By M. Javier. Villanova University.

With the advent of flexible fibreoptic bronchoscope the success rate has gone upto 70% buy 50mg nizagara otc. With the help of bronchoscopy one can do bronchial brushing and cytologic studies of bronchial washings that may be obtained through broncoscope generic nizagara 50 mg without a prescription. The endoscopist must try to assess the proximal extent of the neoplasm as the resectability of the tumour depends on its closeness with the tracheal carina purchase generic nizagara from india. The mediastinoscope is introduced through the incision along the anterior course of the trachea. If nodes of the other side are involved resection of the tumour is contraindicated. Many surgeons now favour a short anterior or lateral thoracotomy in preference to medi­ astinoscopy. Mediastinoscopy may be associated with serious and fatal complications including haemorrhage from an arterial or venous source. Computed tomography correctly predicts the presence or absence of mediastinal metastasis with accuracy of more than 90%. But false positive result may be achieved due to lymphadenopathy from other causes than metastasis. Mediastinal glands may press on the oesophagus which will also be revealed by this technique. There are a few instances when the patient cannot be operated on and these cases are considered to be inoperable. It must be remembered that when a diagnosis of carcinoma of lung is made, half of the patients are found to be inoperable from the outset Of the 50% upon whom exploratory thoracotomy is performed, half of these will be found to have such extensive disease that a radical resection cannot be performed. Thus radical resection is possible in only 25% of patients in the best centres of the world and this figure is much less in our country. Most surgeons prefer posterior thoracotomy through the 5th or 6th intercostal space. However an anterior thoracotomy through the 3rd intercostal space is sometimes preferred by a few surgeons since ventilation is much better achieved during the operation with this approach. When the tumour has involved the main bronchus, pneumonectomy is the operation of choice. For carcinomas occurring in the periphery of the lung, particularly in patients with reduced pulmonary reserve, a local wedge resection can be an entirely satisfactory procedure. In certain patients in whom an extensive pulmonary resection is hazardous, sleeve resection may be performed in which one lobar bronchus together with a part of the right or left main bronchus is excised and the distal bronchus is then reanastomosed to the proximal bronchus. At the initial stage the pulmonary veins from the affected lobe should be tied to reduce the risk of tumour embolism. The remaining vessels are then isolated and secured by double ligatures before they are divided. The bronchus is divided as close to its origin as possible without leaving behind any redundant stump which may be devitalised. The paratracheal, subcarinal and para­ aortic lymph nodes should be removed with surrounding areolar tissue alongwith lung resection. The bronchus is closed with sutures of wire or nylon using interrupted figure of ‘8’ stitches. Nowadays automatic stapling device has been introduced to staple for closure of bronchus. Sometimes the lobes may be adhered to each other and such adhesions are to be divided by sharp dissection. The bronchus is divided between clamps close to its origin from the main bronchus. The bronchus is closed with interrupted sutures of silk, nylon or steel wire A stapler may also be used instead of sutures. Any involved lymph nodes in the mediastinum should be removed alongwith surrounding areolar tissue with lobectomy. After thoracotomy, it may be seen that the growth is not suitable for radical resection, (i) Spread of the tumour involving the parietal pleura, (ii) pericardium, (iii) heart or (iv) other mediastinal structures are signs which indicate non-suitability of the case for resection of the tumour, (v) Involvement of the chest wall in most cases indicate non-operability, but in certain cases it is possible to resect the tumour en bloc with the chest wall. If on thoracotomy the growth is not suitable for complete resection, a palliative resection should be undertaken. This is quite helpful to the patients as it will not give chance for subsequent bronchial obstruction to develop. The generally recommended dose in the treatment of carcinoma of the lung is 5000 to 6000 rads given 5 times weekly for 5 to 6 weeks. Preoperative irradiation has only been successful in carcinoma of the superior pulmonary sulcus (Pancoast tumour) which becomes more operable after this radiation therapy. Otherwise the scope of preoperative irradiation is not satisfactory due to increased incidence of bronchopleural fistulas following resection and no improvement in the survival rate. Postoperative irradiation has a limited scope when the risk of recurrence following surgical therapy is anticipated. This has also a place when a portion of the growth has not been removed during operation. For such patients a dose of approximately 5000 rads is given over a period of 5 weeks to the left out primary tumour and involved lymph nodes. Palliative radiation therapy can be very useful in improving the quality of life by improving chest pain, haemoptysis and paroxysmal coughing. Relief of pain from bone metastasis is often achieved by palliative radiation therapy. Brain metastases can also be palliated by whole brain radiation with doses upto 4000 rads given over 4 weeks period. Pneumonitis is generally associated with mild cough, fever and minimal haemoptysis. The current treatment protocols of small cell carcinoma include cyclophosphamide, doxorubicin and vincristin. When these drugs are administered in conjunction with a course of radiation (3000 rads), this combination has achieved considerable remission. The response rate is as high as 75% with limited disease and complete remission has been obtained in 14% of patients with extensive disease. For non-small cell bronchogenic carcinomas the effect of chemotherapy has been variable. It is more effective in adenocarcinoma and large-cell carcinoma than for squamous cell carcinoma. In adenocarcinomas by using combination of radiation therapy and chemotherapy considerable remission has been achieved. In these cases 4 drugs therapy should be introduced with cyclophosphamide, adriamycin, methotrexate and cis- platinum.

