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While performing trigonectomy purchase discount femara on line women's health magazine weight loss tips, care must be taken to save the two ureters which should be catheterised purchase femara uk womens health 30 day ab challenge. It is better to do this wedge resection before attempting to arrest haemorrhage from the prostatic bed as it will facilitate proper inspection of the bed and identification of the bleeding points discount 2.5 mg femara visa menopause las vegas. Trigonectomy itself may cause a little bleeding but one or two such bleeding vessels will require ligation or diathermy coagulation. The closure of the bladder definitely shortens the convalescent period but the surgeon must have adequate experience to be satisfied with the effec tive arrest of haemorrhage. Otherwise clot retention will give tremendous trouble in the early postoperative period. If in doubt, the bladder is closed around a suprapubic drainage, at the same time there will be Foley’s indwelling urethral catheter inside the prostatic bed. By this, the bladder is washed out and hardly gives any chance for clot retention to occur. If at all urine comes out, one can use surface suction provided with a tube which is pushed through the suprapubic opening upto the surface of the bladder. Just after removal of the urethral catheter, partial lack of control is expected for a week or so. When there is no suprapubic drainage, the Foley’s catheter should have three ends — one end to inflate the balloon, the second one for drainage and the third one to introduce sterile water through drip system for continuous bladder wash. In this case the convalescent period is less and when the fluid coming out is absolutely free from blood, the catheter can be removed from 5th to 8th day. An intravenous drip, which was introduced preoperatively for transfusion of blood, is still continued with 5% Dex trose solution for 1 day or so. It is of no use increasing the load to the heart of an old man by increasing infusion of fluid. The patient is allowed to drink freely, so that there will be more urine and less chance of postoperative infection. It is a good practice to do a routine haematological examination to see that the patient’s Hb is upto the standard. Urine examination should be carried out for culture and sensitivity test and he is given the right antibiotic. Position of the patient and the incision are same as those of the suprapubic prostatectomy. A self-retaining retractor is placed in position, the lateral blades of which retract the two recti muscles and the middle blade depresses the bladder which is protected by a wet mop. With small piece of gauze, the anterior surface ofthe prostate in the retropubic space is cleared. With a cutting diathermy, a trans verse incision is made through the fascial sheath, the fibrous capsule and the surgical capsule of the prostate about 2 cm below its junction with the bladder. As soon as the adenoma is reached, it will be visualised by its rather whitish colour. The two margins of the incision are now slightly undermined upwards and downwards. The urethra and the mucosal cuff connecting it with the bladder are divided to bring the adenomatous mass out. The packing is now gently withdrawn and the bleeding points are electrocoagulated. It is a good practice to insert two stitches one on each angle of the prostatic bed to control the prostatic branches of the inferior vesical artery. Remaining nodules of the prostatic tissue or loose tags of the capsule or the mucosa are removed. A final inspection is made to be sure that the haemorrhage has been controlled properly. This suture must be placed closely, so that it will not only arrest haemorrhage but also will prevent leakage of urine. The bladder is irrigated a few times with sterile water and then 100 cc of 5% citrate solution is pushed through the urethral catheter and the catheter is spigotted. The 2nd end is used to irrigate the bladder, while the 3rd end is used for drainage. The 2nd end is joined to a drip set containing sterile water and the 3rd end is joined to a polythene bag to collect urine outside the bed. This continuous bladder wash is continued till the urine collected in the bag becomes clear. At this time the continuous bladder wash is stopped and the catheter is kept for 4 to 5 days after operation, after which it is removed. Millin advised that the catheter could be removed on the 3rd postoperative day unless there was any contraindication. Blood can easily come out from this space through the drainage opening, (iii) Probably the most important advantage is its relatively short convalescent period. The only disadvantage of this operation is that the interior of the bladder is not exposed, so presence of stone, diverticulum or neoplasm may be missed. It is always advisable to perform cystoscopy just before retropubic prostatec tomy. The resection is carried out under direct vision either by means of a wire loop diathermy or by a circular punch. The instrument is of large calibre and meatotomy or urethral dilatation may be required before introduction. It goes without saying that it is the operation for specialists and the general surgeons hardly venture to perform this