By N. Gunock. Niagara University.

The high school completion rate for this sample was slightly higher than the national average of 80% for Blacks (Crissey buy zithromax 250mg, 2009) order zithromax online now, and more than half of this sample had greater than a high school education cheap zithromax 100 mg on-line. In the current study cheap zithromax 250mg online, there was no statistically significant association between education and medication adherence. Results of this study suggest that educational level does not necessarily have an effect on antihypertensive medication adherence. In contrast, a study on medication adherence to antihypertensive medication in a Nigerian population found that higher education predicted medication adherence (Ikechuwku, Obinna, & Ogochukwu, 2010). In contrast, women with less than a high school education were less adherent than women with higher education. These results suggest that there may be a disconnect between educational obtainment and adherence. Increased levels of education may not necessarily provide an assurance of adherence. In fact, Braverman and Dedier (2009) reported that clients with higher education may better understand content only to become argumentative and resistive to the information provided. This perspective closely resembles reactance behaviors whereby if a client is told what to do; he/she is likely to do the opposite (J. However, no studies were found that examined the association of reactance behaviors to higher educational levels. One issue that may help to explain medication nonadherence is illiteracy and education, in those with less than and greater than a high school education. With the advent of inflated grades in the educational system, illiteracy may be problematic for clients with low educational levels as well as those with higher education. Thus, educational level may not be a good surrogate model of a client‘s intelligence and ability to learn, apply knowledge, and choose appropriate lifestyle modifications. Therefore, other models of educational attainment may be necessary to assess literacy, especially as it pertains to a client‘s basic medical knowledge. The current study examined the relationship between medication adherence and religion. Religion and spirituality are frequently used interchangeably but are different terms. Whereby religion is overtly expressed in adherence behaviors to prescribed religious beliefs, spirituality is inwardly expressed but not tangible (L. Just as God allows people to freely choose to adhere or not adhere to His laws, the same freedom to adhere or not adhere to the treatment regimen is available. While nonadherence to God‘s laws has consequences, the same holds true for nonadherence to the health care regimen. Both religion and health promoting behaviors employ similar characteristics in that both require people to be doers of prescribed beliefs or the prescribed treatment regimen to achieve optimal benefits. In the current study, there was no statistically significant association between religion and medication adherence. These results suggest that religion does not necessarily have an effect on antihypertensive medication adherence. The majority of the sample was recruited by snowball or social nomination from church members. Therefore, 150 all participants reported affiliation with a religious denomination even though a small percentage of the sample did not identify membership in a church or place of worship. However, no studies were found that explored if adherence to religious activity is associated with adherence to the prescribed treatment regimen. A study of this nature may help clarify the true nature of a client‘s claim to religiosity or spirituality versus an affiliation with a religious group that serves as a social club. Conversely, if a client is not truly adherent to their religious practice, this may be evident in other areas of their lives. Yet, there is an underlining assumption that reported adherence to religious activity equates to adherence to other activities. Because religious principles and medication adherence are both predicated on the multifaceted nature of 151 human behavior that is impacted by social, psychological, physical, and environmental stimuli, oftentimes the rationale and mechanisms that drive free choice are not easily understood, predicted, or responsive to change. This may provide an explanation why spirituality is rarely recognized or encouraged by health care providers even though they claim to provide holistic health care (Black et al. It is imperative that appropriate assessment methods, such as longitudinal studies, are developed to capture an accurate depiction of religiosity and spirituality over time to uncover predictors of adherence that can be conveyed to other activities. Once mechanisms are devised to measure religious fidelity, the true impact of religion in other areas such as medication adherence may be determined. However, when examining the relation between adherence to antihypertensive medication and family history in this study, the relation between these variables was not significant. These results suggest that family history does not necessarily have an effect on antihypertensive medication adherence. These results indicate that health does not take precedence over other life issues until a serious health calamity occurs, especially for Black women. This laissez-faire attitude of Black women in relation to their health deserves further exploration. One