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Long-term success rates for percu- cytochemistry evaluation of islet cell tumors routinely yields taneous endoscopic and endoluminal decompression have the presence of various other islet cell products in addition to been approximately 70 % buy nizagara 50 mg on-line. These data are comparable to the the primary one associated with the endocrinopathy in indi- known operative success rates for external drainage of pseu- vidual patients buy generic nizagara from india. In other words nizagara 100mg for sale, a patient with an insulinoma docysts established decades ago, which typically were about is likely to have somatostatin and possibly glucagon or gas- 70 % as well. Although some endoscopic and some interven- trin in the islets present within the insulinoma. In view of the tional studies have reported slightly higher success rates, added specificity of octreotide scanning, it is most recom- long-term follow-up has been scant. These modalities may reveal lesions not material that is unlikely to be adequately drained through found using conventional imaging techniques. It poses a for both procedures is their ability to access the duodenal wall, risk for secondary infection after being exposed to microor- which is the most common site of extrapancreatic gastrinoma. Once diagnosed, the problem of intraoperative localiza- The options for providing operative drainage include cysto- tion remains. Intraoperative ultrasonography plays a major gastrostomy and Roux-en-Y cyst jejunostomy. The so-called gastrinoma triangle is bounded by a verti- the pancreatic pseudocyst is also an option and is generally cal line drawn between the pylorus and the third portion of reserved for cysts in the body and tail of the pancreas. The apex of the triangle is the hilum of the obtain an intraoperative frozen section biopsy specimen of the liver, which is a reasonable starting point for assessing the wall of the cyst to rule out the presence of a cystic neoplasm. For all other islet cell tumors, With regard to cystic neoplasms, the presence of a cystad- the primary site is almost always within the pancreatic paren- enoma in a cyst surrounding the pancreas has been recog- chyma. In this regard, we simply advise careful evaluation of nized as a possibility for decades. More recently, the the uncinate process and the inferior border of the pancreas important distinction between serous and mucinous adeno- as the superior mesenteric vein progresses underneath it. Serous cystadenomas are rarely Each of these sites is somewhat remote until adequate dis- malignant, but mucinous cystadenomas are considered to be section has been performed. If there is any evi- with recognized mucinous cystadenomas are candidates for dence of extension beyond the capsule or if lymph node resection at all times. In addition, several trinoma metastatic to the liver may be present in a patient for investigators have suggested measuring tumor markers decades. Spontaneous closure pancreas and the related cystic papillary neoplasms are again should be anticipated in more than 98 % of patients. Diagnosis Dehiscence of the gastrointestinal anastomoses represents is suspected when copious mucus is seen exuding from the the least frequent of all complications. Resection is indicated; total pan- by following the normal precepts of intestinal anastomotic createctomy is rarely employed even though the disease may technique. For that reason clear Complications of Pancreatic Surgery dissection of these structures is recommended. Unfortunately, superior mesenteric vein and portal vein injuries may occur Any pancreatic resection carries an associated risk of pancre- simply because of dense adhesion to these structures due to atic fistula. In the past, this complication was considered to be chronic pancreatitis or to invasion of these structures by the cause of the high mortality rate associated with these carcinoma. Pancreaticoduodenectomy