Lipoma Rare location for this well-circumscribed mesen- chymal tumor purchase propranolol no prescription karan capillaries pvt ltd, which has a predilection for the mainstem bronchi cheap propranolol 80mg mastercard capillaries vs veins vs arteries. Parenchymal lesions Hamartoma Most common benign pulmonary neoplasm, which (Fig C 56-2) typically presents as a solitary nodule in the periphery of the lung. On plain chest radiographs, the nodule is sharply marginated and may contain popcorn calcifications. The demonstration of intranodular fat is considered a reliable indicator of hamartoma and may preclude the need for needle aspiration biopsy. Lipoma is typically detected as an incidental finding on plain chest radiographs as a solitary pulmonary nodule in the periphery surrounded by normal lung tissue. Lipoid pneumonia Uncommon condition resulting from chronic (Fig C 56-4) aspiration of animal, vegetable, or mineral oil into the lung. Plain chest radiographs can show air- space consolidation, an irregular mass-like lesion, or a reticulonodular pattern that most often involves the dependent portions of the lung. Mediastinal lesions Lipoma/lipomatosis Lipomas are well-circumscribed mesenchymal (Fig C 56-5) tumors that grow slowly and typically are detected incidentally on routine chest radiographs. They may produce symptoms due to the mass com- pressing of the primary bronchi, esophagus, veins, or phrenic or vagus nerves. Medi- astinal lipomatosis is diffuse, unencapsulated infiltrative deposition of fat that is commonly associated with obesity or steroid therapy. Thymolipoma Rare, slow-growing, benign tumor of the anterior- superior mediastinum that contains a mixture of thymic parenchyma and mature adipose tissue. The demonstration of a connection between the tumor and the superior mediastinum strongly suggests this diagnosis. Malignant teratomas are usually more nodular or poorly defined, contain fat less often, and may have a thick capsule that demonstrates contrast enhancement. Large, fat-attenuation lesion that surrounds and elevates the left anterior descending artery, a finding consistent with a sub- pericardial lipoma. Lipomatous hypertrophy Benign accumulation of fat linked to increasing of the interatrial septum patient age and obesity. Pleural and extrapleural lesions Soft, encapsulated fatty tumor that demonstrates Lipoma slow growth and may become extremely large. Extrapleural fat may produce a soft- tissue shadow that can be confused with pleural thickening on plain chest radiographs. Unlike pleural plaques, extrapleural fat is typically bilateral and symmetric and does not calcify. Diaphragmatic hernias Fat within herniated abdominal contents can be (Figs C 56-11 to C 56-13) found in hiatal and paraesophageal hernias, as well as hernias through the foramina of Morgagni (anterior) and Bochdalek (posterior). It is essential to differentiate juxtacaval fat from an intracaval thrombus or tumor. Continuity between the juxta- caval fat (arrowhead) and paraesophageal fat (arrow) can often be seen. Peripheral filling defects due to acute pulmonary embolism typically form acute angles with the arterial wall. A large occluding embolus prevents any enhancement of the lumen of the artery, which may be enlarged when compared with adjacent patent vessels. Chronic pulmonary One manifestation is a peripheral, crescent-shaped embolism intraluminal defect that forms obtuse angles with (Figs C 57-2 and C 57-3) the vessel wall. Other signs include complete occlusion of a vessel that is smaller than adjacent patent vessels, a web or flap within a contrast-filled artery, and extensive bronchial or other systemic collateral vessels. The main pulmonary artery is typically enlarged, reflecting the presence of associated pulmonary arterial hypertension. An eccentrically strates a large filling defect within the right main and left interlobar located thrombus forms obtuse angles with the vessel pulmonary arteries. Detection of an accompanying pulmo- nary artery that shows normal filling with contrast material should provide a clue to the presence of this artifact. Its true nature can also be understood by viewing the bronchus on contiguous images. Extensive collateral bronchial arter- Lung algorithm artifact mimicking pulmonary ies (arrows) associated with the large embolus in the main and embolus. The posterobasal segment of the right lower lobe bronchus is dilated as well as filled with mucus. Identifi- cation of the normal accompanying pulmonary arteries (arrowheads) allows the correct interpretation of this finding. Intraluminal thrombosis can occasionally be identified in a pulmonary artery stump. The proper diagnosis can be made if thrombus is only seen at the surgical site and all other remote pulmonary vessels are clear. Un- (Fig C 57-7 and C 57-8) like acute pulmonary embolism, pulmonary artery sarcoma shows contrast enhancement. Chronic pulmonary embolism also can enhance, but it forms obtuse angles with the vessel wall unlike pulmonary artery sarcoma, which is lobulated and forms acute angles with