operation. The instrument has a sheath, which has a curved beak bearing a lamp to illuminate the urethra and the bladder. On the opposite side of the sheath, there is a large gap just close to the bend of the sheath. Within the sheath, there is a tubular knife, which moves to and fro, instead of a telescope. Now under direct vision, the sheath is gradually withdrawn till an adenomatous mass of the prostate protrudes through the gap of the sheath. At this time, the tubular knife is inserted and pressed home with a punching movement to shear off the projecting tissue. The knife is partially withdrawn and the sheath is moved slightly, so that another mass of glandular tissue projects through the gap, which is again sheared off by the tubular knife. This process continues till the whole of the adenomatous prostate or fibrous prostate, which is causing obstruction, is removed. The cuts are made in an upward direction, away from the verumontanum, so external sphincter is not damaged. The sheath has a separate channel to pass a diathermy electrode to arrest bleeding. This ‘cold punch’ technique, according to its advocates, has the advantage that the cutting is made with a sharp knife, instead of the diathermy current, so the questions of devitalisation of the prostatic tissue and sepsis do not arise. Like the previous instrument, it has got a sheath but unlike the previous one, the sheath is straight. The sheath has got a telescope within which it supports a diathermy electrode, consisting of a loop of tungsten wire.
Medical treatment is used for metastatic disease and involves progestins and cytotoxic agents purchase femara 2.5mg on-line womens health website. Management of Endometrial Hyperplasia Postmenopausal women taking estrogen replacement therapy must also be treated with progestins to prevent unopposed estrogen stimulation cheap 2.5 mg femara fast delivery menstrual tracker, which may lead to endometrial cancer buy 2.5mg femara with amex pregnancy nausea. Endovaginal pelvic ultrasound shows a 6 cm, round, fluid-filled, simple ovarian cyst without septations or calcifications. During those years the ovaries are functionally active, producing a dominant follicle (in the first half of the cycle) and a corpus luteum after ovulation (in the second half of the menstrual cycle). Either of these structures can become fluid-filled and enlarged, producing a functional cyst. Pregnancy: most common cause of a pelvic mass in the reproductive years Complex mass: most common complex adnexal mass in young women is a dermoid cyst or benign cystic teratoma; other diagnoses include endometrioma, tubo-ovarian abscess, and ovarian cancer Diagnosis. Most functional cysts can be managed expectantly, but surgery is indicated if certain characteristics are present. If the sonogram shows a simple cyst it is probably benign, but careful follow-up is needed. Follow-up exam should be in 6–8 weeks, at which time the functional cyst should have spontaneously resolved. During this period of observation the patient should be alerted to the possibility of acute onset of pain, which may be indicative of torsion of the adnexal cyst. Oral contraceptive medication can be used to help prevent further functional cysts from forming. Even if the cyst is simple in appearance, surgical evaluation should be performed if the cyst >7 cm or if patient had been on prior steroid contraception. Functional cysts should not form if the patient has been on oral contraception for at least two months because gonadotropins should have been suppressed. This is due to high circulating androgens and high circulating insulin levels causing arrest of follicular development in various stages. This, along with stromal hyperplasia and a thickened ovarian capsule, results in enlarged ovaries bilaterally. Large amounts of androgens are produced, leading to increased peripheral estrone production and markedly increased risk of endometrial hyperplasia and carcinoma. Most patients will have severe insulin-resistance, with type 2 diabetes mellitus and cardiovascular disease. It is usually asymptomatic and is found incidentally during a cesarean section or postpartum tubal ligation. It can be hormonally active and produce androgens resulting in maternal and fetal hirsutism and virilization. They are associated with twins and molar pregnancies but they are only rarely associated with a normal singleton pregnancy. The natural course of these tumors is postpartum spontaneous regression and require only conservative management. Pelvic examination is consistent with a 7 cm right adnexal mass, and there is lower abdominal tenderness but no rebound present. During the prepubertal and the postmenopausal years, functional ovarian cysts are not possible because ovarian follicles are not functioning. Sudden onset of acute abdominal pain is a typical presentation of germ cell tumors of the ovary. These tumors characteristically grow rapidly and give early symptomatology, as opposed to the epithelial cancers of the ovary that are diagnosed in advanced stages. Germ cell tumors of the ovary are most common in young women and present in early stage disease. If sonography shows a complex adnexal mass in a girl or teenager, the possibility of germ cell tumors of the ovary