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Physical Examinations Urinary: 141 · Diuretics · Diabetes insipidus · Uncontrolled diabetes mellitus diabetes symptoms signs feet cheap avapro 300 mg buy on-line. Significance of high central venous pressure Superior venacaval obstruction: No jugular venous pulse and abdominal hepatojugular reflux is negative. Obstruction to right ventricular inflow: Tricuspid stenosis Right atrial myxoma Cardiac tamponade Constrictive pericarditis. Decreased right ventricular compliance: Factors those cause elevation right ventricular and diastolic pressure: Pulmonary stenosis Pulmonary hypertension Right ventricular infarction/failure. Left ventricular failure: Patient presenting with dyspnea, angina, high central venous pressure indicates left ventricular failure. Prognostic significance of abnormal jugular venous pressure Together with third heart sound, abnormal jugular venous pressure is an ominous prognostic sign of adverse outcome. Neck veins in cardiac tamponade Distended neck vein together with dyspnea/tachypnea, tachycardia and clear lungs-have 5 differential diagnoses: 1. Hepatojugular reflux Physiology: Steady pressure on the abdomen Shift the blood from splanchnic bed to thorax To jugular vein To right atrium To right ventricle In case of slightly elevated jugular venous pressure, the raised pressure becomes overt. Uses of hepatojugular reflux: Subclinical right ventricular failure Silent tricuspid regurgitation Symptomatic left ventricular failure. Method of performing abdominojugular reflux: Position the supine patient in inclined position at a degree, so that the venous column can be best monitored. Physical Examinations 143 Patient is asked to relax, breath normally through mouth. This will avoid false positive increase in jugular venous pressure caused by valsalva maneuver. Apply pressure over the abdomen in periumbelical area with palm of the hand having fingers widely apart-gradual and progressively increasing pressure for at least 15 seconds. Direction of pressure is firm, inward, cephalad, soon reaching pressure 30 to 35 mm of Hg. Throughout the maneuver (before, during and after compression) observe the column of blood in internal and external jugular vein. During release of abdominal pressure, there is abrupt fall of jugular venous pressure and the drop must be > 4 cm. Significance of positive abdominojugular reflux: In patients presenting with dyspnea/angina: Positive abdominojugular reflux favors biventricular failure with pulmonary capillary wedge pressure >15 mm Hg. In these patients: Low ejection fraction Low stroke volume Increased left atrial pressure Increased pulmonary capillary wedge pressure Right atrial pressure. In absence of left ventricular failure, positive test signifies inability of right atrium and right ventricle to handle the increased venous return-diagnoses may be: Increased right ventricular preload (increased intravascular volume). Positive test signifies: Right atrial pressure > 9 mm Hg Right ventricular and diastolic pressure >12 mm Hg. It occurs in: Tricuspid regurgitation Tricuspid stenosis Restrictive cardiomyopathy Constrictive pericarditis. The causes are: Corpulmonale (acute or chronic) Restrictive cardiomyopathy Constrictive pericarditis Tricuspid stenosis Right ventricular infarction.
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In spinal cord level-at the level of tension- absent Absent Increased Absent Present Impaired May be present Lower motor neurons Generalized - predominantly proximal, predominantly distal or focal diabetes diet to follow discount avapro 300 mg on-line. Superficial reflexes absent, deep tendon reflex (except in acute condition, when it is absent) are increased. Anterior cerebral artery occlusions Contralateral spastic hemiparesis or hemiplegia involving leg more than the arm and face. Cervical cord involvement Upper motor neuron type hyperreflexic quadriparesis below the level of lesion. Sensory loss (pain, touch, temperature-due to spinothalamic tract involvement and joint and position sensation due to involvement of posterior column). Cauda equina syndrome Asymmetric hyporeflexic paraparesis Bladder, bowel dysfunction, sexual dysfunction Sensory loss. Anterior horn cell involvement In early stage - focal muscle involvement Late stage-generalized muscle involvement No sensory loss Denervation atrophy, fasciculation Bulbar weakness. Single nerve root Areflexic paralysis of the muscles innervated by the involved dermatome Sensory loss of the affected dermatome Pain in the involved dermatome. Plexus involvement Plexus pattern of involvement of the innervated muscle Areflexia of the involved muscles Sensory loss Pain is common mainly in brachial plexus area. Mononeuropathy Muscles of the affected nerve becomes atrophic Areflexia, weakness of affected muscles Sensory loss along the distribution of affected nerve. Polyneuropathy Distal limb muscles are more involved than the proximal muscles Muscles become weak, areflexic Sensory involvement along the involved dermatome Atrophy is late feature. Bulbar muscles may be involved No sensory involvement Reflexes are normal Ptosis, ophthalmoparesis, fatigue with muscles use. Neurology 1167 Muscle involvement Proximal muscles are more involved than distal muscles Reflexes-deep tendon reflexes-normal No sensory loss. Different pattern of muscle involvement: Limb-girdle Facioscapulohumeral Pseudohypertrophy Myotonia. There may be following results: Inability to stand with feet together: Cerebellar disease Posterior column lesion Vestibular disease. Any type of curve stretches the nerve roots opposite to the convexity, because here the nerve has to travel long route from exit foramina, so it may undergo tension. Paraspinal muscle spasm may be related to involvement and stimulation of anterior horn cell. Localization of tenderness in between spinous processes by the thumb is an excellent objective sign of back disease. To elicit weakness of back muscle the patient is asked to sit followed by asking to stand. Bradykinesia this is characterized by: Slowness of movement Slow in initiation Neurology 1169 No or minimal spontaneous movement Eye blinking <7/min (normal 14/min) Difficulty in turning in the bed Difficulty in changing motor program-during walking, the patient freezes suddenly-then utilizes small cautious steps to change direction. Position In basal ganglia disease: Flexed truncal posture Flexed arms Hand flexed at metacarpophalangeal joint Flexed head. In motor neuron disease, myasthenia gravis, poliomyelitis: Head falls forward on the chest.