method used by Blacks to preserve family behaviors is oral cultural traditions. Oral traditions, while common to West African literary and cultural expressions, were rooted in slavery as a mechanism to educate, enlighten minds, and free souls because reading, writing, and speaking in native languages were forbidden (Papa, Gerber, & Mohamed, 2008). Self-talk aided in building confidence, self-esteem, and in the adoption of healthy practices and positive behavior change. The study also noted that self-talk could hinder health promotion if it was stimulated by fear, negativism, and criticism. Thus, Black families could unknowingly use oral traditions to perpetuate negative health practices. Thus, neglecting self-care needs with an ―it does not matter‖ or ―it‘s all in God‘s hands‖ attitude is not easily understood. Similarly, in a study of cancer fatalism, Powe and Finnie (2003) reported that as families experience cancer diagnosis and death over time, fatalism is reinforced and perpetuated like a self-fulfilling prophecy. Those diagnosed with cancer direct their efforts toward daily survival rather than healthy behaviors, especially if asymptomatic, and by the time symptoms manifest, treatment options are limited and the prognosis is poor. To the client, fatalism is viewed as a rational behavior because their interpretation of reality is that the treatment regimen is not beneficial. Black women with high cancer fatalism also had high perceptions of spirituality that are believed to serve as a coping strategy. Although these co-payments seem modest, they quickly become costly as the number of health care provider visits and medications increase. Thus, examining both the number of comorbidities and the number of medications is important when exploring adherence. Consistent with this finding, clients in the current study had an average of three comorbidities. As comorbidities increase, clients tend to get sicker and the likelihood of taking prescribed medications may decrease. Excluding medication cost factors, sicker clients may select only those medications that allow them a reasonable ability to function and feel better. However, when examining the relationship between comorbidities and medication adherence in the current study, there was no significant association between the variables. These challenges may contribute to nonadherence to the treatment regimen as the client struggles to maintain an adequate quality of life. Increased medication use, or polypharmacy, is one issue that may affect medication adherence. With polypharmacy, medication interactions may cause untoward side effects (Moss & Crane, 2010; West et al. In addition, many clients may have difficulty organizing complex medication regimens. Because multiple antihypertensive medications and multiple doses are often required, fixed-dose combinations (two or different medicine classifications in one tablet or pill form) aid adherence (Chobanian et al. However, cost of fixed-dose combinations may be an issue that affects adherence because many third party payers will either not pay for combination medications that are not available in the generic form or substantially increase the copay (Chobanian et al. Disputes over the more expensive fixed-dose combinations may become a future policy issue.

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It is metabolized by bacteria in the colon with the production of organic acids and is used to treat constipation and the encephalopathy that develops in patients with advanced cirrhosis of the liver order zithromax discount. The unabsorbed sugar produces diarrhea and the acid pH helps to contain ammonia in the feces Laryngeal edema – swelling of the larynx in the throat Laryngospasm - spasm of the larynx in the throat Lavage – washing out of a cavity order zithromax 100mg online, example the eye or the abdomen abdomen Lecithin – any of a group of phospholipids common in plants and animals cheap zithromax 100mg online. They are found in the liver order zithromax 250mg with mastercard, nerve tissue, semen, and in smaller amounts in bile and blood. They are essential in the metabolism of fats and are used in the processing of foods, pharmaceuticals products, cosmetics, and inks. Deficiency leads to hepatic and renal disorders, high serum cholesterol levels, atherosclerosis, and arteriosclerosis Lennox-Gestaut - blanket term covering a variety of seizures (atonic drop attacks, complex partial, absence, and occasional tonic clonic) associated with significant delay in motor and intellectual development and does not respond well to drugs Lens – a transparent refractory as in the lens of the eye Lethargy – a condition of functional sluggishness, stupor, a state similar to hypnosis, or the first stage of hypnotism Leukocytosis – an increase in the number of leukocytes in the blood. It occurs most commonly in disease processes involving infection, inflammation, trauma, or stress, but it also can result occasionally from the use of some medications Leukopenia – abnormal decrease of white blood cells usually below 5000. A great number of drugs may cause leucopenia, as can failure of the bone marrow Leukorrhea – a white estrogen related scant/moderate odorless physiological vaginal discharge, normally preceding menarche and occurring during ovulation, during pregnancy, and in response to sexual excitement. Some women note an increased discharge related to oral contraceptive or hormone replacement therapy. Chronic cervicitis and