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Examine for: Consistency Reducibility Tenderness Auscultation for peristalsis Difference between inguinal hernia & hydrocele: hernia Transmitted Not possible May or may not be reduced Negative hydrocele Not transmitted Possible Not reducible Positive Cough impulse Getting above the swelling Reducibility Transillumination 65 Gastrointestinal system Rectal examination: - this is to herbs and uses buy cheap karela 60caps on line be done at the end - Need not be routine in children - Explain to herbals on deck order 60 caps karela with visa the child & the parents - Use lubricant - Keep the child in the left lateral position with the knees flexed - Indicated in: o Acute abdomen o Chronic constipation o Rectal bleeding o Suspected child abuse Inspected for: o Anal fissure: common in the 6 O-clock & 12 O-clock positions o Skin tags o Fistula o Fecal soiling o Thread worms o Signs of child abuse earthworm herbals 60 caps karela free shipping. Signs are variable herbs for anxiety 60caps karela amex, but may include nausea, vomiting, diarrhea, abdominal pain, and excess flatulence What causes most cases of acute gastroenteritis? Good hygiene and hand washing help reduce the risk of infection List 3 ways viral gastroenteritis is diagnosed. Antibiotic therapy is usually not indicated because illnesses are often self-limited. Extraintestinal infections (including sepsis) are indications for antibiotic treatment. Loss of 3­5% of body weight, normal hemodynamic variables and skin turgor, dry mucous membranes, slight decrease in urine output, and decreased tearing List 6 findings in moderate dehydration. Loss of 8­10% of body weight, decreased skin turgor, dry mucous membranes, relatively normal hemodynamic variables, decreased urine output, and slight to moderate increase in heart rate What are the findings in severe dehydration? No clinical dehydration Appears well Alert and responsive Normal Normal Warm Normal Moist Normal Normal Normal Normal Normal Normal Clinical dehydration Appears unwell or deteriorating Altered responsiveness. However, infants have poor ability to concentrate urine; thus, specific gravity may reach only 1. Calculate fluid and electrolyte losses using body weight, electrolyte values, and estimated time of dehydration. Note: Replace K+ more slowly because K+ needs time to move intracellularly, where it is the predominant electrolyte. Loss of more body water than solute, or administration of excess sodium, resulting in elevated serum sodium (>145 mEq/L) What are the 4 causes of hypernatremic dehydration? Abnormal central control of osmotic balance (essential hypernatremia) List 5 signs and symptoms. Lethargy, irritability, muscle weakness, convulsions, coma Why is hypernatremic dehydration dangerous? Because losses are more from intracellular than intravascular spaces, the symptoms may be masked until dehydration becomes severe How is hypernatremic dehydration treated? Rehydrate slowly with low-sodium fluid to avoid rapid fluid shifts to the intracellular spaces. Usually, the deficit should be replaced over the course of 48 hours What may happen if correction is too rapid? Anorexia, nausea, muscle cramps, lethargy, disorientation, agitation, diminished or pathologic reflexes, Cheyne-Stokes respiration, hypothermia, pseudobulbar palsy, seizures What is the treatment? Isotonic saline, administered at a rate determined by the assessment of fluid and electrolyte losses and adequacy of rehydration. Hypertrophy of the pyloric muscle, causing gastric outlet obstruction What are the etiologic factors? Suggested processes include decreased number of ganglion cells, hypergastrinemia, edema secondary to feeding, and a decrease in nitric oxide synthase. Progressive, projectile, non-bilious vomiting that occurs after feeding (The infant is then very hungry again. Potential toxicity in accidental poisoning in infants and young children, with some examples: Toxicity Medicines Household products Plants Low Oral contraceptives, most Chalk and crayons, washing powder Cyclamen, sweet pea antibiotics Intermediate Paracetamol elixir, salbutamol Bleach, disinfectants, window Fuchsia, holly cleaners High Alcoholic drinks, digoxin, iron, Acids, alkalis, petroleum distillates, Deadly nightshade, salicylate, tricyclic antidepressants organophosphorus insecticides laburnum, yew What is the usual age at presentation for deliberate poisoning? Tachypnoea Slow respiratory rate Hypertension Hypotension Convulsions Tachycardia Bradycardia Large pupils Small pupils Aspirin, carbon monoxide Opiates, alcohol Amphetamines, cocaine Tricyclics, opiates, -blockers, iron (secondary to shock) Tricyclics, organophosphates Cocaine, antidepressants, amphetamines -blockers Tricyclics, cocaine, cannabis, amphetamines Opiates, organophosphates List the important points in history. Some authorities recommend removal if not passed within 48 h to avoid danger of disintegration Serious toxicity if >60 mg/kg elemental iron Abdominal X-ray to count the number of tablets Serum iron levels Gastric lavage considered in severe cases if <1 h after ingestion Intravenous desferrioxamine for chelation Digoxin Disc or button batteries Iron Paracetamol - large ingestion uncommon in young children as tablets are difficult to swallow and elixir is too sweet Petroleum distillates (paraffin/kerosene, white spirit) Salicylates Tricyclic antidepressants Aspiration causing pneumonitis Tinnitus, deafness, nausea, vomiting, dehydration Hyperventilation causing respiratory alkalosis. Disorientation Sinus tachycardia Conduction disorders Dry mouth, blurred vision Agitation, confusion, convulsions, coma Hypotension Respiratory depression Check plasma concentration after 4 h after ingestion. If >150 mg/kg paracetamol is thought to have been taken, or the plasma concentration is high, start intravenous acetylcysteine Monitor prothrombin time, liver function tests and plasma creatinine Emesis and gastric lavage contraindicated Usually no treatment required Measure plasma salicylate concentration Gastric lavage if <1 h. Give activated charcoal Monitor fluid and electrolyte balance Correct dehydration, electrolyte imbalance and acidosis.