Significance of Enlarged Inguinal Lymph Nodes Adult diabetes questions purchase 300 mg avapro with amex, who uses to walk in the outdoor. Infections: Cellulitis Venereal disease: Syphilis Chancroid Genital herpes Lymphogranuloma venereum. Femoral Lymph Nodes Femoral nodes are medial to inguinal lymph nodes and closer to genital area They are much less significant Their enlargement is associated with dermatophytosis of the foot. The causes are: Adenocarcinoma of stomach Ovarian cancer Large bowel cancer Pancreatic cancer. In 14 to 33 percent of cases, umbilical metastasis is the first and diagnostic manifestation of occult neoplasm. Characteristics of Lymph Nodes during Palpation Size Inguinal lymph node-normally up to 1. Neoplastic (metastatic or lymphoma) Inflammatory (sarcoid) Chronic infection (tuberculosis, lymphogranuloma venereum). Relationship with Surrounding Tissue Adherence to surrounding subcutaneous tissue and skin show- neoplastic lesion. In other words: Benign nodes: Small, discrete, nontender, mobile, soft Neoplastic nodes: Large, nontender, rock-hard, matted fixed, rubbery Inflammatory: Tender, firm, occasionally fluctuant, matted and fixed. Normally, palpable lymph nodes are: Submandibular nodes Inguinal nodes Axillary nodes occasionally. Lymph node enlargement occurs due to: Stimulation by regional or systemic immune response Direct infection of the node lead to suppuration 74 Clinical Methods and Interpretation in Medicine Deposition of intracellular or extracellular material Infiltration with neoplastic cells. Lymphadenopathy Presence of abnormal lymph nodes in terms of: Size Consistency Number. Lymphadenopathy may be: Localized: When enlargement of the lymph node occur in a single region or one group in a single region. Ulceroglandular syndromes: It is due to cutaneous inoculation of infectious agents followed by spread through subcutaneous lymphatics producing inflammation and indurations of the nodes Acute cervical lymphadenopathy: Localized infections of scalp, face, mouth, teeth, pharynx associated with inflammed draining nodes Genital lesion with satellite nodes: Syphilis, chancroid, herpes simplex, lymphogranuloma venereum, tuberculosis associated with enlarged draining nodes Suppurative lymphadenopathy. Generalized lymphadenopathy: When enlargement occur in two or more contagious sites: Due to systemic process-infectious, inflammatory or neoplastic. Shotty Lymph Nodes They are small, like tiny peas, nontender, nonstony or hard, equal, mobile, round, well demarcated, found in cervical region in children with viral illness. Bacterial: · Cutaneous infections-Staphylococcus, Streptococcus · Cat-scratch fever · Chancroid · Tuberculosis · Atypical mycobacteria · Primary syphilis · Secondary syphilis. Chlamydial infection-Lymphogranuloma Venereum Protozoal-Toxoplasmosis Mycotic-Histoplasmosis Rickettsial-Scrub typhus Helminthic-Filariasis.
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Jesper, 57 years: Excretory function: Liver excretes-bile pigment, cholesterol, bacterial toxin, heavy metals like lead, arsenic, bismuth. The ectopic pregnancy (E) is located in the scar, outside of the uterine cavity and above the cervix (C), surrounded by myometrium.
Aschnu, 56 years: In Ocular bruit Intracranial arteriovenous malformation Intracranial arteriovenous aneurysm. Baroreceptors actually sense not only absolute stretch but also the rate of change of stretch.
Rune, 50 years: Potassium excretion is increased by metabolic alkalosis, diuresis, increased aldosterone release and increased losses from the gastrointestinal tract-all of which occur commonly in the surgical patient. As will be discussed in Chapter 11, very high central venous pressures are a hallmark of patients with congestive heart failure because they have the combination of dysfunctional heart muscle (depressed cardiac func tion curve) and excessive fluid volume (right-shifted venous function curve).
Sigmor, 37 years: Arteries or veins behave more like balloons with one pressure throughout rather than as resistive pipes with a flow-related pressure difference from end to end. Watch the fasciculation of the affected muscles at rest and after induction by percussion.
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