the wall of the artery. Tumor emboli Large emboli in the main, lobar, and segmental (Fig C 57-9) pulmonary arteries can cause intravascular filling defects that mimic acute pulmonary embolism. A rare cause of this appearance, these tumor emboli result from direct invasion of the inferior vena cava or its major branches by various primary neoplasms. Contrast scan shows a het- monary artery stump of an elderly man who had undergone a erogeneously enhancing, lobulated mass within the main pul- previous right pneumonectomy for lung cancer. Large tumor embolus geneous mass that fills the left main pulmonary artery and extends into within the right lower lobe pulmonary ar- the left upper and lower lobe pulmonary arteries (arrows). Only 10% to abrupt tapering of the diameter of the des- 15% of aortograms obtained to evaluate patients cending aorta compared with the ascending with abnormal radiographic findings demonstrate aorta (“pseudocoarctation”). Chronic pseudoaneurysm Frequently calcified mass, typically located at Only 2% of patients with untreated traumatic aortic (Fig C 58-2) the ligamentum arteriosum. Pulmonary and bronchial injury Pneumothorax Extrapulmonary, intrathoracic collection of air Pneumothorax occurs in 30% to 40% of cases of (see Fig C 58-6) that typically collects in the nondependent blunt chest trauma. Contusion Poorly defined local area of consolidation, Traumatic disruption of alveolar spaces with (see Fig C 58-3) usually in the lung periphery adjacent to the formation of a cavity filled with blood or air. Laceration Localized air collection in an area of con- Traumatic blood-filled lung cyst. May be single or multiple, unilateral and result in a traumatic pneumatocele as the or bilateral. Note also the ruptured right hemidiaphragm with herniation of large bowel into the chest. This includes overdistention of the cuff of the tube, protrusion of the tube wall beyond the expected margins of the tracheal lumen, and extraluminal position of the tip of the tube. Tracheal tear Tracheal transactions in the cervical region Uncommon injury that tends to occur within 2.

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Failure of expected betterment of the patient’s condition following operation is probably the most important guide to diagnose discount 80mg propranolol overnight delivery blood vessels repair themselves. The patient becomes ill with rise in pulse rate and peripheral circulatory failure order cheapest propranolol and propranolol cardiovascular physical therapy. The structure hangs in a double fold from the greater curvature of the stomach down to almost pelvis and then folds on itself and moves up in front of the transverse colon and mingles with the transverse mesocolon to end at the anterior border of the pancreas. The right border is attached to the pylorus and first portion of the duodenum while the left border forms the gastrosplenic ligament. The right side is usually longer and heavier and may possess tongue-like process extending into the pelvis. With growth, there is elongation and thickening of the omentum due to deposition of fat within its layers. Whenever there is any pathology within the abdomen, the greater omentum attempts to limit the infective process. In case of acute appendicitis, it has often been found to wrap the appendix to prevent its rupture and general peritonitis. The greater omentum has also been seen trying to seal the perforated peptic ulcer. It has also been seen to plug the neck of the hernial sac to prevent coils of intestine to move into the hernial sac. In case of tuberculous peritonitis or carcinomatosis peritonei, the greater omentum becomes rolled on itself to produce an upper abdominal lump. It has often been questioned how the omentum can act as ‘policeman of the abdomen’. But the displacement probably occurs as a result of postural changes of the individual, diaphragmatic excurtions and intestinal peristalsis and ultimately the omentum becomes fixed to the inflamed structure by the fibrous exudate. The usefulness of the omentum in inflammatory processes is also related to its bectericidal and absorptive properties. This may vary from mild vascular constriction producing oedema to complete strangulation leading to infarction of the distal part. Torsion may be primary or idiopathic when cause is not known and this is rare, though a few predisposing factors have been suggested e. Omental torsion may be secondary when it is associated with intra-abdominal localised inflammation, post-surgical scarring, cysts or tumours at the free end of the omentum or presence of internal or external hemiae. If not excised, the torsioned omentum becomes atrophic and fibrotic and may be autoamputated. Pain is the most important symptom, which is usually sudden with gradual increase in intensity. The pain is mostly periumbilical or may be localised to the right lower quadrant of the abdomen. True cysts are mainly lymphatic cysts either by the growth of congenitally misplaced lymphatic tissue or by obstruction of the lymphatic channels. These may be