There is local tenderness and sometimes crepitus on flexing and extending the hip lotus herbals 3 in 1 matte sunscreen generic 60caps karela fast delivery. X-rays may show evidence of a previous fracture herbs that help you sleep order 60caps karela visa, or a protruding metal implant or trochanteric wires dating from some former operation herbs used for medicine karela 60 caps low cost. There may also be calcification or shadows suggesting swelling of the soft tissues quincy herbals buy discount karela 60 caps. It is important to exclude underlying disorders such as gout, rheumatoid disease and infection (including tuberculosis). Other causes of pain and tenderness over the greater trochanter are stress fractures (in athletes and elderly patients), slipped epiphysis (in adolescents) and bone infection (in children). The snapping is caused by a thickened band in the gluteus maximus aponeurosis flipping over the greater trochanter. Sometimes there is tenderness around the hip, and it may be possible to reproduce the peculiar sensation by flexing and extending the hip while abducted. The condition must be distinguished from other causes of painful clicking, particularly a tear of the acetabular labrum or an osteocartilaginous flap on the femoral head (similar to osteochondritis dissecans). Contrast arthrography, or arthroscopy if this is available, will exclude these entities. Treatment of the snapping tendon is usually unnecessary; the patient merely needs an explanation and reassurance. Occasionally, though, if discomfort is marked the band can be either divided or lengthened by a Z-plasty. This provides adequate exposure for many operations, including open reduction of the dislocated hip in infants and the various types of pelvic osteotomy. The anterolateral (Watson-Jones) approach is also anterior to the gluteus medius, but behind the tensor fasciae femoris. It provides reasonable exposure of the hip joint, with minimal detachment of muscles, but the gluteus medius is in the way and this makes hip replacement difficult. Lateral approaches suffer from the fact that the gluteus medius and minimus obstruct the view of the acetabulum. This provides excellent exposure; however, there may be problems with reattachment of the trochanteric fragment. By splitting the anterior part of gluteus maximus, the rotators at the back of the hip are exposed and the sciatic nerve is retracted safely beneath the bulk of the posterior portion of gluteus maximus. It has two minor disadvantages: orientation is more difficult, especially for placing the acetabular cup; and it is associated with an increased incidence of postoperative dislocation. Tracings of plain x-rays are useful for taking measurements and working out repositioning angles. For the most difficult cases, three-dimensional imaging studies should be obtained. The anterior (Smith-Petersen) approach starts in the plane between sartorius and rectus femoris medially and tensor fasciae femoris laterally and remains anterior to the gluteus medius. The hip capsule is exposed Intertrochanteric osteotomy Rationale Intertrochanteric osteotomy has three objectives: (1) to change the orientation of the femoral head in the socket so as to reduce mechanical stress in a damaged segment; (2) realigning the proximal femur, to improve joint congruity; and (3) transecting the bone, to reduce intraosseous hypertension and relieve pain. Indications In children osteotomy is used to correct angular or rotational deformities of the proximal femur. In adults, the main indication is osteoarthritis associated with joint dysplasia, particularly in patients who are younger than 50 years. Pain is often relieved immediately (probably due to reduced vascular congestion) and sometimes the articular space is gradually restored. The other prime indication is in localized avascular necrosis of the femoral head; if only a small segment is involved, realignment can rotate this segment out of the path of maximum stress. Contraindications Osteotomy is unsuitable in elderly thus turning the femoral head through an arc of 90 degrees or more. Results Provided the indications are strictly observed, the results are moderately good.

