By J. Killian. American Institute for Computer Sciences.

The earlier the diagnosis is made cheap 80 mg tadapox amex, the easier will be the treatment and more will be the chance of cure discount 80 mg tadapox with visa. Extra skin crease along the medial aspect of the thigh in unilateral case and widening of the perineum in bilateral case will be noticed by an observant mother buy tadapox from india. Lastly delayed walking and a limp when the child begins to walk should arouse suspicion of this condition discount tadapox express. In bilateral cases typical waddling gait may be missed by the clinician but will not be missed by an observant mother. Movements are painless, but abduction and rotations are limited in completely dislocated hip. Unlike the previous condition the boys are more affected by this condition and about 4 times commoner than the girls. In the beginning, when the joint becomes rather irritable, more or less all movements are slightly restricted. Later on in the established stage there is limitation of abduction and internal rotation. Muscular wasting of the limb becomes obvious and there may be moderate flexion and adduction deformity. The diagnosis cannot be confirmed without skiagraphy, the findings of which have been discussed in the earlier section. There may be a history of trauma in which case this condition suddenly appears, otherwise the majority of cases are gradual in onset. The earliest symptom is a painful limp and pain may be referred to the knee joint. Continued weight bearing will lead to more pain and limp with shortening and external rotation of the limb. On examination the greater trochanter is higher and more posteriorly placed than the unaffected side. The hip joint is second only to the vertebral column so far as the sites of tuberculosis of the bones and the joints are concerned. The earliest sign is the limp, which in the beginning comes on after the patient has walked some distance. Pain is probably the first symptom which is more often referred to the thigh or Fig. The general signs and symptoms such as malaise, pallor, loss of weight, evening rise of temperature, night sweat etc. On examination, the characteristic deformities of different stages have already been discussed in details under the heading of "attitude". A child with high pyrexia, a limp, pain in the hip with redness and brawny oedematous swelling, should be considered as suffering from acute suppurative arthritis. Diagnosis is confirmed by aspirating the hip joint with a needle under anaesthesia. There will be slight wasting, but the cardinal sign is the limitation of all movements at their extremes. The patient is immediately put to bed and a skin traction is applied to the affected leg. Investigations like examination of the blood and X-ray are essential to come to a diagnosis. The symptoms may mimic acute suppurative arthritis, but absence of toxaemia, high pyrexia, localized redness and oedema will differentiate this condition from acute suppurative arthritis. The inflammatory process leads to destruction of the head and neck of the femur and pathological dislocation may result from it. Besides these infective destructive lesions, spastic paralysis, poliomyelitis may also lead to pathological dislocation of the hip. Pain is the usual presenting symptom which is of boring character, mainly localized to the hip but may be referred to the knee joint. In the beginning the pain is complained of when movement follows a period of rest, later on it is more constant and disturbing. Limp may be noticed early, but more often than not it comes later than pain and stiffness. The limp is due to either pain or stiffness or apparent shortening due to adductor spasm. Some limitation of all movements is detectable but abduction, extension and medial rotation are restricted early. The bone becomes sclerosed with lipping and osteophytes at the margins of the joint. The patient is first examined in the standing position both from front and behind, secondly in the seated position, thirdly in the supine position and lastly in the prone position. During these examinations the hip is also examined, as very often a patient with the pathology in the hip will complain of pain in the knee. In case of locking the patient fails to extend the joint beyond a certain angle and the knee is kept in flexed position f ■ » A w i t h limping. This condition may be confused with superficial r cellulitis, but the latter will Fig. Extra-articular swellings are quite common l * H around the knee due to enlargement of the different bursae around the joint. The semimembranosus bursa is seen behind the knee on its medial aspect and slightly above the joint line. Infrapatellar bursa (lying deep to the ligamentum patellae), bicipital bursa (lying under the biceps tendon) may occasionally be enlarged. The suprapatellar bursa almost always communicates with the knee joint and becomes swollen in effusion of the joint. This condition also gives rise to a swelling on the posterior aspect of the knee joint in its middle and becomes prominent on extension and