adds the risk of bile and gastrointestinal anastomotic leakage. Because of the rich vas- Acknowledgment This chapter was contributed by William H. Nealon cular anatomy in the area of the head of the pancreas, major in the previous edition. The dissection planes include the superior mesenteric vein, portal vein, com- Further Reading mon hepatic artery, and superior mesenteric artery. Duodenum- cular supply or venous drainage to the intestine (superior mes- preserving head resection in chronic pancreatitis changes the natural enteric artery and portal vein). Thus, necrosis of the liver and course of the disease: a single-center 26-year experience. National failure to operate on early stage pancreatic age in the area of the pancreaticojejunostomy and the hepati- cancer. Cystic tumors of the pancreas: imaging and reached well below 5 % and in capable hands may be 2–3 %. Regression of liver fibrosis after believe that the correlation of pancreatic fistula to mortality biliary drainage in patients with chronic pancreatitis and stenosis of in the past was related to the coexistence of abdominal sep- the common bile duct. Extended drainage versus resection in surgery for chronic pancreatitis: a prospective random- ture of the pancreas is essentially normal and soft (as in ized trial comparing the longitudinal pancreaticojejunostomy com- resection for trauma); it is consequently poorly prepared to bined with local pancreatic head excision with the pylorus-preserving hold a stitch. Results of total most series is a relatively harmless complication, and spon- pancreatectomy for adenocarcinoma of the pancreas. Chemical splanchnicectomy in patients with unresectable Bile fistula may be more lethal than pancreatic fistula. Intraductal papillary mucinous pancreas, duodenum, small bowel, colon, and rectum. Chassin† Indications laparoscopy helps with accurate staging and minimizes nontherapeutic laparotomy for cancer of the pancreas. Carcinoma of ampulla, head of pancreas, distal bile duct, or Prescribe perioperative antibiotics. When a patient suffering from obstructive Postoperative sepsis jaundice has been found to have operable ampullary or pan- Postoperative acute pancreatitis creatic cancer, refer the patient to an appropriate center of Postoperative marginal ulcer with bleeding expertise. Operative Strategy Preoperative Preparation The operation may be conceptualized as consisting of three Correct hypoprothrombinemia with vitamin K. Chassin Obvious disease outside the surgical field precludes resec- Gastric Stress Ulcers or Gastritis. After surgery, use an H -2 tion; if none is found, the pancreas is mobilized to determine blocker or proton pump inhibitor to maintain the gastric pH at if local invasion (most commonly into the portal vein) ≥5. Full mobilization is performed before cal patients who are at risk of developing stress bleeding. A generous Kocher maneuver is performed to confirm Marginal Ulcer that the pancreas is not adherent to the inferior vena cava. With the standard pancreaticoduodenectomy, the incidence The lesser sac is entered and the stomach elevated to display of marginal ulcer is decreased by performing an adequate the pancreas. The most hazardous part of the operation antrectomy and/or adding truncal vagotomy. This is less of a occurs next, when the pancreas is gently elevated from the concern with current methods of pharmacological control of portal vein. Hemorrhage secondary to the digestion of retroperitoneal Avoiding and Managing Intraoperative tissues by activated pancreatic juice is best prevented by Hemorrhage observing the operative strategy (outlined below) aimed at minimizing the chance of pancreatojejunal anastomotic leak. The greatest risk of major intraoperative hemorrhage occurs Hemorrhage that results from a ligature slipping off the gas- when the surgeon is dissecting the portal vein away from the troduodenal or right gastric artery is a result of careless oper- neck of the pancreas.