vaginal infections are the most common causes of abnormal genital discharge. Signs of infection include increased discharge, change in color and consistency, odor, vulvar irritation, dysuria, and itching Limbic – the edge or border of a part, the margin Lipase – a fat splitting enzyme found in the blood, pancreatic secretion and tissues 420 Liposome – the recycling center of the cell where large molecules are broken down into small molecules to be reused kidney shaped organs of lymphoid tissues that lie at intervals along the lymphatic vessels Lupus Erythematous - tubercular skin disease, acute or subacute circulatory disorders and trauma predispose, reddish brown soft patches, circumscribed with raised edges and depressed centers which are white and scar like when scales drop off, disease spreads slowly, middle life females are predisposing factors. A chronic autoimmune inflammatory disease involving multiple organ systems and marked by periodic acute episodes. The disease is more prevalent is women of childbearing ages Lymphadenopathy – disease of the lymph nodes Lymphocyte – a white blood cell responsible for much of the body’s immune protection. Fewer than 1% are present in the circulating blood; the rest lie in the lymph nodes, spleen, and other lymphoid organs, where they can maximize contact with foreign antigens Lymph nodes – one of thousands of small kidneyed shaped organs of lymphoid tissue that lie at intervals along the lymphatic vessels Lysis – the gradual decline of a fever or disease; the opposite of crisis. The death of cells or microorganisms, caused by antibodies, complement, enzymes, or other substances M Macrocythemia – condition in which erythrocytes are larger than larger, example in folate or vitamin B12 deficiencies Malaise – discomfort, uneasiness, indisposition, often indicative of infection Malassezia – a genus of fungi that infects animals and humans. In hospitals, the infection tends to occur in patients receiving lipid (fat) infusions. Infections of the bloodstream result in sepsis Mania – madness, characterized by excessive excitement, a form of psychosis characterized by exalted feelings, delusions of grandeur, elevation of mood, psychomotor, over activity and overproduction of ideas Meckel’s diverticulum – a congenital sac or blind pouch sometimes found in the lower portion of the ileum. Sometimes it is continued to the umbilicus as a cord or as a tube forming a fistulous opening at the umbilicus. Strangulation may cause intestinal obstruction 421 Medulla – the lower portion of the brain stem in the brain – inner or central portion of an organ Megablastic anemia – a hemotologic disorder characterized by the production and peripheral proliferation of immature, large, and dysfunctional erythrocytes. Megablasts are usually associated with severe pernicious anemia or folic acid deficiency anemia Melanoma – a malignant tumor of melanocytes that often begins in a darkly pigmented mole and can metastasize widely. The incidence of melanoma is rising more rapidly than that of any often cancer Melasma – any discoloration of the skin Melena – black vomit, evacuations resembling tar, due to action of the intestinal juices on free blood Meningitis – inflammation of the membranes of the spinal cord or brain, caused by bacteria, viruses, or other organisms which reach the meninges from other points in the body through blood or lymph, through trauma, or from adjacent bony structures (sinuses, mastoid cells) Menorrhagia – excessive bleeding at the time of a menstrual period, either in number of days or amount of blood or both Menorrhea – normal menstruation or free of profuse menstruation Metabolic – the sum of all physical and chemical changes which take place within an organism, all energy and material transformations which occur within living cells, the food we eat is metabolized into fats, proteins, carbohydrates that our bodies need Metabolic acidosis – a condition resulting from excessive absorption of retention of acid or excessive excretion of bicarbonate. In starvation and in uncontrolled diabetes, glucose is not present or is not available for oxidation for cellular nutrition. The plasma bicarbonate of the body is used up in neutralizing the ketones produced by the breakdown of body fat for energy that occurs in compensation for the lack of glucose. Metabolic acidosis also occurs when oxidation takes place without adequate oxygen, as in heart failure or shock. Severe diarrhea, renal failure, and lactic acidosis may also result in metabolic acidosis. Signs of metabolic acidosis include shock, coma, tachypnea, and almond breath odor. Hyperkalemia often accompanies the condition Metabolites – any product of metabolism Metabolized – to alter the characteristics of a food substance biochemically. To break down a compound to its constituents by biological mechanisms 422 Methamphetamine – a sympathomimetic drug used as a stimulant or weight loss promoter. It is a controlled substance that causes euphoria and has a high potential for abuse Methylcellulose – a tasteless powder that becomes swollen and gummy when wet. It is used as a bulk substance in foods and laxatives and as an adhesive or emulsifier Methylphenidate hydrochloride - a drug that is chemically related to amphetamine. It is used in treating narcolepsy and attention deficit disorder Microorganisms – a living organism too small to be perceived with the naked eye, especially a virus, bacterium, fungus, protozoan, or intracellular, parasite, and