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The total Health Care
Most common diseases,diagnosis,treatmet & description in brief for graduate & under-graduate medical students.
Friday, September 11, 2015
Respiratory disorders
1)
Obstructive
:- Asthma, Emphysema (where there is increased resistance
to air flow through the tracheobronchial tree.)
2) Restrictive
disorders :- Due to muscle weakness or insufficiency or increasing stiffness of
elastic components.
--- by therapeutic exercises the condition may be improved.
Specially in ICU – Pneumonia may develop
( in dependent part of the lung – atelectasis , retention of secretions
and growth of bacteria.)
a) Performance of
postural drainage (Percussion or clapping and vibration)
b)
Splinting the
chest or incision site to facilitate coughing.
c) Breathing
exercises ( which is gradual and graded
)
Other maneuvers :- Mist Inhalation to moisten the upper airways and help liquefy
secretions.
Wednesday, March 27, 2013
Hernia
Introduction-
A hernia is a protrusion
of a viscus or part of a viscus through an abnormal opening in the wall of its
containing cavity. The external abdominal hernia is the most common form, the
most frequent varieties being the inguin
Figure:Hernia |
Aetiology
Any condition that rises the
intra-abdominal pressure such as powerful muscular efforts, may produce a
hernia. Whooping cough is a predisposing cause in childhood, whereas chronic
cough, straining on micturation or straining on defaecation may precipitate a
hernia in adult. Hernias are more common in smokers, intra-abdominal malignancy
can be a cause of hernia. Stretching of the abdominal musculature because of an
increase in contents as in obesity can be another factor. Fat acts to separate
muscle bundles and layers, weaken aponeuroses and favour the appearance of
para-umbilical, direct inguinal and hiatus hernia. An indirect inguinal hernia
may occur in a congenital preformed sac- the remains of the processus
vaginalis.
Composition of hernia
A hernia
consists of three parts- the sac, the covering of the sac, and the contents of
sac.
The sac- The
sac is a diverticulum of peritoneum consisting of mouth, neck, body and fundus.
The neck is usually well defined but in some
direct inguinal hernia and many incisional hernias, there is no actual neck.
The body of the sac varies greatly in size
and is not necessarily occupied. In long standing case the wall of the sac may
be comparatively thick.
The coverings of the sac-Coverings are derived from the layers of the
abdominal wall through which the sac passes. In longstanding cases they become
atrophied from stretching and so amalgamated that they are indistinguishable
from each others.
Contents
These can be-
- Omentum- Omentocele
- Intestine- Enterocele
- A portion of circumference of the intestine- Richter’s hernia
- A portion of bladder may constitute part of or sole content of direct inguinal, a sliding inguinal or a femoral
- Ovary with or without the corresponding fallopian tube.
- A meckle’s diverticulum- a little’s hernia.
- Fluid as a part of ascites or residuum there of.
Classification- Irrespective of site, a hernia can be classified
into five different types-
·
Reducible hernia- The hernia either reduces itself when the patient lies down or can be
reduced by the patients or the surgeon. The intestine usually gurgles on
reduction and the first portion is more difficult to reduce than the last.
Omentum in contrast is described as doughy and the last portion is more
difficult to reduce than the first. A reducible hernia imparts an expansile
impulse on coughing.
·
Irreducible hernia- In this case the contents cannot be return to the abdomen but there
is no evidence of other complications. It is usually due to adhesions between
the sac and its contents or overcrowding with in the sac.
·
Obstructed hernia- This is an irreducible hernia containing intestine that is obstructed
from without or within but there is no interference to the blood supply to the
bowel. The symptoms are less severe and the onset more gradual than in
strangulated hernia (colicky abdominal pain).
·
Incarcerated hernia- The term incarceration is often used loosely as an alternative to
obstruction or strangulation but is correctly employed only when it is
considered that the lumen of that portion of the colon occupying hernial sac is
loaded with feces.
·
Strangulated hernia- A hernia becomes strangulated when the blood supply of its contents
is seriously impaired, rendering the contents are ischaemic. Gangrene may occur
as early as 5-6 hours after the onset of first symptoms. Although inguinal
hernia may be 10 times more common than femoral hernia, a femoral is more
likely to strangulate.