asymptomatic and only large cysts become palpable and produce symptoms like heaviness or pain or torsion. The most common is the metastatic carcinoma, the primary source of which is usually in the stomach or colon or pancreas or ovaries. In case of metastatic carcinoma, removal of the primary as well as total omentectomy may be performed if the other organs are not involved. Isolated injury to the mesentery and mesenteric vessels following blunt abdominal trauma is rare and in 60% of cases it is associated with rupture of intestine. If the tear in the mesentery is a large one and particularly transverse, the blood supply to that part of the intestine is cut off. So that portion of the small intestine should be resected with end-to-end anastomosis. Small tear in the long axis of the mesentery without any damage to the vascular supply of the any part of the small intestine may be only sutured. It must be remembered before securing any bleeding vessel in the mesentery that this vessel supplies a part of small intestine. So ligature of that vessel means that part of the intestine has to be resected followed by end-to-end anastomosis. If long segments of small intestine are of doubtful viability, it is best to leave in place to be re-examined at a second operation 24 hours later. If a small segment of small intestine is of doubtful viability that segment may be exteriorized to see later on whether it remains viable or not. If it remains viable, the segment is returned to the abdomen, whereas if it loses viability, that portion of small intestine should be resected. Its true incidence is not known, as it can only be accurately diagnosed at laparotomy and as it is a self-limiting disease. It is still considered to be the most common cause of inflammatory enlargement of the abdominal lymph glands. This disease is important because of its clinical similarity to several acute adbominal conditions which require immediate surgical intervention, particularly acute appendicitis. Respiratory infection often precedes an attack of non-specific mesenteric lymphadenitis. Sometimes appendicitis has been incriminated to cause this condition, though in majority of these cases the appendix is found absolutely normal. It seems likely that this condition represents a reaction of some type of material absorbed from the small intestine, probably a hypersensitive reaction to a foreign protein. This may be due to the concentration of mesenteric nodes in this area and because of abundant lymphatic drainage of the intestinal tract from the distal ileum. Moreover stasis of intestinal content in the terminal ileum favours absorption of bacterial products or toxins from the bowel lumen. Later on there is involvement of the intermediate and central groups of lymph nodes. Small amount of clear serous fluid is frequently present within the peritoneal cavity. The nodes which are nearer the attachment of the mesentery are usually the larger. Occasionally specific mesenteric adenitis due to beta haemolytic streptococci may occur. In these instances there is acute febrile illness with signs of peritoneal involvement. Very often there is a history of upper respiratory tract infection or sore throat. The initial pain is usually in the upper abdomen, though eventually the pain localises to the slight lower quadrant. On examination, there may be slight tenderness ill the right lower quadrant of the abdomen, slightly higher and more medial and less in intensity than that of acute appendicitis. Early in attack, the temperature is moderately elevated, though often the temperature may be normal.

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Treatment is direct suturing and closure of the defect by continuous suture with prolene buy propranolol 80mg low cost cardiovascular research institute. If direct suturing is not possible buy discount propranolol 40mg on line arteries back of neck, a prosthetic patch of knitted dacron or pericardium may be inserted. This defect is usually associated with incomplete formation of mitral and tricuspid valves. Initially the cleft in the mitral valve is closed with interrupted sutures placed from the ventricular septum out to the free margin of the mitral orifice. After repair of the cleft mitral valve, the septal defect is repaired with a patch of pericardium inserted with interrupted sutures. A defect in the tricuspid valve is frequent but usually not amenable to repair by direct suturing. The right pulmonary veins usually enter the superior vena cava inferior to the point of entry of azygos vein, or enter into the right atrium or into the inferior vena cava. When treatment is required, the anomalous veins can be corrected by insertion of prosthetic patch so that the defect is closed and the pulmonary veins are made to enter the left atrium. Ventricular defect is mostly situated in the membranous part or fibrous part of the septum. The membranous septal defects are either located posteriorly or anteriorly in relation to the crista supraventricularis. The posterior defects are close to the tricuspid valve