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When pain is accompanied by other features of inflammation such as swelling erectile dysfunction only with partner discount levitra oral jelly 20 mg with amex, redness, and increased temperature, the term arthritis is used. Joint Swelling Joint swelling is the result of an increase in synovial fluid volume. Joint Mass Lesions An increase in size of a joint may result from the presence of solid tissue within the cavity. The distinction between a mass lesion and fluid can be made by x-ray examination, needle aspiration, and careful clinical examination: A mass lesion produces a "boggy" feel compared with the fluctuant feel of fluid, and a fluid thrill is absent. Joint Crepitus the movement of one articular surface on another is normally smooth and silent. Crepitus is an abnormal sensation and sound of grating that accompanies joint movement. Because the articular cartilage represents the rubbing surface of a normal joint, crepitus occurs in diseases associated with loss of articular cartilage and exposure of subchondral bone. Abnormal Joint Mobility Most joint diseases result in restricted range of motion in the affected joints due to pain or stiffness. Rarely, the range of motion may be increased, as when structural components that hold the joint together are damaged. Tearing of cruciate ligaments in the knee and the general destruction associated with neuropathic joints are examples of disorders associated with an abnormal increase of joint mobility. Increased joint mobility may also be seen in congenital diseases characterized by abnormal collagen synthesis (eg, Ehlers-Danlos syndrome). Radiologic abnormalities may include (1) an increase in the joint space when there is fluid, blood, a solid mass lesion, or proliferation of the synovium; (2) decreased joint space in diseases associated with degeneration of the articular cartilage; (3) abnormalities in articular cartilage, such as opacification, and subchondral bone, such as erosion and cyst formation; and (4) the presence of abnormal loose bodies in the joint space. Laboratory Evaluation Examination of aspirated synovial fluid is very useful in the diagnosis of inflammatory and metabolic diseases (Table 68-1). Fluid is cultured and examined chemically and microscopically for its protein content, specific gravity, the presence and type of inflammatory cells, and the presence of urate and calcium pyrophosphate crystals. Arthroscopic Examination Insertion of a fiberoptic arthroscope into the joint space through a small incision in the joint capsule permits direct visualization of the joint. The presence of joint swelling is best assessed by measurement of its circumference and comparing it with the normal counterpart in the case of paired joints. With some joints (eg, atlantoaxial, intervertebral), the presence of inflammation may be difficult to establish. Joint swelling may be caused by fluid (fluctuant with a fluid thrill), blood, or solid mass. Unless it is corrected soon after birth, abnormal stresses cause malformation of the developing femoral neck with a characteristic limp (if unilateral) or waddling gait (if bilateral). Treatment requires early diagnosis with splinting of the hips in abduction during the first few months of life to allow development of the acetabulum. Diagnosis & Treatment the diagnosis of pyogenic arthritis is made by clinical examination. In untreated cases, infection spreads to the articular cartilage and adjacent bone, causing destruction and permanent disability.
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The regional mesenteric lymph nodes are frequently enlarged and may contain noncaseating granulomas erectile dysfunction age 25 buy generic levitra oral jelly 20 mg. In the acute phase, fever, diarrhea, and right lower quadrant pain may mimic acute appendicitis. Chronic disease is characterized by remissions and relapses over a long period of time. Diagnosis Diagnosis is based on a combination of clinical, radiologic, and pathologic findings. Fistulas between the ileum and the colon result in malabsorption as a result of colonization of the ileum with colonic bacteria; those between ileal loops may short-circuit the bowel, again resulting in malabsorption. Enterovesical fistulas lead to urinary infections and passage of gas and feces with urine. Malabsorption syndrome may also follow disease in the terminal ileum, in which there may be failure of absorption of vitamin B12 and bile acids, resulting in megaloblastic anemia and fat malabsorption. Iron deficiency anemia may occur as a result of chronic occult bleeding, and protein-losing enteropathy as a result of loss of protein from the inflamed mucosa. Incidence In the United States, about 400,000 patients suffer from ulcerative colitis, and there are about 25,000 new cases every year. In the United States, whites are more often affected than blacks, and Jews more often than nonJews. Worldwide, the disease is most prevalent in North America and Western Europe and less prevalent in Asia, Africa, and South America. Antibodies that cross-react with intestinal epithelial cells and certain serotypes of Escherichia coli have been demonstrated in the serum of some patients with ulcerative colitis. Allergy to food proteins has been suggested as a possible cause but without proof. Psychologic stress frequently precipitates ulcerative colitis, leading to the suggestion that the disease has a psychosomatic basis. Sites of Involvement: Ulcerative colitis is a disease of the rectum, which is involved in almost all cases and in some patients remains the only site of disease, and the colon. The disease extends proximally from the rectum in a continuous manner without skip areas. The ileum is not involved as a rule; 10% of cases show mild nonspecific mucosal inflammation for a few centimeters proximal to the ileocecal valve (backwash ileitis). Even in severe disease, the external appearance of the affected colon shows nothing other than mild hyperemia. In very rare cases of severe acute ulcerative colitis, toxic dilation (megacolon) occurs.
