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The scaphoid is palpated at the anatomical snuff-box with the wrist bent medially to expose the bone for palpation generic 250mcg seroflo fast delivery. If there is any fracture of the scaphoid bone seroflo 250 mcg low price, the patient will complain of pain as soon as a pressure is made over the anatomical snuff-box discount seroflo 250 mcg overnight delivery. This bone may be dislocated anteriorly and requires careful palpation for the diagnosis of this condition purchase seroflo 250mcg amex. For this, the examiner should run his finger along the length of the said bone to find out any gap, bony irregularity, bony tenderness or abnormal projection. A careful palpation of the metacarpo-phalangeal joints and inter phalangeal joints should be a must to exclude subluxation or dislocation of the said joints which are often missed. In case of metacarpal fractures movement of the metacarpo-phalangeal joints will be restricted. Similarly in fractures of the phalanges movement of the interphalangeal joints will be painful and restricted. In differential diagnosis complications of the important fractures around the wrist will be discussed in nut-shell. In all fractures, not only the fracture is diagnosed but also a careful study of the displacement of the fractured fragments will help the clinician in reduction of the fracture concerned. In this case, to reduce the fracture a pull is directed downwards, slightly medially and anteriorly holding the thumb and the heads of the metacarpals of the patient simultaneously, while with the two thumbs of the clinician the upper edge of the lower fragment is pushed anteriorly so that the normal alignment of the radius is restored. After discussing the general points, the peculiarity of the X-ray examination of the scaphoid requires special mention. Very often the orthodox antero-posterior and lateral views fail to detect a minor crack fracture of the scaphoid. For this an oblique view and views from different angles are very much essential to diagnose fracture of the scaphoid bone. If clinical findings go very much in favour of the diagnosis of fracture of the scaphoid, one should treat the case according to that and take another X-ray after ten days, as by that time the fracture line often delineates itself. The victims are usually elderly ladies, which is attributed to the osteoporosis in post-menopausal women. The fracture line lies about 2 cm proximal to the distal articular surface of the radius. The distal fragment is displaced dorsally, proximally, slightly laterally and angulated backwards. On examination, there is tenderness and bony irregularity of the lower end of the radius. The radial styloid process does not remain lower than the ulnar styloid process which is normal. On the contrary it remains at the same level or a little higher than the ulnar styloid process. Again the usual victims are the elderly women and diagnosis both clinically by anterior projection of lower fragment and radiologically is not very difficult. The mechanism is due to a fall on the dorsum of the palmar-flexed wrist and not to a fall on the palm of the outstretched hand. A commoner injury at this region with anterior displacement is the fracture dislocation of the lower end of the radius. In this case the radial fracture is obliquely vertical extending upwards and forwards from the wrist joint and separated anterior fragment of the radius shifts proximally carrying the hand with it. The fracture line is usually transverse extending laterally from the articular surface of the radius and the fracture is more often undisplaced. The mechanism seems to be fall on the hand with a rotational force superimposed on it. The most important test which most clinicians forget to perform is to look for ulnar nerve lesion — a common associate with this condition. On inspection there is a very prominent dorsal displacement of the lower end of the ulna. While majority favour congenital theory, yet the advocates of acquired theory postulate that repeated minor injuries may delay growth of the radius while the ulna continues to grow forcing the lower end of the ulna to subluxate. The appearance of the wrist is deceptively normal most of the time with little impairment of the function of the wrist. Tenderness at the anatomical snuff box, while the wrist is deviated medially adds more to the suspicion. Repeated X-ray after a week or so is essential when the suspicion still remains even after the negative first X-ray. The importance of this fracture is mainly due to the fact that it is notorious for two complications — (i) non-union for which a prolonged immobilization is required and (ii) avascular necrosis of the proximal fragment which may later on cause osteoarthritis of the wrist joint. Usually the hand immediately snaps forward again but while doing so the lunate is displaced forwards out of position (lunate dislocation). Sometimes the lunate bone may be dislocated without prior perilunar dislocation and this is probably due to forced dorsiflexion of the wrist which throws away the lunate bone forwards. On examination, the displacement of the lunate may be obscured by swelling of the wrist. Median nerve compression in the carpal tunnel occurs almost always with this condition and a particular examination in this regard is very much essential. X-ray examination is again confirmatory and a lateral view is more essential for the diagnosis of this condition. The antero-posterior view is important to exclude the associated fracture of the scaphoid. It is an oblique fracture at the base of the first metacarpal bone extending distally and medially from its articular surface. So a triangular piece of bone remains in its position whereas the main shaft dislocates proximally and laterally on the trapezium. On examination there is abnormal swelling at the base of the first metacarpal bone and if the clinician pushes the projection distally and medially with his thumb the dislocated shaft moves causing a great pain to the patient. Dislocation of the metacarpo-phalangeal joint is diagnosed by careful palpation at the metacarpo­ phalangeal joint where the head of the metacarpal bone is dislocated anteriorly most of the time. The cause is usually a forced flexion of the terminal phalanx when the extensor is contracting. On examination, the typical flexion deformity of the terminal phalanx to a position of 30° flexion is obvious. The patient is unable to extend the distal interphalangeal joint to the full extent. Radiological investigation is of value in case of chip fracture of the terminal phalanx. Patient complains of severe pain in the region of the pelvis, which gets worse on moving the legs or the body. On examination, bruising and swelling over the injured site can be easily revealed. A careful palpation of the whole pelvis is required to know the exact type of fracture.