on the right and the mitral valve on the left. The anterior defect is safely away from the conduction bundle and its closure is easier than that of the posterior defect. The defects smaller than 1 cm is called ‘small’ defect and larger than 1 cm is called ‘large’ defect. The defect allows passage of blood from the left to the right ventricle resulting in over-filling of the right heart and pulmonary hypertension. But those with larger defects are usually symptomatic and the first and most common symptom is dyspnoea on exertion. On Physical examination a loud pansystolic murmur is typically present in the 3rd and 4th intercostal space along the left sternal border. Enlargement of pulmonary artery and its tributaries and pulmonary congestion may be visible in X-ray. Cardiac catheterisation confirms the diagnosis and it also assesses the extent of left to right shunt. If symptoms are not disabling, the time for operation may be deferred to 4 to 6 years. A longitudinal ventriculotomy is performed usually in the infundibular part of the right ventricle and near the anterior descending coronary artery. The alternate approach is through the right atrium, particularly when pulmonary vascular resistance is significantly increased. The defect is usually closed with an oval patch of knitted Dacron by mattress sutures (prolene) posteriorly and continuous suture (prolene) anteriorly. Postoperatively, Digitalis is usually given, as some degree of right ventricular failure is common. The risk of operation increases somewhat if pulmonary vascular resistance is increased. Earlier diagnosis and treatment have brought down operative mortality to as low as 1 to 2%. The right ventricular obstruction increases right ventricular systolic pressure equal to that of the left ventricle. The right ventricular obstruction may be an infundibular stenosis or a valvular stenosis or a combination of the two. In this condition due to obstruction in the right ventricular outflow and presence of ventricular septal defect, the venous blood entering thcright ventricle is shunted direcdy into the aorta to produce cyanosis. This condition also decreases pulmonary blood flow and thus limits and ability to absorb oxygen. Due to presence of large ventricular septal defect, right ventricular pressure can never exceed left ventricular pressure inspite of presence of pulmonary stenosis. Arterial oxygen saturation may come down to 30 to 35%, when the body can walk only a short distance. Very low saturations of 10 to 20% is also seen in rare cases when the infant is not only unable to walk, but also may lose consciousness due to cerebral anoxia. Chronic anoxia may produce compensatory polycythemia and eventually clubbing of the extremities. About l/3rd of patients are cyanotic at birth, these patients often do not survive infancy unless operation is performed quickly. Walking for short distances, interrupted by squatting, is a pathognomonic symptom of this condition. He created an anastomosis between the left subclavian artery and the left pulmonary artery. In fact the subclavian artery is divided at a distance from its origin and the cut proximal end of the subclavian artery is then anastomosed to the upper border of the left pulmonary artery which is already mobilised and doubly clampped for convenience of performing the anastomosis. A continuous thrill is felt over the anastomosis as soon as the clamps are released. A side-to-side anastomosis between the ascending aorta and the right pulmonary artery was advocated by Waterson. An anastomosis is made between the descending aorta and left pulmonary artery (Pott’s). Superior vena cava is sometimes anastomosed with the right pulmonary artery (Glenn). A high vertical ventriculotomy is performed which stops near the pulmonary annulus and is limited to the infundibular portion of the right ventricle. Through this incision the ventricular septal defect is closed with a Dacron patch. The pulmonary vulvular and infundibular obstruction is also widened with a patch graft of Dacron. Following closure of the ventriculotomy and removal of air from all cardiac chambers, extracorporeal circulation is stopped. Now the intracardiac pressure is measured to confirm that the right ventricular systolic pressure is reduced to less than 60 to 70% of that of the left ventricle. If right ventricular pressure is still elevated, more correction of the ventricular obstruction becomes necessary. While the risk is about 10% for smaller children, it is only 2 to 5% in older children. As a result venous blood is ejected through the aorta and the oxygenated blood returning from the lungs into the left atrium enters the left ventricle and is again pumped through the pulmonary artery to the lungs. This is obviously incompatible with life except for if a communication exists between the pulmonary and systemic circulations in the form of a patent ductus arteriosus, an atrial septal defect or a ventricular septal defect. One or more of these congenital anomalies must exist for the infant to survive even a few hours after birth.