Pathology-
The intestine is obstructed
and its blood supply impaired. Initially only the venous return is impeded; the
wall of intestine becomes congested and bright red with the transudation of
serous fluid into the sac. As congestion increases the wall of the intestine
becomes purple in color. The intestinal pressure increase, distending the
intestinal loop and impairing the venous return further. As venous stasis
increase, the arterial supply becomes more and more impaired. Blood is
extravasated under the serosa and is effused into the lumen. The fluid in the
sac becomes blood stained and the shining serosa dull because of a fibrinous,
sticky exudate. At this stage the walls of the intestine have lost their tone
and becomes friable. Bacterial transudation
occurs secondary to the lowered
intestinal viability and the sac fluid becomes infected. Gangrene appears at
the rings of constriction, which become deeply indented and grey in color. The
gangrene then develops in the anti mesenteric border. The mesentery involved by
the strangulation also becomes gangrenous. If the strangulation is unrelieved
perforation of wall of the intestine occurs.
Clinical features
Sudden pain, at first situated over the hernia, is
followed by generalized abdominal pain, colicky in nature and often located
mainly at the umbilicus. Nausea and subsequently vomiting ensue. The patient
may complain of an increase in hernia size. On examination, the hernia is
tense, extremely tender and irreducible, and there is no expansile cough
impulse.
Strangulated hernias
·
Present with local then general abdominal pain and
vomiting.
·
A normal hernia can strangulate at any time.
·
Most common in hernias with narrow necks such as
femoral hernias.
·
Require urgent surgery.
Types of hernia
·
Reducible-
Contents can be return to abdomen
·
Irreducible-
Contents cannot be returned but there are no other complications.
·
Obstructed-
bowel in the hernia has good blood supply but bowel is obstructed.
·
Strangulated-
blood supply of bowel is obstructed.
·
Inflamed-
contents of the sac have become inflamed.
Natural
history of hernias
·
Irreducible hernias-there is a risk of strangulation
at any time
·
Obstructed hernias- usually go on to strangulation
·
Strangulated hernias-Gangrene can occur within 6
hours.
Richter’s hernia
Richter’s hernia is a hernia in which the sac contains
only a portion of the circumference of the intestine (usually small intestine).
It usually complicates femoral and rarely, obturator hernias.
Inflamed hernia
Inflammation can occur from inflammation of the
contents of the sac, e.g. acute appendicitis or salphingitis, or from external
cause, e.g. the tropic ulcers that develop in the dependent area of large
umbilical or incisional hernias. The hernia is usually tender but not tense and
the overlying skin red and edematous. Treatment is based on treatment of
underlying cause.
Inguinal hernia
Surgical
anatomy- The superficial inguinal ring is a triangular aperture in the
aponeurosis of the external oblique muscle and lies 1.25cm above the pubic
tubercle.
The deep
inguinal ring is a U shaped
condensation of the transversalis fascia and lies 1.25cm above the inguinal
ligament, midway between the symphysis pubis and the anterior superior iliac
spine. The transversalis fascia is the fascial envelope of the abdomen and the
competency of the deep inguinal ring depends on the integrity of this fascia.
Figure:Inguinal Hernia |
The
inguinal canal
In infant
the superficial and deep inguinal rings are superimposed and the obliquity of
the canal is slight. In adult the inguinal canal which is about 3.75cm long and
directed downwards and medially from the deep to superficial inguinal ring. In
male the inguinal canal transmit the spermatic cord, the ilio-inguinal nerve
and the genital branch of genito-femoral nerve. In the female the round
ligament replaces the spermatic cord. The anterior boundary comprises mainly
the external oblique aponeurosis with the conjoined muscle laterally. The
posterior boundary is formed by the fascia transversales and the conjoined
tendon. The inferior epigastric vessels lie posteriorly and medially to the
deep inguinal ring. The superior boundary is formed by the conjoined muscle and
the inferior boundary is the inguinal ligament.
An indirect inguinal hernia travels
down the canal on the outer side of the spermatic cord. A direct hernia comes
out directly towards directly forwards through the posterior wall of the
inguinal canal. The neck of the indirect inguinal hernia is lateral to the
inferior epigastric vessels, the direct hernia usually emerges medial to this.
Natural history
of inguinal hernia
- Inguinal hernia in babies are the result of a persistent processus vaginalis.
- Indirect inguinal hernia is the most common hernia of all specially in the young.
- Direct inguinal hernia becomes more common in the elderly.
Indirect (oblique) inguinal hernia
This is the most common form of hernia. Indirect hernias are most common
in the young whereas direct hernias are most common in the old. In the first
decade of life, inguinal hernia is more common on the right side in the male.