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This can be done by positioning the limb properly (as for example order 250mcg seroflo with amex, flexion of the limb) to help their approximation purchase seroflo 250 mcg amex. When the limb is more or less fully extended buy seroflo 250mcg low cost, the second operation is ventured and proper suturing of the nerve is peformed effective 250 mcg seroflo. This is occasionally carried out to repair the radial nerve when it is associated with ununited fracture of the humerus. In this case the result will not be good even if the two untrimmed ends are anchored or the limb is gradually extended. The donor nerve is generally an autogenous graft from the saphenous nerve of the thigh, sural nerve of the leg or the medial cutaneous nerve of the forearm. This type of nerve grafting does not help to restore the motor function but can restore sensory function to some extent. The epineurium of the graft is to be sutured with the epineurium of the host nerve. When the nerve is of bigger calibre, cable grafts may be-used, in which nerve of same diameter is sutured in the form of cable with the host nerve. Nerve grafting does not become successful if the intervening gap between the nerve ends becomes a mass of dense scar tissue. Microscopic surgery in nerve grafting is being popularised in States but its superiority is yet to be proved. Moreover formation of scar tissue following infection will also lessen the possibility of good nerve repair. This will definitely decrease the possibility of good result after nerve suturing. Irritant suture material will increase fibrosis and hence disturb good nerve regeneration. The limb should be immobilized in this position for at least a month, after that the limb is gradually straightened to bring to its normal position. An attempt at suturing of the partially divided nerve will simply initiate scar tissue formation and will deteriorate the function of the intact portion of the nerve. There is so much overlapping in the nervous system that even 4/5th division produces very little disability. Nerve suturing is only indicated when partial division has resulted in a siginificant deficit. Obviously full function cannot be expected, but again uncontrolled contractures may be found. When this nerve is injured there is partial (hyposmia) or total loss (anosmia) of smell of the corresponding side. When this nerve is injured, there may be partial or complete blindness of the affected eye. When this nerve is injured the main feature is dilated pupil on the affected side. With this there may be ptosis of the upper eye lid due to paralysis of levator palpebrae superioris. There may be proptosis or unusual protrusion of the eye ball due to paralysis of majority ocular muscles. Diplopia and external strabismus are due to unopposed action of the external rectus and superior oblique muscles of the eye ball which are not supplied by this nerve. There will also be loss of accommodation due to paralysis of the sphincter papillae and the ciliaris. This nerve supplies the superior oblique muscle of the eyeball and its damage will lead to diplopia and deficient movement of the eye to turn it downwards and laterally. It divides into 3 main branches — the ophthalmic, the maxillary and the mandibular. Pain is often precipitated by exposure to cold, eating, talking, touching certain parts of the face and even during walking. Various operative procedures have been suggested — (i) The trunks of the maxillary and mandibular nerves and the trigeminal ganglion itself is injected with alcohol with varying degrees of success. Endeavour is made to preserve the ophthalmic fibres which lie in the upper and medial part of the root. This is to avoid the complications of anaesthesia affecting the surface of the eye. Through the middle fossa the trigeminal ganglion is approached either extra- or intradurally. Through the posterior fossa the root of the 5th nerve is approached near the cerebello-pontine angle. This nerve supplies the lateral rectus muscle of the eye ball and this muscle becomes paralysed if this nerve is injured leading to internal strabismus. Damage of this nerve will cause complete to partial paralysis of the stemomastoid muscle and the trapezius muscle. When the nerve is involved in the upper part of the anterior triangle of the neck there may be paralysis of both stemomastoid and trapezius muscles. If the nerve is injured in the posterior triangle of the neck, which is more common, only