The injuries are generally of three types — (i) external rotation buy propranolol once a day coronary heart zone, (ii) internal rotation and (iii) vertical compression purchase 80 mg propranolol with amex heart disease or anxiety. Palpation of the lower end of the tibia and fibula and the two malleoli are not very difficult. The calcaneum is palpated from posterior aspect while the talus is palpated by deep pressure with the thumb in front and just below the ankle. If the foot is turned to the opposite direction to stretch the ligament concerned the patient will complain of pain. Springing the fibula — By squeezing the upper ends of the tibia and fibula pain will be elicited at the lower part of the fibula if it is fractured. Lastly one must palpate tendo Achilles to find if there is any gap or tenderness at its attachment with the os calcis. Palpation of injuries around the ankle remains incomplete if this examination is missed. By holding the ankle joint with one hand, slight active or passive movement of the ankle with the other hand will give an indication about the type of fracture that has probably occurred. Similarly the distances between the lateral malleolus to the head of the 5th metatarsal bone and the point of the heel are important. In fracture of the calcaneus the distances between the malleoli and the point of the heel are shortened if there is upward displacement of the tuberosity, (iii) Broadening of the ankle as measured by means of calipers, is often seen in inferior tibio-fibular diastasis. Only in cases of suspected fracture of the calcaneus axial X-ray may be needed to detect displacement in vertical fractures involving the joint. This angle is formed at the back of the ankle by two lines — one passing over the non-articular surface of the calcaneus and the other along the articular surface of the same bone for the talus. In fractures when the tuberosity is displaced upwards lifting the posterior non-articular surface, this angle is reduced (Fig. In complete tear of any collateral ligament of the ankle joint an antero-posterior X-ray is taken with the foot forcibly tilted towards the opposite direction. With continuing force the medial malleolus may be avulsed or fractured transversely. Further rotation will lead to avulsion of the posterior fragment of the tibia to which the tibio-fibular ligament is attached leading to tibio-fibular diastasis. A continuing force may also avulse the medial malleolus and later on avulsion of the posterior fragment of the tibia with tibio-fibular diastasis. This is the most important differentiating feature from the external rotation or abduction injury in which the medial malleolus is fractured transversely. Diagrammatic representation of adduction Vertical injury with an upward thrust injury of ankle. Sometimes this vertical fracture may join a transverse fracture of the lower end of the tibia about 2 to 3 inches above the ankle joint. In adolescents this type of injury will cause fracture-separation of the lower tibial epiphysis. The larger lateral segment is usually shifted laterally and the smaller medial segment is displaced upwards. In rotational injury with eversion and plantar flexion commonly the first metatarsal bone is injured near its base. The typical rotational injury with forced inversion will avulse the base of the 5th metatarsal bone. Insidious onset is the feature of chronic arthritis including tuberculous variety, rheumatoid arthritis and osteoarthritis. The clinician should take a proper history of the pain regarding its site, its character, its relation to movements of the joint and its relation with the new and full moon. But in osteoarthritis pain is first felt in the early morning when the patient gets up from the bed. With gradual movement of the joint the pain is eased off due to increase in synovial secretion. Such deformity is seen in late stage of rheumatoid arthritis, osteoarthritis and tuberculous arthritis. The joint should be inspected from all sides, particularly the posterior aspect which is often overlooked. A careful watch must be made to differentiate between generalized swelling of the joint due to effusion and a localized swelling from a bursa or a ganglion. A bursa often communicates with the joint and may become prominent in presence of effusion in the joint. This can be found in any joint which is pathologically involved to produce such deformity. After the Latin names they are called Coxa (hip) valgus or varus, Genu (knee) valgus or varus, Cubitus (forearm) valgus or varus and Manus (hand) valgus or varus. This position is adduction, slight flexion and internal rotation for the shoulder joint; slight flexion, abduction and external rotation for the hip joint; flexion and slight pronation for the elbow joint; slight flexion for knee joints; slight flexion for wrist joint and slight plantar flexion and inversion for the ankle joint. Scar, sinus, ulcer and deformities of the joint are the late features of tuberculous arthritis. In case of the knee joint the quadriceps muscles waste first, similarly in case of hip the glutei waste first. The temperature of the diseased joint must be compared with that of the healthy joint. The teaching is that always feel the joint of the sound side first and then the diseased joint. The bones in the vicinity of the joint and the bony attachments of various ligaments are carefully palpated for tenderness, as the former will be tender in fracture and the latter will be tender in sprain. An enlarged bursa will be soft and cystic and will correspond with the anatomical position of the bursa. Occasionally a swelling at the joint may not be due to effusion but due to swelling like subcutaneous lipoma or cyst. It is always advisable to examine the sound side first so that the patient knows what is to be done with the affected joint and his fear and muscle spasm can be greatly eliminated. If so, when does the pain start and when does it disappear, (b) Is there any restriction of the movements? In certain diseases certain types of movements are restricted whereas the other movements remain normal, (c) Is there any protective muscular spasm? To demonstrate, a short sharp movement is made and the muscle will be seen to go into spasm. Muscular spasm is almost always associated with active stage of arthritis, (d) Is there any crepitus felt during movement of the joint? Limitation of movements in all directions is an important feature of acute arthritis. One thing must be borne in mind during examination of movements of different joints that a few joints e. This is due to the movements of the neighbouring joints, as for example in case of shoulder joint the movement of the scapula, acromioclavicular and sternoclavicular joints; in case of the hip such movements occur at the lumbar spine; in case of the ankle movements may occur at the subtaloid and midtarsal joints. In early cases of osteoarthritis fine crepitation may be missed by the palpating fingers.