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A complete had a chance to become established increases the risk of a portal lymphadenectomy is also performed as part of the free bile leak trusted 25mg nizagara. Even when removed at the appropriate time buy nizagara 50 mg otc, some patients In advanced stages purchase nizagara 25 mg on-line, palliative biliary drainage should be will nonetheless develop sudden, severe abdominal pain, performed to relieve the symptoms of obstruction. Thankfully, most of these leaks are mild and self- become isolated from each other due to tumor infiltration of limited, with resolution of pain within hours. Persistent pain the bifurcation, making the endoscopic approach in effec- should be treated the same as de novo bile leaks, with prompt tive. Chemoembolization rising incidence of hepatocellular carcinoma as well the and oral tyrosine kinase inhibitors are modalities that can improvements in survival achieved with hepatic metastasec- slow the progression of the tumor, but are not curative (Bruix tomy of colorectal tumors. The patients who will benefit the most from hepatic teria of arterial enhancement and venous washout (Fig. In general, transplantation is preferred for patients When a patient presents with resectable liver metastases, a with multifocal disease or underlying cirrhosis. Resection is limited course of neoadjuvant chemotherapy prior to surgery preferred in patients with a single-lesion and well-preserved may be considered. First, liver function, since it avoids the morbidity of transplanta- it allows a period of time for the tumor to declare its biology; tion and the need for lifelong immunosuppression (Bruix if the lesion continues to grow on treatment, or other lesions and Sherman 2010 ). Ablative procedures can also be used as an alternative fluid boluses or those needing repeated blood transfusions to or to supplement resection. If recurrences develop, repeat interventions can be perihepatic packing (Pachter and Feliciano 1996). If hemorrhage continues after packing, the Hepatic Trauma Pringle maneuver can be applied by placement of an atrau- matic vascular clamp across the porta hepatis. This provides The liver is the largest intra-abdominal organ and the most the surgeon the ability to visualize and repair the site of frequently injured by trauma. Liver resection is only indicated in patients with shat- very resilient, and as a result most hepatic trauma can be tered or devascularized hepatic lobes. Minor bile leaks after nonoperative quently fatal even with prompt exploration since the mobili- management are not unusual, but these can be effectively zation of the liver required to access this portion of the cava managed by percutaneous drainage as described above. The classic example of this The choice of an anatomic resection versus a non-anatomic situation is the tachycardic patient with blunt abdominal (or wedge) resection depends on both the tumor type and the 698 U. Through this mechanism, preserve liver parenchyma when feasible – particularly in thrombocytopenia serves as a surrogate marker for hepatic patients with borderline liver function. The presence of esophageal varices is an alternate suggest that for primary liver cancer, an anatomic resection marker of portal hypertension resulting from the same patho- of the functional liver unit provides improved survival physiologic process. This concept does appear not hold for More sophisticated methods of quantifying the function metastatic colorectal lesions which arrived by hematogenous of the future liver remnant have been investigated, but none dissemination and are not based within a functional hepatic have proven consistently useful or superior. Certain In determining resectability, strict rules as to the number and patients with borderline liver function can be optimized by location of hepatic lesions have not proven to be useful in portal vein embolization to induce hypertrophy of the future guiding decision making. Mortality following liver resection should be rare, with rates In general, the determination of whether a liver lesion is of 1–3 % at high-volume centers (Torzilli et al. The resectable can be guided by ascertaining “inflow, outflow, major intraoperative risk of hepatectomy is that of massive and parenchyma. Intimate knowledge of the intrahepatic vascula- tomy were to be performed, the surgeon should consider ture – specifically the hepatic veins – is necessary to plan whether there will remain blood inflow to the remnant liver, lines of transection and to prevent inadvertent injury. Control venous outflow from the remnant, and sufficient hepatic of hepatic inflow by clamping the hepatoduodenal ligament, parenchyma to support liver function. Inflow may be the known as the Pringle maneuver, is useful to limit bleeding concern when, for example, a cholangiocarcinoma encases during transection. The Pringle maneuver can be applied the bifurcation of the hepatic artery or portal vein. While this may at first seem counterintuitive, maintenance of In a noncirrhotic patient with normal liver function, low intravascular volume leads to lower blood loss during approximately 80 % of the liver can be