has to be considered. In a prepubertal patient who is symptomatic and has U/S evidence of an adnexal mass, a surgical evaluation is recommended. Simple mass: If the U/S shows the consistency of the mass to be simple (no septations or solid components), this mass can be evaluated through a laparoscopic approach. Complex mass: If the mass has septations or solid components, a laparoscopy or laparotomy should be performed, depending on the experience of the surgeon. Surgical diagnosis Simple cyst Laparoscopy Complex mass Laparotomy Management Benign Cystectomy Annual follow-up Malignant Unilateral S&O Staging, chemotherapy Prognosis 95% survival with chemotherapy Definition of abbreviations: S&O, Salpingo-oophorectomy. Because of the patient’s age the surgical goal should be toward conservation of both ovaries. A unilateral salpingo-oophorectomy and surgical staging (peritoneal and diaphragmatic biopsies, peritoneal cytology, pelvic and para- aortic lymphadenectomy, and omentectomy) should be done. Follow-up after conservative surgery is every three months with pelvic examination and tumor marker measurements. The current survival rate is >95% in patients with germ cell tumors managed with conservative management and chemotherapy. An endovaginal sonogram in the emergency department confirms a 7 cm, mobile, irregular complex mass with prominent calcifications. Patients of reproductive age with a complex adnexal mass should be treated surgically (laparoscopy or laparotomy, depending on experience of the surgeon). At the time of surgery an ovarian cystectomy should be attempted to preserve ovarian function in the reproductive age. Careful evaluation of the opposite adnexa should be performed, as dermoid cysts can occur bilaterally in 10–15% of cases. If an ovarian cystectomy cannot be done because of the size of the dermoid cyst, then an oophorectomy is performed, but conservative management should always be attempted before an oophorectomy is done. The most common histology seen is ectodermal skin appendages (hair, sebaceous glands), thus the name “dermoid. Thyroid tissue can also be identified, and if it comprises >50% of the dermoid, then the condition of struma ovarii is identified. She was at work when she suddenly developed lower abdominal discomfort and pain, which got progressively worse. On examination the abdomen is tender, although no rebound tenderness is present, and there is a suggestion of an adnexal mass in the cul-de-sac area. Ultrasound shows an 8 cm left adnexal mass with a suggestion of torsion of the ovary. Sudden onset of severe lower abdominal pain in the presence of an adnexal mass is presumptive evidence of ovarian torsion. Untwist the ovary (with laparoscopy or laparotomy) and observe the ovary for a few minutes in the operating room to ensure revitalization. If revitalization occurs, an ovarian cystectomy can be performed with preservation of the ovary. The pathology report should be checked carefully to confirm it is benign; if that is the case, go to routine follow-up.
Interstitial cystitis and vesical ulceration caused by tuberculosis or bilharziasis may cause suprapubic discomfort when the bladder becomes full and is usually relieved by urination cheapest generic femara uk menstrual globs. In chronic retention of urine the patient experiences little or no suprapubic discomfort even though the bladder reaches the umbilicus discount femara 2.5 mg fast delivery women's health clinic kenmore. Cystitis buy femara with a visa womens health kaiser roseville, the commonest cause of bladder pain, does not produce any pain over the suprapubic region but is referred to the distal urethra during micturition. Pain is often referred to the tip of the penis with or without haematuria towards the end of micturition and is diagnostic of vesical calculus. In children, vesical calculus is indicated by sudden screaming and pulling at the prepuce during micturition. The patient may feel a vague discomfort or fullness in the perineal or rectal area (S2-4). Lumbosacral backache is occasionally experienced as referred pain from the prostate but is not a common symptom of prostatitis. When a middle-aged man comes with such a swelling with short history one must suspect a carcinoma in the kidney. Similar painless swelling may be the presenting feature in case of children under the age of 5 years. Sometimes a swelling with long history may become diminished in size immediately after passing urine. Bilateral renal swelling in a man of 40 years of age is typical of polycystic disease of the kidney. One kidney may be affected earlier or may be more swollen than the other kidney to cause confusion to the diagnosis (the case is then considered to be unilateral swelling of the kidney). Enquiry must be made about its quantity, its relation to micturition — whether blood appears at the beginning of the act (urethral), towards the end of the act (vesical) or is intimately mixed throughout the process (prerenal, renal or vesical). Some individuals will pass red urine after eating beets or taking laxatives containing phenolphthalein, in which case the urine is translucent and does not contain red cells. Sometimes children may pass red urine after ingestion of cakes, cold drinks, fruit juice containing