In adult males 65% of the inguinal hernias are indirect and 55% are right
sided. The hernia is bilateral in 12% of cases.
Natural history of inguinal hernias
·
Inguinal hernias in babies are the result of a persistent
processus vaginalis
·
Indirect inguinal hernia is the most common hernia of
all, specially in the young
·
Direct inguinal hernia becomes more common in the
elderly.
Types of
indirect inguinal hernia
1)
Bubonocele-The
hernia is limited to the inguinal canal.
2)
Funicular - the processus vaginalis is closed just above
the epididymis. The contents of the sac can be felt separately from the testes,which
lies below the hernia.
3)
Complete – A
complete inguinal hernia is rarely present at birth but is commonly encountered
in infancy. It also occurs in the adolescence or in adulthood. The testis
appears to lie within the lower part of the hernia.
Differential diagnosis in the male
- Vaginal hydrocele
- Encysted hydrocele of the cord
- Spermatocele
- Femoral hernia
- Incompletely descended testis in the inguinal canal- an inguinal hernia is often associated with this condition;
- Lipoma of the cord
Differential diagnosis in the female
- Hydrocele of the canal of Nuck
- Femoral hernia.
Treatment
Operation is the treatment of
choice.
Treatment of hernias
- Surgery is the treatment of choice
- Surgery is either open or laparoscopic
- Any hernia can strangulate.
Direct inguinal hernia
In adult
35% of the inguinal hernia are direct. A direct inguinal hernia is always
acquired. The sac passes through a weakness or defect of transversalis fascia
in the posterior wall of the inguinal canal. In some cases the defect is small
and is represented by a discrete in the transversalis fascia, whereas in others
there is a generalized bulge.
Direct hernias do not often attain a large
size or descend into the scrotum. In contrast to an indirect inguinal hernia, a
direct inguinal hernia lies behind the spermatic cord. The sac is often smaller
than the hernial mass would indicate, the protruding mass mainly consisting of
extra-peritoneal fat. As the neck of the sac is wide, direct inguinal hernias
do not often strangulate.
Direct inguinal hernias
- All are acquired
- They are most common in older man
- They rarely strangulate
Operation for direct inguinal hernia
The principles of repair of
direct inguinal hernias are the same as those of indirect hernia, with the
exception that the hernia sac can usually be simply inverted after it has been
dissected free and the transversalis fascia reconstructed in front of it. The
reconstruction of the posterior wall of the inguinal canal should be undertaken
by the Shouldice repair or by using
a mesh implant according to the Lichtenstein technique. The ‘Bassini’ darn
operation is no longer acceptable because of its high recurrence rate and slow
rehabilitation.
Sliding hernia ( hernia-en-glissade)
As a result of slipping of the
posterior parietal peritoneum on the underlying retroperitoneal structures, the
posterior wall of the sac is not formed of peritoneum alone, but the sigmoid
colon and its mesentery on the left side, the caecum on the right side and
sometimes on either side by a portion of the bladder.
Clinical features
A sliding hernia
occurs almost exclusively in men. Five out of six sliding hernias are situated
on the left side; bilateral sliding hernias are rare. The patient is always
over 40 years of age, the incidence rising with age. It should be suspected in
a very large globular inguinal hernia descending well into the scrotum.
Treatment
A sliding hernia is
impossible to control with a truss and as a rule, the hernia is a cause of
considerable discomfort. Consequently, operation is indicated and the result is
very good.
Monday, February 20, 2012
Adenoid
Definition : Hypertrophy of the nasopharyngeal tonsil sufficient enough to obstruct the airway.
Age incidence : Usually 3-7 years
Regress : From 10 years
Complete regress : Within 20 years
Clinical features are due to –
Hypertrophy of the adenoid causing mechanical obstruction
Inflammation
Generalized symptoms
Symptoms due to nasal obstruction -- Mouth breathing
Dryness of throat
Dribbling of saliva
Sore throat due to associated pharyngitis
Deafness, earache( Due to blockage of Eustachian tube)
Due to inflammation :
I. Nasal discharge
II. Post-nasal drip
III. Recurrent acute suppurative otitis
media
IV. Persistence of chronic suppurative
otitis media
V. Rhinitis/Sinusitis
Generalized disturbances :
Mental apathy
Mental dullness
Nocturnal enuresis
Night terror
In long standing cases patient may develop adenoid facies.