Asteroid bodies are smaller and have a central pink zone surrounded by a clear halo that is traversed by fine radial pink lines erectile dysfunction doctor visit discount levitra oral jelly 20mg without prescription. Granulomas may also be found in lymph nodes, liver, spleen, skin, and many other organs. A finding of noncaseating epithelioid granulomas on histologic examination of biopsies provides confirmatory evidence when cultures of these tissues do not grow out mycobacteria and fungi. The cells in the granuloma release angiotensin-converting enzyme into the serum; the detection of elevated levels of this enzyme in serum (seen in 60% of patients) is a useful test for sarcoidosis. High serum levels of angiotensin-converting enzyme indicate activity of sarcoidosis and, when present, provide an important method of monitoring the course of disease. Clinical Features (Table 35-7) In the United States, sarcoidosis occurs 10 times more frequently in blacks than in whites. Women are more commonly affected, and the most common age at onset is between 20 and 35 years. An abnormality in the chest x-ray is present in over 90% of patients with sarcoidosis. Steroids are effective in controlling the disease and are indicated when there is symptomatic lung involvement, ocular lesions, cardiac disease, or neurologic disease. Lung in sarcoidosis, showing noncaseating epithelioid cell granuloma in the alveolar septum. The inflammatory reaction around the affected vessel is granulomatous, with scattered neutrophils, eosinophils, and lymphocytes. The classic form of the disease involves (1) the nose, paranasal sinuses, and nasopharynx; (2) the lungs; and (3) the kidneys. Variants with involvement of other organs or sparing of one or two of the classic sites also occur. Pulmonary involvement is characterized by a rapidly expanding infiltrate that tends to be bilateral, with multiple nodular mass lesions that tend to cavitate. The renal disease is a necrotizing glomerulitis that frequently progresses to crescentic glomerulonephritis and renal failure. Clinical progression is rapid, with death from either the renal or pulmonary lesions in the majority of cases. It is characterized by filling of the alveolar spaces with a homogeneous, proteinaceous, lipid-rich material thought to be composed of surfactant and cellular debris. Increased production or decreased clearance of surfactant has been suggested as the cause.
Syndromes
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Abe, 46 years: Thalassemia syndromes are common in persons of Mediterranean, African, and Asian ancestry. Squamous carcinoma has a strong male predominance, is strongly associated with cigarette smoking, and accounts for 25-35% of all lung cancers.
Ningal, 51 years: Antibodies against Entamoeba histolytica useful in diagnosis of extraintestinal amebiasis. High-density lipoproteins are believed to remove cholesterol liberated from cell turnover.
Darmok, 63 years: Dyspnea is any alteration of this normal state and may therefore be a sensation of obstruction or pain associated with breathing or active awareness of the process of breathing. The joints are involved asymmetrically, and the inflammation tends to move from joint to joint (migratory polyarthritis).
Lars, 30 years: Kuru has occurred mainly among cannibalistic tribes in Papua New Guinea, where the disease is believed to be transmitted by the ritualistic practice of eating brain tissue from deceased persons. Patients who have a genetic susceptibility to diabetes cannot compensate because of their inherent defect in insulin secretion.
Georg, 32 years: Coxsackie virus B is most frequently implicated; others include mumps, influenza, echo, polio, varicella, and measles viruses. The more superficial lesions can be treated by local excision and have a good prognosis.
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