resected without con- hepatic transection (Wang et al. A hepatic trisegmentectomy for multi- that although the surgeon can control hepatic inflow using focal colorectal liver metastases is an example of this type of the Pringle maneuver, back bleeding of the inferior vena massive resection of parenchyma that can be performed with cava through the hepatic venous branches still occurs. However, bleeding is exacerbated when aggressive infusion of intrave- this amount of tissue loss would not be tolerated in a cir- nous fluids leads to a full vena cava. Maintenance of low rhotic patient where even a limited wedge resection can lead intravascular volume requires good communication between to fatal postoperative liver failure. Turcotte-Pugh score is a useful starting point, since liver There are several acceptable techniques for performing resection is uniformly fatal in Child C cirrhotics, and only transection of the liver parenchyma, based on surgeon pref- the most limited resections are tolerated in select Child B erence. However, the Child A designation is a large umbrella sected vessels should be ligated with gentle figure-of-eight term and contains too wide of a group of patients to be suf- sutures. Generalized oozing from the cut surface of the liver ficiently sensitive to guide resection (Poon and Fan 2005 ). In these patients, certain laboratory values can be used as Argon beam cautery and thrombin-soaked foam sponges can surrogate markers of the presence of cirrhosis and can help be useful adjuncts, but cannot be relied upon to remedy sur- guide decision making. Significant hepatic fibrosis Use of Drains leads to portal hypertension; the back pressure into the The use of drains following liver resection is at the discretion splanchnic circulation leads to splenomegaly, which in turn of the operating surgeon. Percutaneous cholecystostomy in patients with acute cholecystitis: experience of (Gurusamy et al. Mechanisms of controlled release of ascitic fluid and prevents the weeping of major biliary injury during laparoscopic cholecystectomy. Trends in survival of patients with hepatocellular carcinoma between 1977 and 1996 in the United States. Postoperative Management Prognostic factors for the development of gangrenous cholecystitis. Clinical score The major complication of hepatectomy in the postoperative for predicting recurrence after hepatic resection for metastatic period is liver failure. All patients will demonstrate a transa- colorectal cancer: analysis of 1001 consecutive cases. Trends in the leading causes of death in parameters, and the presence of new ascites. Management of acute cholecystitis in the laparoscopic era; results ally resolve with supportive care. Gastrointest Endosc Overburdening the remnant liver with high volumes is Clin N Am. Therefore, especially in of lamivudine on outcome after liver resection for hepatocellular cirrhotics, many hepatic surgeons allow relatively low urine carcinoma in patients with active replication of hepatitis B virus. A comparative study of antiviral therapy after resection of hepatocellular carcinoma in jaundice, coagulopathy, and encephalopathy. Follow-up after combined surgical and radiologic within the first week after resection, as evidenced by the wel- management. Common duct diameter as an independent predictor of choledocholithiasis: is it useful?

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Upper airway obstruction may occur in patients with bums of head and neck during first 48 hours order nizagara 50mg amex. Such obstruction is due to soft tissue oedema of oral pharynx and vocal cords due to exposure to hot fumes buy generic nizagara online. Direct thermal injury to the lower respiratory tract is very uncommon cheapest generic nizagara uk, as nose and oral pharynx are quite efficient heat exchangers allowing cooling of inhaled hot gas prior to its entrance into the trachea. Though lower respiratory tract injury does occur when the patients are injured by superheated steam as it is difficult to extract heat from liquid. Impending upper airway obstruction is treated by immediate insertion of endotracheal tube. Once introduced endotracheal tube is not removed until 3rd postbum day, since reintubation becomes technically difficult. The clinical signs of such diminished distal flow include cyanosis, impaired capillary refilling and progressive neurologic signs particularly paresthesia. Restriction of chest wall motion to the point at which ventilatory exchange is impaired is an indication of the need for a chest wall escharotomy. Escharotomy is performed as a ward procedure and neither general nor local anaesthesia is required. The eschar, which is insensitive, is incised on either midlateral or midmedial line. The incision should extend along the entire length of the burned area and carried down deep through the eschar and the superficial fascia to a depth sufficient to allow the cut edges of the eschar to separate. Chest wall escharotomies are made on the anterior axillary line bilaterally extending from the clavicle to the costal margin. The need for limb escharotomies may be reduced by continuous elevation of the burned extremity and active motion of