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Nutritional assessment and program modifi- risk factors generic dapoxetine 60 mg without a prescription erectile dysfunction medicine in bangladesh, including a significant recent history of cations can be done by the physician generic dapoxetine 60mg with mastercard erectile dysfunction treatment with diabetes, trained nursing staff discount 60 mg dapoxetine with visa erectile dysfunction protocol download free, or smoking cheap dapoxetine 30mg visa impotence emedicine. Patients typically lose 11 to 22 pounds, but Obesity and Dyslipidemia 239 attrition is high. The triglyc- sleep apnea and restrictive lung disease, but not chronic eride level of 1,000 mg/dL is in the monogenic category of obstructive pulmonary disease. Gallstones, especially cholesterol stones, occur in greater incidence in obesity, most likely because of the higher 15. The definition of obesity requires cholesterol levels found in obesity; for uterine cancer, the that the patient be 20% overweight. By body mass criteria, moderate obe- Above 27, health problems begin to accumulate in pro- sity for women is defined as 30 to 40; severe obesity as portion to the degree that the individual is overweight. A diet of 1,300 calories, with 175 g of carbohydrate, 50 g of fat, and 50 g of protein, would be a well-designed 11. About 30% of patients with moderate modest weight-reduction diet; 1,300 calories meets a or severe obesity have a binge-eating disorder. Obese people guideline for the maintenance needs of a 130-lb (59 kg) consume more calories than needed for maintenance of a woman; 175 g of carbohydrate approximates 55% of total stable body weight, but the amount is typically less than that calories, and 50 g of fat provides less than 30% of the total found in age-, height-, and sex-comparable nonobese con- calories. Fluoxetine, likewise, is reserved logical problems associated with obesity are a complicated for severe cases (e. Most adults who succeed in weight-loss programs experience an increase in self-esteem, although 16. Atorvastatin is already at the maximum allowable precluding or severely interfering with employment, fam- dosage. Osteoporosis is not associ- statin is in place because of the increased risk of myolysis, ated with obesity as being overweight is in fact a protective a known side effect of the statins. Thus, it does not enter into sequestrant colestipol is a valid option but does not hold the decision for bariatric surgery. New York/Chicago : Lange; McGraw-Hill ; American Society of Bariatric Surgery Web site: www. After a week of the definitive dosing, she been told of the adverse effects of smoking if requested a visit and complained of a side effect suf- they have seen other physicians recently. Which of (B) Smoking in the physician’s office should only be the following is the most likely side effect that forced allowed in partitioned, ventilated smoking areas. The incidence of which of the follow- is known to increase asbestosis and asbestosis multi- ing childhood diseases is increased in households plies the risk of lung cancer, which of the following is with smokers present? In advising her to stop He is seriously considering quitting but asks your smoking, you tell her that her baby will be at increased advice as to whether it is too late to reduce his risk of risk for which of the following, if she continues to lung cancer. His first cigarette of the day is usu- cancer patients have smoked for more than ally midmorning, after he has completed a phase of a 20 years before contracting the disease. Because you consider him not to be addicted, you discuss with him forgoing nico- 7 You are counseling a 50-year-old man who has been tine replacement therapy in favor of buproprion smoking for 20 years. In which of the following situations would he be contraindication to bupropion in this patient? She is applying (D) He relapsed after being exposed to a situation a new patch each day. Nausea is the most common side asthma, the smoke can serve as a respiratory irritant that effect of varenicline, and it was reported in 40% of patients precipitates the asthma. No causal relationship span, anxiety and depression have garnered much atten- between parental cigarette smoking and sudden infant tion they arise in only 1% to 2% of patients. The metabo- death syndrome or childhood malignancies has been lism of metformin is not affected by Chantix; therefore, established. The risk of lung cancer begins sig- icline than would be the case if she were not taking the nificantly to subside at 10 years after cessation of smok- drug. Varenicline functions as an acetyl-choline agonist, ing, and it approaches the expected risk of non-smokers resulting in decreased urge to smoke during withdrawal. This estimate is on less secure ground with the passage of time due to the