rhodamine B. Haemoglobinuria following haemolytic syndromes may also cause the urine to be red. Inflammation of the bladder and benign hypertrophy of the prostate are the most common conditions which cause increased frequency of micturition. Retention of urine in the bladder following inadequate emptying may be one of Figs. In the second figure the lateral two lobes be asked whether the are enlarged and increased intravesical pressure will lead to frequency of micturition is approximation of the intravesical parts of the lateral lobes and thus more at night (nocturnal occludes the internal urethral meatus. The various causes of increased frequency of micturition are discussed later in this chapter. In case of prostatic obstruction there is a delay in starting the act of micturition. Sudden stoppage of the stream during micturition is suggestive of a vesical calculus or pedunculated papilloma of the bladder, the micturition may be started again by changing posture. In retention urine is formed but it cannot be voided due to obstruction in the urethra, so the bladder becomes full of urine and distended. In chronic urethritis or prostatitis a glairy fluid (gleet) is noticed to be discharged particularly in the morning just before micturition. There are five types of incontinence :— (a) True incontinence — when the patient passes urine without warning. This occurs in acute cystitis particularly in women and in benign hypertrophy of prostate in men. Patients with ureteric colic often suffer from severe nausea, vomiting and abdominal distension. Afferent stimuli from the renal capsule or musculature of the pelvis may cause pylorospasm (symptoms of peptic ulcer) by reflex action. Inflammations and swellings of the kidney may produce symptoms due to displacement and irritation of the intraperitoneal viscera lying in close relation with the kidney concerned (e. A patient, who had suffered from pulmonary tuberculosis or bone tuberculosis even in his childhood, if presents with vague symptoms this time (after about 20 years), may be suffering from tuberculous affection of the kidney. Phenacetin, cyclophosphamide, saccharine and excessive caffeine intake have been incriminated to cause bladder cancer. Whether it is dry or moist (the protruded tongue is touched), clear or covered with white or brown fur. Cachexia is sometimes detected in cases of malignancy of kidney, urinary bladder and in renal tuberculosis. Blood pressure is always examined, as hypertension is often present with various kidney diseases e. However a huge kidney swelling of hydronephrosis or nephroblastoma in case of children may be seen as fullness of the corresponding lumbar region. In sitting posture from behind fullness of the area just below the last rib and lateral to the sacrospinalis muscle is more evident in case of renal swelling (particularly malignancy) and perinephric infection. Presence and persistence of indentations in the skin from lying on wrinkled sheets suggests oedema of the skin secondary to the perinephric abscess. It is very difficult to palpate the kidney by traditional method of palpation of the abdomen. One hand is placed behind the loin at the renal angle which is used to lift the kidney. With each phase of expiration when the abdominal musculature becomes more relaxed the hand in front is gradually pressed posteriorly. After third or fourth expiration the hand in front is sufficiently pushed deep to feel the kidney, if it is palpable. Once the kidney can be felt, an attempt must be made to feel the kidney during inspiration. At this time the kidney moves downwards and the hand in front can trap the kidney and thus palpate the size, shape and consistency of the organ as it slips back into its normal position. Another method of palpating the kidney is to ask the patient to lie on the sound side. The affected side is palpated by two hands in the similar way as has been discussed above. In case of new born babies the hand is placed in such a way that the fingers will be on the renal angle and the thumb anteriorly. In sitting posture one can feel the tenderness of the kidney and swelling quite effectively. The patient sits up and folds his arms in front so that the back is stretched enough for better palpation. The clinician presses his thumb on the renal angle formed by the lower border of the 12th rib and outer border of erector spinae.
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On examination bowel sounds may be detected in the chest order 2.5 mg femara with mastercard menstruation question, unless there is paralytic ileus order femara 2.5 mg mastercard menstrual jars. X-ray examination is confirmatory as it shows fundal gas or gas of the transverse colon inside the chest femara 2.5mg discount pregnancy brain. Basal opacity may confuse the diagnosis and the condition may resemble a pneumothorax. Treatment is reduction of hemia and repair of the tear in the diaphragm with non absorbable sutures. The access may be obtained through lower thoracotomy or thoracoabdominal incision. Initially one of these may be affected, but its failure very rapidly involves the other. But it must be reiterated that cardiac arrest is also seen in minor operations and even in case of diagnostic procedures. The other