some helminths Micturition – the voiding of urine Miosis – abnormal contraction of the pupil, period of distinguishing symptoms in a disease, method of cell division which allows each daughter nucleus to receive half the number of chromosomes present in the somatic cell Mitochondrial – cell organelles or rod or oval shape. Nonselective versions of these medications produced hypertensive crisis and other severe side effects when they were taken with tyramine-containing foods (some cheeses) and several other drugs. Newer members of this class of drugs do not have these effects, but should be used with caution, especially in persons who take selective reuptake inhibitors Mononucleosis – presence of an abnormally high number of mononuclear leukocytes in the blood. An acute infectious disease caused by the Epstein Barr virus, a member of the herpes virus group. The virus is transmitted through the saliva with an incubation period of 30 to 45 days. Symptoms include a gradual onset of 7 to 14 days of flu like symptoms including a severe sore throat, fatigue, headache, chest pain, and myalgia. Findings include enlarged lymph nodes, exudative tonsillitis, and an enlarged spleen. It is caused by antibodies to the acetylcholine receptor in the neuromuscular junction and a decrease in receptor sites for acetylcholine. Because the smallest concentration of acetylcholine receptors in the body is in the cranial nerves, weakness and fatigue of the eye muscles, muscles of mastication, and pharyngeal muscles are the most prominently affected in most patients. The disease is rare, affecting about 60 persons out of one million Mydriasis – abnormal dilatation of the pupil like fright, sudden emotion, anemia, anesthesia, drugs, coma, hysteria, botulism irritation of cervical sympathetic nerve Myelosuppressive – inhibition of bone marrow function Myelotoxicity – destroying bone marrow; pertaining to or arising from diseased bone marrow Myocardial – pertaining to the heart muscle Myocarditis – inflammation of heart muscle, usually as a consequence of infections Myoclonus – twitching or clonic spasm of a muscle or group of muscles, condition marked by persistent and continuous muscular spasms Myopia – defect in vision so that objects can only be seen distinctly when very close to the eyes, nearsightedness Myxedema – infiltration of the skin by mucopolysaccharides, giving it a waxy or coarsened appearance. The clinical 424 and metabolic manifestations of hypothyroidism in adults, adolescents and children are complaints of sluggishness, cold intolerance, apathy, fatigue and constipation. Findings may include infiltration of the subcutaneous layers of the skin by mucopolysaccharides, which coarsen the features and create nonpitting edema. If the syndrome is left untreated, hypothermia, coma, and death may result N Narcolepsy – a disorder marked by recurrent, uncontrollable attacks of daytime sleepiness, often associated with temporary muscular paralysis (cataplexy) that may occur after powerful emotional experiences. Typically, narcoleptic patients arouse from sleep relatively easily Narcotic – producing stupor or sleep, a drug which in moderate doses depress the central nervous system thus relieving pain and producing sleep, but which in excessive doses produces unconsciousness, stupor, coma, and possibly death Nasopharyngitis – inflammation of the nasopharynx (throat/part of the pharynx situated above the soft palate) Necrolysis – necrosis and dissolution of tissue – death of cells, tissues or organs Necrosis – deaths of areas of tissue surrounded by healthy parts, a gradual degeneration caused by blood supply to the area, physical agents such as trauma, radiant energy or products (toxins) of bacteria Neonates – a newborn infant up to 1 month of age Nephrolithiasis – a disorder characterized by the presence of calculi (stones) in the kidney Nephrotoxic – a specific toxin (poison), which destroys renal (kidney) cells Nerve terminal – a small nerve originating in the cerebral hemisphere in the region st of the olfactory trigone, the 1 cranial nerve. The terminal nerve courses anteriorly (in front of) along the olfactory tract and passes through the ethmoid bone. Most filaments of the nerve form a single strand, which passes to the membrane near the anterior superior border of the nasal septum and communicates in the nasal cavity with the ophthalmic division of the trigeminal nerve. The central communications of the terminal nerve end in the septal nuclei, the olfactory lobe, and the posterior commissural and supraoptic regions of the brain Neuralgia – severe pain along the course of a nerve due to pressure on nerve trunks, faulty nerve nutrition, toxins, neuritis, usually no changes can be detected 425 Neuroleptic – a condition of the nervous system, exhaustion of a nerve or nerves from prolonged stimulation, stretching of a nerve to relieve tension, loosening of adhesions surrounding a nerve, disintegration of nerve tissue Neuromuscular – concerning the nerves and muscles Neuroma – former term for any type of tumor composed of nerve cells. Classification is now made with respect to the specific portion of the nerve involved Neuron – a nerve cell, the structural and functional unit of the nervous system, consisting of a cell body and its processes, an axon and one or more dendrites, neurons function in the initiation and conduction of impulses Neurosis – also called psychoneurosis, a disorder of the thought processes not due to demonstrable disease