disappears on flexion of the joint. This condition is often associated with tuberculosis or osteoarthritis of the joint. But in affections of the knee joint if there be any muscular wasting, it is more obvious in the thigh. So far as the effusion of the joint is concerned, two important tests may be performed — fluctuation and "patellar tap". Fluctuation is demonstrated by pressing the --------- suprapatellar pouch with one hand and feeling the impulse with the thumb and the fingers of the other hand placed on either side of the patella or the ligamentum patellae. With the index finger of other hand the patella is pushed backwards towards the femoral condyles with a sharp and jerky movement. A moderate amount of fluid must be present in the joint to make this test positive. For demonstration of small amount of fluid in the knee joint two tests can be performed. The patient keeps standing and gentle pressure is applied over one of the obliterated hollows on either side of the ligamentum patellae (in order to displace fluid) and now the pressure is released. A thickened synovial membrane may also present a fluctuating swelling in the joint line, on either side of the patella and just above the patella. Its "spongy" or "boggy" feel and absence of patellar tap differentiate it from effusion of the joint. The edge of the thickened synovial membrane can be rolled under the finger as in Fig. When a swelling appears to be an enlarged bursa, its relation with the tendon (by making the appropriate tendon taut), its consistency, its mobility and translucency are ascertained. Any swelling in the popliteal fossa (particularly in the midline) should be examined for expansile pulsation. Transillumination test should always be performed in case of swellings around the knee joint. This test will be positive when swelling is an enlarged bursa or any cystic swelling e. In case of swellings containing blood (aneurysm) or pus, this test will be negative. It must be remembered that examination of the knee joint is incomplete without examination of the popliteal fossa. The knee joint is flexed and the popliteal fossa is palpated popliteal artery, the areolar tissue, the vein and nerves and the tendons in and around the Fig. Flexion of the knee greatly facilitates palpation of the tenderness, irregularity and swelling. If the click is associated with discomfort or pain, one should carefully examine to detect pathology.

In chronic pancreatitis the earliest change is a definite flattening of the medial margin of the duodenal loop and later on inverted "3" sign is seen order genuine tadapox line. Besides these order tadapox 80mg on line, intrinsic lesions of the duodenum like diverticula tadapox 80 mg, papilloma buy 80 mg tadapox with amex, carcinoma etc. For the radiological investigation of the biliary tract, the patient should be prepared with an aperient, enema and pitressin in order to expel faeces and gas which interfere with biliary shadows. If visualized, they look like rings in which the centres remain radiotranslucent whereas the periphery shows calcification. Very rarely a calcified gallbladder or limy bile within the gallbladder may be seen. Double contrast enema, in which after keeping the enema for sometime the barium enema is evacuated and instead air is pumped through the anal canal. Thus the barium lining in the wall of the colon will be more clearly delineated against the contrast dark background of air filling the colon. In the second figure note that the gallstone lies in front of the lumbar vertebra (cf. The dye is absorbed from the intestine, excreted by the liver and concentrated in the gallbladder. If the dye is not eliminated by vomiting or excessive diarrhoea a normal functioning gallbladder should be visualized in skiagraphy. Of course, in a jaundiced patient with impaired liver function the dye may not be excreted and concentrated in the amount to make the gallbladder visible. After 2 or 3 films have been exposed the patient is given a drink R X containing gt ■ lfl| |9fl[ sufficient amount of to contraction k , ft gallbladder. Biloptin in the evening and solubiloptin in the next morning followed 3 hours later by radiography may show the bile ducts as well as the gallbladder. The biliary tract is frequently visualized due to higher concentration of the dye (about 50 to 100 times) within the bile. By showing a good picture of the biliary tree, stone or other pathology can be easily detected. Though positive finding is of immense importance, yet a negative finding is of no value because the incidence of false negative is unacceptably high. There are two places where this test surpasses oral cholecystography in diagnosing cholecystitis. Firstly when the absorption of the dye is impaired as when the patient is vomiting or suffering from diarrhoea and the secondly in case of acute cholecystitis. This investigation shows intra- or extra-hepatic biliary obstruction due to various causes. This should be done in the operation theatre keeping everything ready for operation, if be needed. The needle ensheathed by a flexible polypropylene