it for 5 minutes every hour. If escharotomy has been performed, constant coverage of the escharotomy wound with a topical antimicrobial agent is essential. Sometimes escharotomy may not result in improvement of blood flow to the peripheral part. Fasciotomy should be performed under general anaesthesia and the fascia of all involved compartments should be adequately released. Such fasciotomy is usually required in severe bums with extensive damage to the underlying fat and muscles. Fasciotomy is also required in the treatment of electrical bums where there is extensive muscle injury. Fasciotomy incisions, like escharotomy incisions, should be protected with bandage soaked in topical antimicrobial agent. But this is effective only if the patient receives a booster dose within the preceding 10 years. In case of absence of active immunisation within 10 years prior to bum injury 250 to 500 units of tetanus immunoglobulin (human) should be simultaneously administered at another site using different syringe and needle. These organisms will proliferate if topical chemotherapeutic agents are not applied. That is why there is a place of prophylactic administration of penicillin to patients with bums. But such systemic administration of antibiotics should be given on 1st or 2nd day, as the full thickness bum becomes relatively avascular after 48 hours. Once necrosis occurs, the wound is essentially avascular, which prevents effective delivery of systemic antibiotics if infection occurs. By the late 1960s, gram-negative bacteria, primarily pseudomonas species emerge as the dominant organism. Microbial species colonise the surface of the wound and may penetrate the avascular eschar. Bacterial proliferation may occur beneath the eschar at the viable-non- viable interface, leading to subeschar suppuration and seperation of the eschar. In a few patients micro-organisms invade the underlying viable tissue producing systemic sepsis. Topical antibiotic has a significant role to play in bum infection, though systemic infections are not uncommon and such infections have actually increased as principal causes of death. Bronchopneumonia in burn patients is commonly caused by opportunistic organisms especially gram-negative bacteria. Haematogenous pneumonia may also begin relatively late in burn patients due to haematogenous spread of microorganisms from a remote septic focus. Bronchial secretions should be cultured and antibiotic treatment is begun on the basis of the sensitivity test. Usually an aminoglycoside and a semisynthetic penicillin are administered as the common causative organism is often a strain of Pseudomonas. It must be remembered that prophylactic antibiotics are to be avoided and antibiotics should be administered only on the basis of a clinical or laboratory diagnosis of infection. Indiscriminate use of antibiotics will develop antibiotic resistance in the bacteria present in the burn wound and elsewhere. To minimise such dissemination of organisms and development of bacteremias, antibiotics active against both gram-positive and gram-negative organisms should be administered to patients undergoing surgical debridement of the bum wound or bum wound excision. In bum patients with sepsis, blood cultures should be obtained and proper antibiotic should be administered. Resting metabolic rate approaches approximately twice normal in patients with burns of more than 50% of total body surface. Such hypermetabolism is also manifested by increased oxygen consumption, elevated cardiac output, increased core temperature, wasting of body mass and increased urinary nitrogen excretion. Adult patients with bums of over 40% of the total body surface such measurement estimates about 2000 calories per square meter of body surface per day. So one must be careful in providing adequate exogenous calorie and nitrogen to prevent excessive catabolism in bum patients. Wherever possible tube feeding should be utilised to provide nutritional needs of the patients. Feedings may be accomplished by insertion of a small silastic nasogastric feeding tube through which nutrients are delivered 24 hours a day with a constant delivery pump. If diarrhoea or ileus precludes gastrointestinal feeding, parenteral nutrition should be initiated using an intravenous cannula placed in a large-calibre high-flow central vein. Solutions of synthetic aminoacids mixed with hypertonic solutions of glucose are primarily used with blood sugar levels frequently monitored and kept below 200 mg/100 ml. Sudden intolerance of a previously well-tolerated glucose load is an early sign of sepsis and a careful search should be made for source of infection and its adequate cine. There always remains a high risk intravenous sepsis at the site of intravenous cannula, the site of which should be changed every 48 to 72 hours. That is why patients with major bums require introduction of a nasogastric suction to effectively decompress the stomach and upper small intestine until intestinal motility can be demonstrated. Moreover patients with major burns are at risk of haemorrhagic gastritis due to increased stress. So gastric aspirates should be monitored frequently for the presence of frank blood.