of the structure of the central nervous system, probably due to unresolved internal conflicts which make for an uneasy adjustment in life, contact with reality is maintained which is not the case in psychosis, the neuroses are classified as fatigue, simple nervousness (anxiety), phobic, obsessive compulsive, hysteria, hypochondrial, reactive depression, the disease rarely occurs in one of these pure forms, thus most neurotic persons would be classes as having mixed psychoneuroses Neurosyphillis – an infection of the central nervous system by syphilis organisms, which may invade the meninges and cerebrovascular system. If the brain tissue is affected by the disease, general paresis may result; if the spinal cord is infected, tabes dorsalis (an abnormal condition characterized by the slow degeneration of all or part of the body and the progressive loss of peripherial reflexes) may result Neutropenia – the presence of an abnormally small number of neutrophils (a white blood cell) in the blood. Severely low levels predispose patients to infection Neurotoxicity – having the capability to be poisonous or harmful to the nerve cells Neutropenia – abnormally small number neutrophil (white blood cell) cells in the blood Neutrotransmitter – a substance (norepinephrine, acetylcholine, dopamine) that is released when the axon terminals of a presynaptic neuron is excited and acts by inhibiting or exciting a target cell. Many patients experience side effects of these medications, including upper gastrointestinal inflammation or bleeding. These side effects occur most often in elderly people, tobacco users, and people who drink alcohol. Other potential complications include acute and chronic renal failure, liver function abnormalities, and aseptic meningitis Norepinephrine – a hormone produced by the adrenal gland similar in chemical and pharmalogical, properties to epinephrine but is chiefly a vasoconstrictor and has little effect on cardiac output Nucleic acid – any one of a group of high-molecular weight chemicals that carry the genetic information crucial to the replication of cells and the manufacturing of cellular proteins. They have a complex structure formed of sugars, phorphoric acid, and nitrogen bases. The hallmarks of the disease are thickening, scaling, and discoloration of the nailbed. The treatment may cause liver dysfunction and the drugs are extremely expensive Ophthalmic – pertaining to the eye Ophthalmology – the science dealing with the eye and its diseases Opiates – a drug derived from opium, a drug inducing sleep, to deaden, to put to sleep, very habit forming Organic brain syndrome – a disease usually of the elderly associated with a gradual deterioration of the cognitive portion of the brain memory, comprehension, ideation, and orientation become defective Oropharyngeal – the central portion of the pharynx lying between the soft palate and the upper palate and the upper portion of the epiglottis Orthostatic – standing or an erect position Osmotic – the movement of a pure solvent, as water, through a semipermiable membrame from a solution that has a lower solute concentration to one that has a higher solute concentration. The rate of osmosis depends on the concentration of solute, the temperature of the solution, the electrical charge of the solute, and the difference between the osmotic pressures exerted by the solutions. Movement across the membrane continues until the concentrations of the solutions equalize Osteomalacia – a vitamin D deficiency in adults that results in a shortage or loss of calcium salts, causing bones to become increasingly soft, flexible, brittle, and deformed. An adult form of rickets, osteomalacia can also be traced to liver disease, cancer, or other ailments that inhibit normal metabolism of vitamin D Osteoporosis – softening of the bone, a disease marked by increasing softness of the bone, so that they become more flexible and brittle and cause deformities, it is attended with rheumatic pains, the limbs, spine, thorax and pelvis especially are affected, anemia and signs of deficiency disease are resent, the patient becomes weak, and finally dies from exhaustion, occurs chiefly in adults – could be a deficiency of calcium salts or Vitamin D Otitis – inflamed condition of the ear, it is differentiated as externa, media, and interna depending on the portion of the ear which is involved 428 Ototoxicity – having a detrimental effect on the eighth nerve or the organs of hearing Ovulation – the periodic ripening and rupture of the mature follicle and the discharge of an ovum from the cortex of the ovary, occurs approximately 14 days before the next menstrual period Oxidation – the process of a substance combining with oxygen, the loss of electrons with an accompanying increase in positive valence P Pallor – lack of color Palpitations – rapid, violent or throbbing pulsation, as an abnormally rapid throbbing, or fluttering of the heart Pancreatic – concerning the pancreas Pancreatitis – inflammation of the pancreas – sudden and intense pain in the epigastric region, vomiting, belching of gas, sometimes hiccups, collapse, rigidity and tenderness over the belly button, constipation, slow pulse, possible jaundice – treatment is a slow long process, eating only clear liquids for several weeks Pancytopenia – a reduction in all cellular elements of the blood Papillary – a small nipple like protuberance or elevation Papule – a small bump or pimple, that rises above the surface of the neighboring skin.

