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These are tone and contractility of the muscles of the lower limb being encircled by a tough deep fascia lady era 100 mg with mastercard womens health ukiah ca. Incompetence of valves order lady era 100 mg on-line womens health yuma az, which may be a sequel of venous thrombosis, seems to be the most important factor in initiating this condition. Varicosity may also be secondary, predisposed by any obstruction which hampers venous return e. In younger age group congenital arteriovenous fistula may be the cause of varicose vein. Varicose veins may also occur in individuals involved in excessive muscular contractions e. It is doubtful if these occupations cause the varicose veins or they just exacerbate the symptoms already present. The pain gets worse when the patient stands up for a long time and is relieved when he lies down. One thing the student must always remember that it is not the varicose veins which produce the symptoms, but it is the disordered psychology which is the root of all evils. So it is not impossible to come across asymptomatic varicose veins on one side and severe symptoms with very few visible varicose veins on the other side. Patient may complain of bursting pain while walking, which indicates deep vein thrombosis. The ankle may swell towards the end of the day and the skin of the leg may be itching. If the patient is suffering from constipation or a swelling in the abdomen, it may be a cause of secondary varicose vein. Any serious illness or previous complicated operation may cause deep vein thrombosis which is the cause of varicose vein now. If the patient had contraceptive pills for quite a long time, as this may cause deep vein thrombosis. In case of the former a large venous trunk is seen on the medial side of the leg starting from in front of the medial malleolus to the medial side of the knee and along the medial side of the thigh upwards to the saphenous opening. In case of short saphenous vein varicosity the dilated venous trunk is seen in the leg from behind the lateral malleolus upwards in the posterior aspect of the leg and ends in the popliteal fossa. Localized swelling may also be due to superficial thrombophlebitis, (b) Generalized swelling of the leg is mostly due to deep vein thrombosis. More important for this chapter is when the skin of the limb becomes congested and blue due to deep vein thrombosis and this condition is called phlegmasia cerulea dolens. In such severe venous obstruction the arterial pulses may gradually disappear and venous gangrene may ensue. The aim is to locate the incompetent valves communicating the superficial and deep veins. In both the methods, the patient is first placed in the recumbent position and his legs are raised to empty the veins. The sapheno-femoral junction is now compressed with the thumb of the clinician or a tourniquet is applied just below the sapheno-femoral junction and the patient is asked to stand up quickly. If the varices fill very quickly by a column of blood from above, it indicates incompetency of the sapheno-femoral valve. This is also considered as a positive Trendelenburg test and the positive tests are indications for operation. In case of short saphenous vein same test is done by pressing the sapheno-popliteal junction. In this test the tourniquet is tied round the thigh or the leg at different levels after the superficial veins have been made empty by raising the leg in recumbent position. If the veins above the tourniquet fill up and those below it remain collapsed, it indicates presence of incompetent communicating vein above the tourniquet. Similarly if the veins below the tourniquet fill rapidly whereas veins above the tourniquet remain empty, the incompetent communicating vein must be below the tourniquet. The number of incompetent communicating sources in the lower limb in the long saphenous vein is the sapheno-femoral junction (most important), the mid-thigh perforator, the lower-thigh perforator and the lower leg perforators on the medial side. In case of short saphenous incompetence — application of the venous tourniquet to the upper thigh has the paradoxical effect of increasing the strength of the reflux, as shown by faster filling time. The sign, which has not been described before, is pathognomonic of varices of the short saphenous system. The mechanism is very simple — application of the upper thigh tourniquet blocks off the normal internal saphenous system which is carrying most of the superficial venous return and thus thrown into greater prominence the retrograde leak for the saphenous-popliteal junction. Final definite proof of short saphenous incompetence is obtained through following examination :— The saphenopopliteal junction is marked with a pen with the patient standing. The short saphenous vein is emptied by elevation of the leg, firm thumb pressure is applied to the ink mark. For