the trapezius muscle will be affected. Trapezius paralysis also unables the patient to continue abduction of the arm after 90°. Strength of stemomastoid muscle can be tested by asking the patient to turn his face to the opposite side against resistance. It is only in case of this nerve that secondary suture may not be successful due to retraction of the cut ends. Though this, nerve supplies the Styloglossus, Hyoglossus, Geniohyoid and Genioglossus, yet its main supply is to the intrinsic muscles of the tongue. In this case, there will be anaesthesia of the whole upper limb except the upper part of the arm which is supplied by C3, 4 & 5 and by the intercostobrachial nerve. There will be also complete paralysis of the arm and scapular muscles, occasionally the long thoracic nerve supplying the serratus anterior or the nerve supplying the rhomboids may escape. It may affect new bom babies during difficult confinements or adult by a fall of weight on the shoulder. The muscles affected are biceps, brachialis, brachioradialis, supinator and deltoid. But if the 6th nerve is also affected, there will be an area of anaesthesia over the outerside of the arm and upper part of the outerside of the forearm. As the innervation of the hand is intact, functional improvement may be obtained conservatively by maintaining full range of passive movement of the limb to prevent contracture and the anaesthetic skin is protected to avoid pressure sores etc. Function of the limb can be best restored by arthrodesis of the shoulder and elbow joints.

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Phenytoin can cause thickening of the heel pad accumulation of cytoplasmic phospholipid inclusions within similar to that of acromegaly generic 250mcg seroflo. On lateral plain macrophages order seroflo 250 mcg online, hepatic cells 250mcg seroflo fast delivery, and all body tissues as a cytotoxic radiographs seroflo 250mcg overnight delivery, the soft-tissue density of the heel pad is efect of amiodarone and its metabolite desethylamiodarone. Patchy alveolar infiltrations with hilar include steatosis, necrosis, and cirrhosis. Patients may present lymphadenopathy may be seen rarely on chest with signs of hepatic liver dysfunction and hepatomegaly, radiographs due to hypersensitivity syndrome with mild liver enzymes elevation. Other manifestations of amiodarone toxicity include cutaneous photosensitivity, skin discoloration, vomiting, anorexia, and peripheral neuropathy. Amiodarone is Hepatic phospholipidosis is detected as highly known to cause long-term complications that include pul- echogenic liver due to steatosis, with or without signs of monary, endocrinal, ophthalmic, and hepatic manifestations. Amiodarone can induce pulmonary toxicity found in the alveoli and the interstitial septae, inducing infammatory reaction and fbrosis (13% of patients using amiodarone). Te mechanism of amiodarone- induced pulmonary toxicity is presumed to be related to Signs on Radiographs hypersensitivity pneumonitis or direct toxicity related to pro- Amiodarone causes nonspecific patchy alveolar duction of free radicals and phospholipidosis. Hepatic phospholipidosis is typically detected as unilateral with visual loss that is not completely reversible. In low-density liver due to steatosis, with or without contrast, amiodarone optic neuropathy is typically bilateral signs of cirrhosis. Glucocorticoids cytotoxic efector and helper T cells without direct lympho- can induce pseudo-Cushing’s disease features such as obesity, cytotoxicity. It is one of the most commonly used drugs for hirsutism, osteoporosis, avascular necrosis (due to fat transplantation rejection afer steroids. Bone osteoporosis is a well-known feature of two diferent manifestation patterns: early and late. Cyclosporine A toxicity causes reversible posterior leukoencephalopathy, which is seen as bilateral symmetrical occipital vasogenic edema that resolves when the drug is continued. Abnormal high T2 signal intensity with contrast Lipomatosis is seen as noncapsulated proliferation of enhancement affecting the parietal cortex bilaterally fatty tissues. Classically, glucocorticoids-induced has been reported in the literature to occur with lipomatosis can be seen within the mediastinum, cyclosporine toxicity. Classically on post-contrast images, there is an outer joint contractures, and extensive intra- and periarticular low intensity line with an inner high intensity line seen in soft-tissue calcification. T2W sequence