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If these tests are negative discount 100mg nizagara, an orthopedic or neurologic specialist should be consulted cheap nizagara 100 mg visa. A bone scan may be helpful in diagnosing occult fractures generic nizagara 100 mg with visa, metastases, or osteomyelitis. If multiple sclerosis, Guillain–Barré syndrome, or central nervous system lues is suspected, a spinal tap may be done. Blood tests are now available to rule out all the various vitamin deficiencies that may cause paresthesias. Nevertheless, a trial of therapy is often necessary to rule out the nutritional neuropathies. Lumbar puncture, as already mentioned, is useful in diagnosing Guillain–Barré syndrome. These findings would suggest a diagnosis of cerebral vascular disease, a space-occupying lesion of the brain, migraine, or multiple sclerosis. Pain in the involved extremity, particularly radicular pain, should suggest a herniated cervical disk, spinal cord tumor, or cervical spondylosis. However, many other conditions, such as brachial plexus neuropathy, thoracic outlet syndrome, a cervical rib, Pancoast’s tumor, Raynaud’s disease, and sympathetic dystrophy, should also be considered. Finally, the various entrapment syndromes should be considered, such as carpal tunnel syndrome and ulnar nerve entrapment at the elbow. If the radial pulse diminishes in certain positions of the neck and shoulders, a thoracic outlet syndrome or cervical rib should be considered. A positive Tinel’s sign at the wrist would suggest a carpal tunnel syndrome and can be confirmed by a positive Phalen’s test. The ulnar nerve may also be entrapped in Guyon’s canal and the median nerve may be trapped at the elbow in a pronator syndrome. The presence of a positive cervical compression test or a positive Spurling’s test would suggest cervical spondylosis and herniated cervical disk. The presence of hyperactive reflexes in the upper or lower extremity would suggest a spinal cord tumor, multiple sclerosis, degenerative disease of the spinal cord, such as syringomyelia or amyotrophic lateral sclerosis, anterior spinal artery occlusion, and cervical spondylosis. The presence of normal or hypoactive reflexes in the involved extremity should prompt consideration of peripheral neuropathy, pernicious anemia, and brachial plexus neuropathy. If these are negative, the next logical step is to consult a neurologist or neurosurgeon. If tabes dorsalis is suspected, a blood or spinal fluid fluorescent Treponema pallidum antibody test may be done. A therapeutic trial of vitamin B6 or corticosteroids may diagnose carpal tunnel syndrome if a neurologist is not available. If the pathologic reflexes come and go, transient ischemic attacks, multiple sclerosis, migraine, epilepsy, and hypoglycemia should be considered in the differential diagnosis. Unilateral pathologic reflexes should signify either a brain tumor or vascular lesion. Bilateral pathologic reflexes should suggest an inflammatory or degenerative disease. However, multiple sclerosis may present with either unilateral or bilateral pathologic reflexes. Vascular lesions in the basilar circulation may also present with bilateral pathologic reflexes. The presence of facial palsy or other cranial nerve signs should make one look for a lesion in the brain or brain stem. The presence of headache or papilledema should prompt the investigation for a space-occupying lesion of the brain or brain stem. These findings would suggest a cerebral vascular accident such as cerebral hemorrhage or embolism. The findings of bilateral pathologic reflexes or unilateral pathologic reflexes with a normal sensory exam and no cranial nerve signs would suggest amyotrophic lateral sclerosis or primary lateral sclerosis. However, it is wise to get a neurology consultation before undertaking these expensive tests. If vascular disease is suspected, carotid scans to rule out carotid stenosis or plaque and a search for an embolic source using echocardiography and blood culture should be done. In fact, if a cerebral hemorrhage has been ruled out and there is no significant hypertension, a four-vessel cerebral angiographic study should probably be done. Serum protein electrophoresis and immunoelectrophoresis all may be necessary in the workup. The history of menorrhagia or metrorrhagia should suggest ectopic pregnancy, endometriosis, and threatened abortion, as well as retained secundinae. A positive pregnancy test is the key to a diagnosis of ectopic pregnancy when there is abdominal pain along with the abdominal mass. If there is a vaginal discharge, a smear and culture of the material should be made. If a distended bladder is suspected, catheterization for residual urine must be done. The gynecologist may do a laparoscopy, a culdocentesis, and, ultimately, an exploratory laparotomy. There is a history of heavy periods and on examination, she had an enlarged asymmetrical uterus. The pregnancy test is negative so, you suspect either uterine fibroids or endometriosis. The presence of a pelvic mass would suggest salpingo-oophoritis, ectopic pregnancy, endometriosis, uterine fibroid, or an ovarian tumor that is twisting on its pedicle. Be sure to do a rectovaginal examination as there may be a mass or fluid in the cul-de- sac. The history of metrorrhagia or menorrhagia would suggest ectopic pregnancy, threatened abortion, retained secundinae, uterine fibroids, and endometriosis. The presence of a positive pregnancy test would suggest an ectopic pregnancy or threatened abortion. If the pain is related to the menstrual cycle, mittelschmerz should be considered. The next step would logically be a pelvic or transvaginal ultrasound, but it is wise to consult a gynecologist before ordering expensive tests. The gynecologist may proceed with laparoscopy, culdocentesis, and, 486 ultimately, an exploratory laparotomy. If there is fever, a trial of antibiotics may be appropriate even if the workup is negative. The presence of a painful penile sore suggests chancroid, herpes simplex, herpes zoster, and balanitis. On the contrary, a painless penile sore should suggest chancre, lymphogranuloma venereum, epithelioma, granuloma inguinale, and papilloma.

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