all practical purposes that there is no other incompetent perforating vein in the short saphenous system should be remembered. A tourniquet is tied round the upper part of the thigh tight enough to prevent any reflux down the vein. If the communicating and the deep veins are normal the varicose veins will shrink whereas if they are blocked the varicose veins will be more distended. An expansile impulse is felt in the long saphenous vein particularly at the saphenous opening if the sapheno-femoral valve is incompetent. The examiner palpates along the line of the marked varicosities carefully and finds out gaps or pits in the deep fascia which transmit the incompetent perforators. One should look for pitting oedema or thickening, redness or tenderness at the lower part of the leg. These changes are due to chronic venous hypertension following deep vein thrombosis. Sometimes a progressive sclerosis of the skin and subcutaneous tissue may occur due to fibrin deposition, tissue death and scarring. This is known as lipodermatosclerosis and is also due to chronic venous hypertension. Sometimes the percussion wave can be transmitted from above downwards and this will imply absent or incompetent valves between the tapping finger and the palpating finger. Regional lymph nodes (inguinal) — are only enlarged if there be venous ulcer and this is infected. Other limb — should be examined for presence of varicose veins and different tests to exclude deep vein thrombosis, incompetent perforators and venous ulcer to plan treatment. Sometimes a pregnant uterus or intrapelvic tumour (fibroid, ovarian cyst, cancer of cervix or rectum) or abdominal lymphadenopathy may cause pressure on the external iliac vein and becomes responsible for secondary varicosity. Mild phlebitis may be produced by the sclerosing fluid used in the injection treatment. The patients often give previous history of venous thrombosis suggested by painful swelling of the leg. After thrombosis has been recanalised the valves of the deep veins are irreparably damaged. The deoxygenated blood gets stagnated in the lower part of the leg particularly on the medial side where there are plenty of perforating veins.

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Those who work with earth impactors or rivetting machines which are also vibrating tools show similar incidence of this disease generic lady era 100 mg amex women's health clinic colorado springs. Similarly this syndrome is reported in about 50% among food workers working in cold environment generic 100mg lady era mastercard menstruation in africa. Three stages are distinctly observed with exposure to cold or emotional disturbances. These are — (1) Stage of local syncope, (2) Stage of local asphyxia and (3) Stage of recovery. This change starts at the tip of the finger and gradually spreads towards the base. Small amount of blood passes to the capillaries which become dilated due to accumulation of anaerobic metabolities from the previous stage. Slowly flowing blood becomes easily deoxygenated and the part becomes dusky or cyanosed (stage of dusky anoxia). The oxygenated blood returns into the dilated capillaries (under influence of anaerobic metabolites which accumulated in the first stage of pallor) and the fingers become red (stage of red engorgement) and swollen. There may be burning sensation or pain produced by the increased tissue tension within the digits. Patients with scleroderma may have visible changes in their skin and face and may complain of dysphagia. In long standing cases the fingers gradually waste, especially the pulps, which become thin and pointed. Guanethidine has been claimed to be the most effective drug for the symptomatic treatment of this condition in the last decade. Phenoxybenzamine and more recently prazocin and pentoxifylline are the adrenergic blocking drugs which have been claimed to provide good result. The calcium channel-blocking drugs have been used with success by certain investigators. The combination of Nifedipine with low dose of guanethidine or prazocin has frequently appeared to improve results while diminishing the incidence of side effects. Prostaglandin E administered intravenously to these patients have shown benefits as has been reported from a few hospitals of London. So in this operation the sympathetic trunk from the lower half of the stellate ganglion to the just below the 3rd thoracic ganglion should be resected. As mentioned earlier initial results are usually good but recurrence of symptoms in subsequent years is quite common. For this reason sympathectomy is usually employed only when the symptoms are severe and other therapy becomes ineffective. Cervico-thoracic sympathectomy can be performed by one of the three following approaches:- A. The head is rotated to the opposite side and the hand of the corresponding side is pulled downwards. An incision is made about 1/2 inch above the clavicle