causes are — (ii) electrocution, (iii) drowning, (iv) major trauma and (v) asphyxia. This is the commonest cause of cardiac arrest, (ii) Excessive anaesthesia, overdosage of narcotic or tranquillizer drugs may also cause ventilatory failure, (iii) Sudden severe fall in blood pressure may produce hypoxia. All these causes will cause myocardial hypoxia which is the most frequent and important precipitating cause of cardiac arrest. Such coronary occlusion is often seen in coronary artery disease affected with atherosclerosis. Coronary occlusion may be brought about by (i) thrombus, (ii) air, (iii) excessive radiopaque medium injection, (iv) dissection of the wall of the artery or (v) ligation. Reduced cardiac output may also cause cardiac arrest due to marked decrease of cardiac output and rapid fall in blood pressure. This condition may be seen in (i) shock, (ii) cardiac tamponade, (iii) arrhythmia, (iv) cardiac myopathy or (v) myocarditis. The heart muscle is quite sensitive to alteration in its biochcmical environment, particularly to alteration in the extracellular levels of potassium. Such hyperkalaemia may be caused by (i) renal failure, (ii) excessive potassium administration or (iii) rapid infusion of cold stored blood. Such acidosis may be seen in (i) diabetes mellitus, (ii) starvation, (iii) high intestinal fistula, (iv) hypothermia. Myocardium becomes more sensitive to digitalis with rise of concentration of potassium in the serum, (ii) Inotropic drugs e. Constant monitoring of the electrocardiogram is an integral part of any postoperative cardiac unit. It is more probable for already diseased or injured myocardium to go to cardiac arrest with such vagal nerve stimulation. Vagus nerve stimulation may be caused by (i) insertion of a gastric tube, (ii) endotracheal suctioning or (iii) vomiting. Ventricular fibrillation is the most common cause which may lead to cardiac arrest. Ventricular fibrillation is usually associated with diseased heart (myocardial infarction) or with an irritable heart as a result of manipulation, trauma or drugs. In this condition the myocardium of the ventricles contracts irregularly and feebly, so that the cardiac output is very much depressed and cardiac arrest may occur. Only 4 to 6 minutes of anoxia can be tolerated at normal temperature before cellular damage becomes irreversible. Following cessation of circulation the pupils begin to dilate in 30 to 45 seconds. The respiratory drive is lost after approximately 1 minute as the mediulla oblongata becomes depressed. When the cellular damage is irreversible in the brain, restoration of circulation may be accompanied by function of other organs in other areas of the body, but with loss of cerebral function. So diagnosis of cardiac arrest must be made as quickly as possible with immediate management. The additional findings are loss of normal skin colour, failure of mucous membrane perfusion and loss of cerebral function indicated by dilated pupils and unconsciousness. While the patient is being operated on, thecolour of blood gives an indication of cardiac arrest. Electrocardiographic changes cannot be wholly relied upon, as electrical activity can persist long after cardiac action has become ineffective. Monitoring of the electrocardiogram on an oscilloscope may give indications of cardiac fibrillation. Direct monitoring of arterial pressure by an indwelling catheter is also valuable in this respect. These help the anaesthetist in preventing cardiac arrest and if it does happen early treatment can be instituted. In nut-shell, diagnosis of cardiac arrest is made by the following findings — (i) Disappearance of peripheral pulses (by palpating femoral or carotid arteries). Since irreversible brain damage will develop following 3 to 4 minutes of cardiac arrest, it is imperative that immediate treatment should be started as soon as this diagnosis is made. The airway of the patient is opened by tilting his head backward as far as possible placing one hand on the forehead and the other behind the neck. This manoeuvre lifts the tongue from the back of the throat where it would otherwise obstruct the airway. So artificial respiration must be started using mouth to mouth or mouth to nose technique. This can be begun immediately and continued till less laborious meth ods can be arranged. In hospitals, an oral airway, self inflat ing bag and face mask are often available. Similarly most cardiac resuscitation kits include a laryngoscope and an endotracheal tube, which can be inserted by any physician with moderate experience. It must be borne in mind that one of the primary causes of resuscitation failure is at tempted placement of endotracheal tube by an inexperi enced person. Using either direct breathing or an anaes thetic bag for ventilatory resuscitation, inflation should be provided every 5 seconds and the patient is permitted to exhale passively. This is accomplished by intermittent compression of the heart between the sternum and the vertebral column. For performing cardiac massage, the patient must be on a firm surface, such as the floor or a board. The heel of the hand should be placed over the lower third of the sternum and with the other hand above it depress the sternum intermittently for 3 to 4 cm.