surrounding an area of low T1 and high T2 signal intensity within the affected epiphysis (double shadow sign). Diffuse dural thickening and enhancement may be Gadolinium-Based Contrast Media seen. Nephrogenic systemic fbrosis associated with ing (25 %) of the hands and feet, paresthesias (24 %), burning gadolinium use. Clinical and histological fndings in neph- chronic manifestations include bilateral symmetrical plaques rogenic systemic fbrosis. Drug-induced disorders of the central nervous sys- Gd-contrast in patients with moderate-to-severe reduction tem. Te efect is rarely seen to occur few minutes toxicity with high-resolution computerized tomographic to hours afer crack smoking. Renal system efect: a rare condition that occurs afer cocaine abuse characterized by rhabdomyolysis, 12. This condition is referred to as Cocaine and Heroin (Opioids) “cocaine run amok syndrome. Te plant is endogenous in South America, Mexico, Indonesia, and the Heroin, in contrast to cocaine, is another opioid that is West Indies. A small quantity of powder is placed on alu- forming a potently reinforcing compound (Cocaethylene). Te heroin liquefes into a reddish brown glob, which ipe, which was initially sold as a medication. Te glob or favored using kola nuts, also acting as the beverage’s source “dragon” is “chased” with the lighter underneath while the of cafeine. Patients with heroin T e cocaine plant leaves are harvested and soaked with inhalation present with motor restlessness, cerebellar signs, solvents such as kerosene until a thick pasty substance is iso- hypnotic paresis, and pyramidal and pseudobulbar signs. This paste, which contains 40–80% Laboratory investigations to detect cocaine abuse uses cocaine, is treated with hydrochloride acid to form cocaine detection of urinary benzoylecgonine level, which has an hydrochloride salt (cocaine powder). Because of its high elimination half-life of 6 h (compared to cocaine elimination melting point, cocaine hydrochloride cannot be smoked; the half-life of 1 h). Urine benzoylecgonine level can be positive cocaine hydrochloride must be transformed into an alkaline up to 2 days afer recent cocaine abuse. Ingestion of Eryth- form by mixing it with sodium bicarbonate before it can be roxylum coca tea can also result in positive urinary immuno- smoked, a product known as “crack. Also, hair strand analysis for cocaine abuse matopoeia for the sound the substance makes when it is can yield a positive result afer 1 day afer intranasal cocaine heated. Te advantage of hair testing is that the drug persists addictive form of cocaine because its efect can be obtained in hair for longer time intervals than they are present in urine within seconds afer inhalation. Three major drugs type are nervous system is believed to be caused by excess brain smuggled with body packing (marijuana, heroin, and dopamine. Drug-filled packets in the intestine can be self-confdence, disorientation, hyperthermia, detected in plain abdominal radiographs. On plain hemorrhagic stroke, hypertension, cerebral vasculitis, radiographs, marijuana shows X-ray density more and hallucination. Intracranial hemorrhage can occur in than stool, heroin has an air-stool X-ray density, and cocaine abusers even in the absence of predisposing cocaine has an air X-ray density (. Smoking cracks has Crack dancing is a term used to describe choreoathetosis been linked to bilateral diffuse alveolar lung movement of the extremities associated with opacities due to pulmonary hemorrhage. Alcohol toxicity mainly afects the brain and the central and peripheral nervous systems. Chronic alcoholics usually have both central nervous sys- tem neuronal loss and shrinkage. Te brain weight is usually decreased on autopsy reports, with particular atrophy to the cerebellum. Severe malnutrition and reduced glycogen stores are also common features in chronic alcohol abusers. Chronic alcoholism is associated with hypertension, dilated cardiomyopathy (10%), pancreatitis, liver cirrhosis, and fatty liver. Many other diseases and syndromes are almost strictly seen in patients with alcohol abuse. Alcoholic ketoacidosis is a condition typically seen in chronic alcoholic characterized abdominal pain, metabolic. Te body derives energy from burn- that shows abnormal, radio-opaque shadows in the colon ing fat because of the malnutrition and the reduced glycogen (Arrowheads), later was found to be marijuana packing in a drug stores.

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