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The pain is often tearing or burning buy zithromax 250mg low cost, worse during defecation purchase genuine zithromax online, and subsides over a few hours buy zithromax 100mg visa. Anoscopy and proctosigmoidoscopy should be deferred until healing occurs or the procedure can be performed under anesthesia discount zithromax 250 mg on line. Eisenstat in the initial evaluation of a patient with a fissure, they must be per- formed during a subsequent visit because the presence of associated anorectal malignancy or inflammatory bowel disease must be excluded. Ulcers occurring off the midline or away from the mucocutan- eous junction are suspect. Treatment using stool softeners, bulk agents, and sitz baths is suc- cessful in healing 90% of anal fissures. Patients are instructed to soak in a hot bath and contract the sphincters to identify the muscle in spasm and then focus on relaxing that muscle. Botox infiltration into the inter- nal sphincters may be effective in the treatment of anal fissures. Lateral internal sphincterotomy is the procedure of choice for many surgeons after conservative measures have failed. Hemorrhoids Patients with perianal pathology often present or are referred with a chief complaint of “hemorrhoids. Those individuals with painless bleeding due to hemorrhoids must be distinguished from those with bleeding from colorectal malignancy, inflammatory bowel disease, diverticular disease, and adenomatous polyps. Rectal prolapse must be distin- guished from hemorrhoids because it is safe to band a hemorrhoid but not a prolapsed rectum. Hemorrhoidal tissues are part of the normal anatomy of the distal rectum and anal canal. The disease state of “hemorrhoids” exists when the internal complex becomes chronically engorged or the tissue pro- lapses into the anal canal as the result of laxity of the surrounding con- nective tissue and dilatation of the veins. External hemorrhoids may thrombose, leading to acute onset of severe perianal pain. Internal hemorrhoids may have two main pathophysiologic mecha- nisms seen in two distinct but not exclusive groups: older women and younger men. Internal hemorrhoids originate above the dentate line and are lined with insensate rectal columnar and transitional mucosa. In older women, the pathophysiologic mechanism may be related to earlier pregnancy or chronic straining, which leads to vascular engorgement and dilatation, resulting in stretching and disruption of the supporting connective tissue surrounding the vascular channels. Another suggested pathologic mechanism, and the one that may be more important in younger men, is that of increased resting pressures within the anal canal, leading to decreased venous return. Internal hemorrhoids typically do not cause pain but rather bright-red bleed- ing per rectum, mucous discharge, and a sense of rectal fullness or discomfort. External hemorrhoids may develop an acute intravascular thrombus, which is associated with acute onset of extreme perianal pain. Perianal Complaints 475 Grade 1 Rubber banding Internal Repeat as Infrared coagulation Failed needed Determine Grade 2 Sclerotherapy severity Diet changes Failed Initial assessment • History Grade 3 Consider nonsurgical • Exam therapy Failed Surgery • Classification Grade 4 Surgery Thrombectomy, if thrombosed External Improve hygiene Failed Surgery Topical agents Special circumstances • Pregnancy • Inflammatory bowel disease Algorithm 26. Repeated episodes of dilatation and thrombosis may lead to enlargement of the overlying skin, which is seen as a skin tag on physical exam. As in Case 2, the acutely throm- bosed external hemorrhoid is seen as a purplish, edematous, tense sub- cutaneous perianal mass that is quite tender. The complications of internal or external hemorrhoids are the indi- cations for medical or surgical intervention: bleeding, pain, necrosis, mucous discharge, moisture, and, rarely, perianal sepsis. Internal hemorrhoids that fail to respond to medical management may be treated with elastic band ligation, scle- rosis, photocoagulation, cryosurgery, excisional hemorrhoidectomy, and many other local techniques that induce scarring and fixation of the hemorrhoids to the underlying tissues. The acutely thrombosed external hemorrhoid may be treated with excision of the hemorrhoid or clot evacuation if the patient