tube is pushed through the liver into dilated intra- hepatic biliary cannalicula. The needle is withdrawn, the polypropylene tube is attached to a syringe and by trial and error aspiration of bile will be seen flowing into the syringe. At least three attempts should be made before it is presumed that there is no dilatation of the intra- hepatic bile duct. Haemorrhage, biliary leakage and sepsis are the three major complications of this investigation. Modern technique of fibre-optic gastroscopy gives more light and show the actual pathology distinctly. The patient is prepared in the following way: he should fast for 8-10 hours preceding endoscopy. Barium meal X-ray, if required, should be done at least two days before endoscopy. Indications of gastroscopy are (i) any gastric lesion shown or suspected in X-ray studies; (ii) upper gastro-intestinal bleeding; (iii) persistent vomiting and (iv) symptom complained by a post-gastrectomy patient. Further one can detect a peptic ulcer which has not been shown by barium meal X-ray. Last but not the least is its 90 percent accuracy in finding out a stomach ulcer which is often missed by skiagraphy. The stomach has long been accessible to the endoscopist and gastritis, ulceration, haemorrhage, stomata and malignancy were diagnosed conveniently. But regular inspection of the duodenum was not possible till the advent of a slim endoscope which can be passed through the pylorus. Over all extreme flexibility and control of the instrument make it possible for every part of the stomach and duodenum to be inspected and a lesion may be biopsied. Besides the uses already described above, duodenoscopy is particularly indicated in the assessment of dyspepsia. There may be definite oedema, narrowing or permanent distortion of the round orifice of the pylorus. Cannulation of the papilla of Vater is carried out with the instrument so positioned as to give an end-on view of the papilla from Fig. Note that the cannula is made clear of air and common bile duct and hepatic ducts are dilated. The cannula is passed through the instrument taking care not to spill contrast medium into the duodenum since this stimulates peristalsis and makes cannulation difficult. Both biliary and pancreatic ductal systems fill, but usually one duct fills first. When the pancreatic ductules at the tail are filled injection must be stopped since overfilling will lead to extravasation and will cause pain. After pancreatography the tip of the cannula is readjusted to fill the biliary duct. Its main indications are three : (i) Jaundice — Persistent and recurrent undiagnosed jaundice (cause of obstruction will be revealed); (ii) Biliary tract problems. The main complications of this procedure are infection (including cholangitis and serum hepatitis) and pancreatitis. A sonar scan involves minimal patient preparation, takes an average of 15-20 minutes to perform and causes no discomfort to the patient. The barium has a deleterious effect on the scan so if possible ultrasonic examination should be carried out before barium studies. In a supine scan of the upper abdomen it is possible at various levels to outline the liver, spleen, aorta, vena cava and the kidneys. Ultrasound is of particular value in 9 the diagnosis of space- H occupying lesions. The size, shape and consistency of the organs outlined can be assessed and relationships of the H mass to these organs can be identified. Carcinoma of stomach may even be diagnosed as the mass which remains deep to the left lobe of the liver. The palpable mass corresponds exactly to the area of fine echoes : v* the the ■ stomach. Congenital anomalies like duplication of the gallbladder or Phrygian cap can be imaged with ultrasound, even gallbladder size is easily Fig. It may be confessed that ultrasound may even be preferred to oral cholecystography provided the necessary skills are available. The advantage of ultrasound is that additional information about the biliary tract, liver and pancreas can be obtained. Even a thick, oedematous gallbladder without presence of gallstones as well as gangrenous gallbladder may also be identified by ultrasound. It must be remembered that children may be rarely affected by gallbladder disease and ultrasound is an excellent imaging modality for these cases than oral cholecystography without the hazards of ionising radiation. Intrahepatic biliary tree and the common hepatic duct can be clearly identified by real-time ultrasound fluoroscopy. A diameter of more than 7 mm in case of common hepatic duct indicates dilatation of the intra-hepatic biliary tree. It may even show an enlarged gallbladder with obstruction of the lower end of the common bile duct due to carcinoma of the pancreas when the gallbladder is not palpable clinically. The pancreas is difficult to examine as it is effectively screened by the echo-reflecting bowel. Though a normal pancreas cannot be defined, yet an inflammed oedematous pancreas can however be seen as a poorly defined mass in front of the aorta and the vertebral column.

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