starting from the lateral border of the sternal head of the stemomastoid muscle to the medial border of the trapezius. After incising the skin, superficial fascia, platysma and investing layer of the deep cervical fascia, the clavicular head of the stemomastoid is divided and the inferior belly of omohyoid is retracted upwards to expose the scalenus anterior and the phrenic nerve. The phrenic nerve is safeguarded and the scalenus anterior is divided at its insertion to the first rib. The proximal divided end is drawn upwards and all the rami communicantes joining the 3rd and 2nd thoracic ganglia are divided. Finally the sympathetic trunk is divided just below the level of the attachment of rami communicantes to the. This operation can also be performed above the subclavian artery, which is probably a better approach for the short necked patients. But in that case the thyrocervical trunk should be divided between ligatures for better exposure. An incision, about 5 inches in length, is made on the medial wall of the axilla along the line of the 2nd intercostal space. To reach phrenic the intercostal space, the fibres of drawn serratus anterior have to be medially divided, but generally the long pleura thoracic nerve lies a little posterior to the incision and subclavian hence less liable to be damaged. The pleura is incised and the sympathetic trunk is removed according to necessity. A vertical incision is made about 5 cm lateral to the midline keeping the third rib in the centre. For proper exposure, the 2nd and 3rd intercostal nerves may be required to be divided. The convalescent period is much prolonged and the operation is a lengthy procedure. The basic pathology is the slow rate of blood flow through the skin due to chronic arteriolar constriction. This results in a high percentage of reduced haemoglobin in the blood, in the capillaries and this is the cause of cyanotic colour. Coldness and blueness of the fingers and hands are persistently present for many years. There are no trophic changes indicative of chronic tissue ischaemia such as atrophy or sclerosis of the skin or ulceration. If the condition does not respond to above conservative measures, sympathectomy may be carried out with reasonably good results. The syndrome is caused by compression of the brachial plexus or subclavian artery and/or vein in the region near the thoracic outlet. It then passes under the clavicle and subclavius muscle to enter the axilla beneath the pectoralis minor muscle. The subclavian vein passes anterior to scalenus anticus muscle and is in intimate relation with the head of the clavicle and the most medial portion of the first rib. A potential area of compression exists firstly in the interscalene triangle between the scalenus anticus anteriorly, the scalenus medius posteriorly and the first rib interiorly. Distal to this area is again a narrow space — intercostoclavicular space — between the clavicle and the first rib. During hyperabduction the axillary vessels and the brachial plexus are bent at an angle of approximately 90° in this area and are liable to be compressed. Symptoms due to cervical rib are rare in children, but are most frequently seen in thin women in the 3rd and 4th decades. Gradual descent of the shoulder girdle perhaps from atrophy of the regional musculature may cause onset of symptoms in the 2nd or 3rd decade. Vascular symptoms may be intermittent from compression or temporary occlusion of the subclavian artery. Claudication with exercise, pallor, sensation of coldness, numbness or paraesthesia are the various vascular symptoms.

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The size of an ulcer is important to know the time which will be required for healing cheapest generic lady era uk women's health center lebanon nh. To record exactly the size and shape of an ulcer buy lady era american express menstruation gingivitis treatment, a sterile gauge may be pressed on to the ulcer to get its measurements. An ulcer on the medial malleolus of a lower limb which shows varicose veins, is obviously a varicose ulcer. Rodent ulcers are usually confined to the upper part of the face above a line joining the angle of the mouth to the lobule of the ear, occurring frequently near the inner canthus of the eye (see Fig. Tuberculous ulcers are commonly seen where tuberculous adenopathy is commoner, that means in the neck, axilla (Figs. Hun­ terian chancre and soft sores will obviously be found over the external genitalia. Perforating or trophic ulcers are commoner on the heel of the foot or on the ball of the foot, which carries maximum weight of the body. The probe ^ n ^ sP ^r a lnS can be easily insinuated between the edge and ulcer, the edge is Fig. The disease causing the ulcer spreads in and destroys the subcutaneous tissue faster than it destroys the skin. The overhanging skin is thin, friable, reddish blue and unhealthy, (ii) Punched out