An expert jovees herbals cheap karela 60caps amex, usually a physician with considerable experience of the drug concerned herbals ltd buy karela 60 caps lowest price, should supervise desensitization herbals used for mood cheap 60 caps karela. For some krishna herbals buy 60 caps karela overnight delivery, no treatment may even be the best treatment, especially when the disorder is cosmetic or if the treatment would be worse than the condition itself. A patient with minimal vitiligo, for example, may be helped more by careful explanation and reassurance than by prescriptions. If a diagnosis cannot be reached, the doctor has to decide whether a specialist opinion is needed, or whether it is best to observe the rash, perhaps treating it for a while with a bland application. In either case, the indiscriminate use of topical steroids or other medications, in the absence of a working diagnosis, often confuses the picture and may render the future diagnosis more difficult. However, a firm diagnosis can usually be made, and a sensible course of treatment can be planned, but even then results are often better when patients understand their disease and the reasons behind their treatment. The cause and nature of their disease should be explained carefully, in language they can understand, and they must be told what can realistically be expected of their treatment. False optimism or undue pessimism, by patients or doctors, leads only to an unsound relationship. Too often patients become discontented, not because they do not know the correct diagnosis but because they have not been told enough about its cause or prognosis. Even worse, they may have little idea of how to use their treatment and what to expect of it; poor compliance often follows poor instruction. If the treatment is complex, instruction sheets are helpful; they reinforce the spoken word and answer unasked questions. Therapeutic options Some of the treatments used in dermatology are listed in Table 23. Systemic side-effects from absorption are less than those expected from the same drug given systemically: with topical treatment, vital organs such as the marrow, liver and kidneys are exposed to lower drug concentrations than is the skin. However, topical treatment is often messy, time-consuming and incomplete, and takes time to apply, whereas systemic treatment is clean and quick and its effect is uniform over the entire skin surface. When a choice exists, and both possibilities are equally effective, then local treatment is usually to be preferred. Most cases of mild pityriasis versicolor, for example, respond to topical antifungals alone so systemic itraconazole is not the first treatment of choice. Topical treatment Percutaneous absorption A drug used on the skin must be dissolved or suspended in a vehicle (base). The choice of the drug and of the vehicle are both important and depend on the diagnosis and the state of the skin. For a drug to be effective topically, it must pass the barrier to diffusion presented by the horny layer (Chapter 2). This requires the drug to be transferred from its vehicle to the horny layer, from which it will diffuse through the epidermis into the papillary dermis. A rise in skin temperature and in hydration, both achieved by covering a treated area with polyethylene occlusion, encourages penetration. Two extreme examples are palmar skin, with its impermeable thick horny layer, and scrotal skin, which is thin and highly permeable. In humans, absorption through the hair follicles and sweat ducts is of little significance and the amount of hair on the treated site is no guide to its permeability. In many skin diseases, the horny layer becomes abnormal and loses some of its barrier function. The abnormal nucleated (parakeratotic) horny layers of psoriasis and chronic eczema, although thicker than normal, have lost much of their protective qualities. In summary, the penetration of a drug through the skin depends on the following factors: · its concentration; · the base; · its partition coefficient; · its diffusion constant; · the thickness of the horny layer; · the state, including hydration, of the horny layer; and · temperature. Active ingredients these include corticosteroids, tar, dithranol, antibiotics, antifungal and antiviral agents, benzoyl peroxide, retinoic acid and many others (Formulary 1, p. The choice depends on the action required, and prescribers should know how each works.

