontal and ethmoid sinusitis. Now she tells you over the phone that ever since she woke up this morning, she has been seeing double.

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