Adenoid facies :
Open mouth
Pinched nose
Retraction of upper lip
Prominent upper incisor
High arched palate
Flat chest and rounded shoulder
Sign :
Mouth breath
Digital examination
Posterior rhinoscopy
Diagnosis :
By symptoms and Xray nasopharynx lateral view
Differential diagnosis :
Deviated nasal septum
Hypertrophied posterior end of inferior turbinate
Antrochoanal polyp
Congenital chonal atresia
Complications :
Pharyngitis
Tonsillitis
Secretory otitis media
Recurrent acute suppurative otitis media
Persistance of chronic suppurative otitis media
Sleep apnoea
Mental dullness
Treatment :
When symptoms are mild-
Nasal decongestants
Antihistamine
When there is recurrent symptoms and/or complications- Adenoidectomy
In secretory otitis media, myringotomy and possibly insertion of ventilation tube(Grommet) are done together with adenoidectomy.
Age incidence : Usually 3-7 years
Regress : From 10 years
Complete regress : Within 20 years
Clinical features are due to –
Hypertrophy of the adenoid causing mechanical obstruction
Fig:Enlarge adenoid |
Generalized symptoms
Symptoms due to nasal obstruction -- Mouth breathing
Dryness of throat
Dribbling of saliva
Sore throat due to associated pharyngitis
Deafness, earache( Due to blockage of Eustachian tube)
Due to inflammation :
I. Nasal discharge
II. Post-nasal drip
III. Recurrent acute suppurative otitis
media
IV. Persistence of chronic suppurative
otitis media
V. Rhinitis/Sinusitis
Generalized disturbances :
Mental apathy
Mental dullness
Nocturnal enuresis
Night terror
In long standing cases patient may develop adenoid facies.
Adenoid facies :
Open mouth
Pinched nose
Retraction of upper lip
Prominent upper incisor
High arched palate
Flat chest and rounded shoulder
Sign :
Mouth breath
Digital examination
Posterior rhinoscopy
Diagnosis :
By symptoms and Xray nasopharynx lateral view
Differential diagnosis :
Deviated nasal septum
Hypertrophied posterior end of inferior turbinate
Antrochoanal polyp
Congenital chonal atresia
Complications :
Pharyngitis
Tonsillitis
Secretory otitis media
Recurrent acute suppurative otitis media
Persistance of chronic suppurative otitis media
Sleep apnoea
Mental dullness
Treatment :
When symptoms are mild-
Nasal decongestants
Antihistamine
When there is recurrent symptoms and/or complications- Adenoidectomy
In secretory otitis media, myringotomy and possibly insertion of ventilation tube(Grommet) are done together with adenoidectomy.
DIPHTHERIA
It is an acute infection caused by Gram positive bacillus, Corynebacterium Diphtheriae.
It spreads by droplet infection.
Incubation period : 2-6 days
Incidence :
The incidence has fallen markedly in the last quarter of a century.
Children are particularly affected , especially those between 2-5 years of age. But any age group can be affected.
Because of widespread and routine childhood DPT immunizations, diphtheria is now rare in many parts of the world.
Risk factors include crowded environments, poor hygiene, and lack of immunization.
Symptoms :
Sore throat
Painful swallowing
Neck swelling
Low grade fever, headache, malaise
Vomiting
Sign :
Enlarged and tender cervical lymph nodes.
Sometimes presenting a “bull-neck” appearance.
Patches of false membrane are present on the tonsils, faucial pillars, soft palate and occasionally on the posterior pharyngeal pharyngeal wall. It is usually grey in colour. It is firmly attached and when detached, leaves a bleeding surface on which it tends to re-form. It often has a strong foetor. In atypical cases no false membrane is present and picture resembles a simple streptococcal infection.
Pyrexia : The temperature is rarely above 38.30C(1010F), but the pulse rate is usually raised out of proportion.
Toxaemia is marked.( Patient is ill and toxic but fever seldom rises above 380C)
Complications :
Myocarditis
Cardiac arrythmia
Acute circulatory failure
Paralysis of soft palate, diaphragm and ocular muscles.
Laryngeal diphtheria may cause airway obstruction.
Treatment :
Antitoxin must be given immediately, without waiting for the bacteriological results of a swab, when the disease is suspected. 20,000 – 100,000 units are injected.
Systemic penicillin : helps to control the primary and any secondary infection.
Other treatments may include:
Fluids by IV
Oxygen
Bed rest
Heart monitoring
Insertion of a breathing tube
Correction of airway blockages
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