presents within 48 hours of onset of symptoms. If the patient presents more than 48 hours after onset of symptoms, conservation management with warm sitz baths, high-fiber diet, stool softeners, and reassurance is advised. Pilonidal Disease Patients with pilonidal disease may present with small midline pits or an abscess(es) off the midline near the coccyx or sacrum. The workup is limited to a physical exam unless one suspects Crohn’s disease; then 476 S. The differential diag- nosis includes abscess/fistulous disease of the anus, hidradenitis sup- purativa, furuncle, and actinomycosis. For those who fail to heal after 3 months or develop a chronic draining sinus, definitive therapy is recommended. The preferred method is to excise the pilonidal disease and primarily close the defect with rota- tional flaps over closed suction drainage. Neoplasms Historically, the anal canal has been defined as the region above the dentate line, and the anal margin has been defined as the area below the dentate line. Squamous cell tumors of the anal margin are well dif- ferentiated, keratinizing tumors that behave similarly to squamous cell tumors of the skin elsewhere. Tumors of the anal canal are aggressive, high-grade tumors with significant risk for metastasis. Tumors of the Anal Margin Squamous Cell Carcinoma Patients frequently complain of a lump, bleeding, itching, pain, or tenesmus (complaints common to most lesions of this region). Typi- cally, the lesions are large, are centrally ulcerated with rolled everted Table 26. Perianal Complaints 477 edges, and have been present for more than 2 years before detection. All chronic or nonhealing ulcers of the perineum should be biopsied to rule out squamous cell carcinoma. Tumors of the Anal Canal Epidermoid Carcinoma Generally, there is a long history of minor perianal complaints such as bleeding, itching, or perianal discomfort. Early lesions that are small, mobile, confined to the submucosa, and well differentiated may be treated with local excision. Radiation therapy or chemora- diotherapy is the preferred treatment option for larger lesions of the anal canal. Summary Patients with perianal problems often are referred with a diagnosis of hemorrhoids. The sometimes life-threatening causes of perianal complaints require attention to history and a thorough physical examination. While hemorrhoidal disease often can be treated expectantly or by local therapies, improperly treated infectious and malignant causes of such complaints often result in devastating consequences. Chemoradiotherapy versus radiotherapy alone for anal cancer: a retrospective comparison. Lateral internal sphincterotomy remains the treatment of choice for anal fissures that fail conservative therapy [letter; comment]. To be able to discuss the differential diagnosis of inguinal pain and the diagnosis and management of groin masses and hernias. To develop an understanding of the anatomy, loca- tion, and treatment of different types of hernias; this includes the frequency, indications, surgi- cal options, and normal postoperative course for inguinal, femoral, and umbilical hernia repairs. To understand the definition and clarification of the clinical significance of incarcerated, strangu- lated, reducible, and Richter’s hernias. To develop an awareness of the urgency of surgi- cal referral, the urgency of treating some hernias. To develop an understanding of the differential diagnosis of an abdominal wall apparent hernia or mass, including adenopathy, desmoid tumors, rectus sheath hematoma, true hernia, and neoplasm. Cases Case 1 A 74-year-old woman has noted an intermittent small lump in the right groin for 8 months. This has seemed to go away when she lies down, but it is present when she showers in the morning. This morning she felt awful, had a lemon-sized tender right groin mass, and had nausea and some diarrhea. Chandler gurgles heard in the abdomen, and a slightly pink, skin-covered, very tender lump was present in the right groin. Case 2 A male college student, age 20, presents with a 4-year history of inter- mittent soft mass in his groin and a large lump in the right side of the scrotum, which is now uncomfortable. He does not notice any groin mass on awakening, but he becomes aware of the groin and scrotal masses later in the morning, toward noon.

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