edge — is mostly seen in a gummatous ulcer or in a deep trophic ulcer. The diseases sentation of different types of which cause the ulcers are limited to the ulcer itself and do not edge of ulcers. This type of edge develops in invasive cellular disease and becomes necrotic at the centre, (v) Rolled out (Everted) edge — is a characteristic feature of squamous-celled carcinoma or an ulcerated adenocar-cinoma. This ulcer is caused by fast growing cellular disease, the growing portion at the edge of the ulcer heaps up and spills over the normal skin to produce an everted edge. When floor is covered with red granulation tissue, the ulcer seems to be healthy and healing. Wash-leather slough (like wet chamois leather) on the floor of an ulcer is pathognomonic of gummatous ulcer. A trophic ulcer penetrates down even to the bone, which forms the floor in this case. A healing ulcer will show scanty serous discharge, but a spreading and inflamed ulcer will show purulent discharge. Sero-sanguineous discharge is often seen in a tuberculous ulcer or a malignant ulcer. A scar or a wrinkling in the surrounding skin of an ulcer may well indicate an old case of tuberculosis. Presence of varicose vein and deep vein thrombosis will indicate the ulcer to be a varicose ulcer. Activity is maximum at the margin and edge of the ulcer, though the degree of activity will vary according to the type of the ulcer. In palpation the different types of the edge of the ulcers are corroborated with the findings of inspection. Besides this, a careful palpation of the edge and the surrounding tissue will give a clue to the diagnosis. Marked induration (hardness) of the edge is characteristic feature of a carcinoma, be it a squamous-celled carcinoma or adenocarcinoma. A certain degree of induration or thickness is expected in any chronic ulcer, whether it is a gummatous ulcer or a syphilitic chancre or a trophic ulcer. If an attempt is made to pick up the ulcer between the thumb and the index finger, the base will be felt. Slight induration of the base is expected in any chronic ulcer but marked induration (hardness) of the base is an important feature of squamous-celled carcinoma and Hunterian chancre. A gummatous ulcer over a subcutaneous bone (tibia or sternum) is often fixed to it. Increased temperature and tenderness of the surrounding skin indicates the ulcer to be of acute inflammatory origin. It is imperative to know the state of vein around the ulcer particularly when venous ulcer is suspected. In acutely inflamed ulcers, the regional lymph nodes become enlarged, tender and show the signs of acute lymphadenitis. In rodent ulcer also the lymph nodes are not affected possibly because of the early obliteration of the lymphatics by the neoplastic cells. In malignant ulcer the nodes are stony hard and may be fixed to the neighbouring structures in late stages. Simple enlargement of lymph nodes in malignant disease does not suggest lymphatic metastasis. The lymph nodes may be enlarged because of secondary infection rather than anything else. If there is no varicose vein and the cause of ulcer is not determined, the clinician must examine the condition of the arteries proximal to the ulcer. This is mostly seen in the sole, as this is the weight­ bearing zone if there is sensory loss. So presence of trophic ulcer indicates some neurological (particularly sensory) disturbance, either in the form of tabes dorsalis or transverse myelitis or peripheral neuritis. When the ulcer is suspected to be syphilitic, a thorough search should be made for presence of other syphilitic stigmas in the body as shown in Fig. If the ulcer appears to be tuberculous, all the lymph nodes in the body should be examined along with other examination such as the chest, the neck, the abdomen etc. When the ulcer is a trophic (perforating) one general examination must be made to know the type of nervous disease present with this condition. Examination of the Urine — particularly sugar estimation, to exclude diabetes, is important. Bacteriological examination of the discharge of the ulcer is particularly important in inflamed and spreading ulcers. This will not only give a clue as to the type of organism present in the ulcer, but also its sensitivity to a particular antibiotic. Discharge from tuberculous ulcer will show acid fast bacilli and should be sent for guineapig inoculation test. Chest X-ray — is important in tuberculous ulcers to detect any primary focus in the lung. It is important to exclude metastatic deposit in the lungs in case of malignant ulcers. The biopsy is generally taken from the edge of the ulcer taking a portion of surrounding healthy tissue. Biopsy material is then examined histologically to know the type of tumour, its invasiveness and whether differentiated or anaplastic. X-ray of the Bone and Joint — is required when the ulcer is situated very near a bone or joint.

F. Ugo. Bellevue University.