Syndromes

• Rash
• Potatoes
• Atelectasis
• Fluids
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• High insulin-like growth factor 1 (IGF-1) level
• Stuffed nose from a cold or allergies, especially if it lasts a long time

There is usually an associated tenosynovitis within the second extensor compartment containing extensors carpi radialis longus and brevis herbals ltd cheap 60caps karela with visa. Treatment involves rest herbals incense buy karela 60 caps fast delivery, splintage herbals to boost metabolism generic 60caps karela amex, steroid injection and quality herbals buy 60caps karela visa, in resistant cases, surgical widening of the second compartment and exploration of the intersection. Treatment of these conditions is the same as for the other types of tenosynovitis. In some cases there is clinical evidence of tenosynovitis, which could have been caused by unaccustomed or prolonged activity of a particular kind. Epidemiological studies suggest that these conditions are no more common amongst keyboard operators than in the general population. Patients present with pain and crepitus on the dorsum of the wrist; flexing and extending the fingers produces a fine, palpable crepitus over the common extensor compartment. Flexor carpi radialis tendinitis causes pain on the front of the wrist alongside the scaphoid tubercle; symptoms are reproduced by resisted wrist flexion. Although it can appear anywhere around the carpus, it usually develops on the dorsal surface of the scapho-lunate ligament. Palmar wrist ganglia usually arise from the scapho-lunate or scapho-trapeziotrapezoid joint. A firm round swelling over the back of the second and third carpo-metacarpal joint is sometimes seen in a young adult. Treatment involves reassurance; the lump can be excised but if it recurs, the underlying joint should be fused. Chronic inflammation distends the common sheath of the flexor tendons both above and below the flexor retinaculum. The synovial membrane Clinical features the patient, often a young adult, presents with a painless lump, though occasionally there is slight ache and weakness. The lump is well defined, cystic and not tender; it can sometimes be transilluminated. The back of the wrist is the commonest site; less frequently a ganglion emerges alongside the radial artery on the volar aspect. Occasionally a small, hidden ganglion is found to be the cause of compression of the deep (muscular) branch of the ulnar nerve. If it becomes troublesome ­ and certainly if there is any pressure on a nerve ­ operative removal is justified. Even then it may recur with embarrassing persistence; it is not easy to ensure that every shred of abnormal tissue is removed. On examination there is a discrete tender point over the back of the mid-carpus and the pain is reproduced by full passive wrist extension. Treatment should be initially with a steroid injection; if that fails, then arthroscopic excision may succeed. The amount of fluid is increased and it may contain fibrin particles moulded by repeated movement to the shape of melon seeds. The swelling is hourglass in shape, bulging above and below the flexor retinaculum; it is not warm or tender; fluid can be pushed from one part to the other (cross-fluctuation). The contents of the sac are evacuated, streptomycin is instilled and the wrist rested in a splint. Complete excision is also the best treatment when the cause is rheumatoid disease. This relationship, known as ulnar variance, may be altered as a result of growth abnormalities or injury. Normal angles: radial tilt 22 degrees, palmar tilt 11 degrees; scapho-lunate angle 30 to 65 degrees. Carpal height: the ratio between the distal edge of the capitate and proximal edge of the lunate/third metacarpal is usually 0. Just distal to the radial styloid is the scaphoid, immediately beneath the anatomical snuffbox, which is one of the key areas for localizing tenderness. Tenderness at the distal end of the snuffbox may incriminate the carpo-metacarpal joint of the thumb. Dorsal to the snuffbox the oblique course of extensor pollicis longus exposes it to damage by a careless incision. First, the proximal row flexes (to prevent scaphoid blocking flexion between radial styloid and trapezium); distal row slightly extends. Radial­ulnar deviation is provided 60 per cent by the midcarpal and 40 per cent by the radiocarpal/ulno-carpal joints.

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References:

• https://cells4life.com/wp-content/uploads/2016/02/StemCell_Quiz.pdf
• https://www.uhms.org/images/UHMS-Reference-Material.pdf
• http://wallace-online.org/converted/pdf/1876_GeographicalDistribution_S718.1.pdf
• https://www.accessdata.fda.gov/drugsatfda_docs/label/2019/211675s000lbl.pdf