increasing proportion 2. Still, the vast major- symptomatic until at least 15 years after the original expo- ity of lung cancer patients have smoked heavily ( 1 pack sure to asbestos. Each of the other choices could be causes per day) for more than 20 years before contracting the of symptoms and each of which in turn is accelerated in disease. Smoking during pregnancy carries as opposed to those whose impulses to smoke occur in the risk of preterm birth. Smoking during pregnancy is certain situations, such as after dinner, in times of “stress” associated with smaller, premature newborns, but not or when out with friends rather than “on the clock. If he suffered a myocardial infarction 2 weeks ago, the vasoconstrictive effects of nicotine are a 4. Recent myocardial infarction, unstable problem list of anyone who smokes and on the child’s angina, cardiac dysrhythmia, or true hypersensitivity chart of any child in a smoking household. Surveys may reaction to the patch (not just local erythema or pruritus) demonstrate to patients how important the physician are the only real contraindications. The length of the crit- views the impact of smoking on their health and quanti- ical period after a myocardial infarction is generally not fies the habit. However, following perioperative never told them to quit and some will respond to brief guidelines for elective surgery, and allowing for somewhat interventions, but almost never in one session. Smoke- more leeway for smoking versus an assumed compelling free offices are necessary without exception. One need not case for even elective surgery, 3 months would be a good wait for a “propitious” or adequate length of time for ini- estimate. Bupropion is contraindicated where shown statistically to have eventual long-term success, there is history of seizures. Most suitable in situations compared with never mentioning smoking dangers and where the compulsion to smoke appears to be psychologi- the wisdom of cessation at all. Reactive airway disease and exacerba- monoamine oxidase inhibitors, headache, nausea, or tions of known asthma are more likely in children of recent head trauma. Although cigarette reusing a site in rotation is recommended so that contact smoking by the parents is not known to cause childhood irritation can be avoided. How much time for exercise can you tell 1 An obese 45-year-old male wishes to inaugurate an the patient is recommended for American adults by exercise program and asks for advice as to what pre- the Center for Disease Control and Prevention? Each of the following is a (A) 15 minutes of mild-intensity physical activity contraindication for prescribed exercise except for 3 days a week which one? You advise him to begin walking 1 mile every (B) It has four characteristics described by the day. How many calories will he burn if he is (A) The systolic blood pressure rises and the doing fast cycling for 1 hour, maintaining a pulse rate diastolic pressure falls during strenuous exercise. Compensated congestive heart failure maximum pulse is 220 minus the age, in this case 45 years. All the grams by any adult who has not been physically active for other statements regarding the benefits of exercise are a period of years or who has a history of supervention of true. The answer is C, 140 kcal is the estimated caloric con- load and intensity of activity after starting modestly. The incorrect statement as, “In con- memorize: Weight in pounds multiplied by two-thirds.

J 424 Yagi H dapoxetine 30 mg on line impotence emotional causes, Matumoto M cheap dapoxetine 30 mg with visa erectile dysfunction treatment manila, Ishizashi H dapoxetine 90 mg line effexor xr impotence, Kinoshita S cheap dapoxetine 30 mg amex erectile dysfunction statistics canada, Konno Pediatr Hematol Oncol, 20, 69–73. Eur J 414 Nurden P, Debili N, Coupry I, Bryckaert M, Youlyouz‐ Haematol, 64, 151–156. Eur J Hae- Espanol I (2004) Ultrastructural analysis of granulocyte matol, 78, 220–226. Am J 434 Rosthøj S, Hedlund‐Treutiger I and Zeller B on behalf of Hematol, 75, 18–21. ChapteR 9 Disorders of white cells Acquired disorders primarily involving white cells may few blast cells in the peripheral blood. The lymphocyte be either reactive, to a primary usually non‐haemato- and eosinophil counts are reduced. Neoplastic disorders result cyte count occurs later than the rise in the neutrophil from the clonal proliferation of a haemopoietic stem count. During recovery, there is a rise in the eosinophil cell, either myeloid, lymphoid or pluripotent, that has count, sometimes to above normal. Numerical changes in white cells a normocytic normochromic anaemia develops and, if are summarised in Chapter 6. Here the typical periph- the infection becomes chronic, red cells may become eral blood changes in reactive leucocyte disorders are hypochromic and microcytic. There is an increase in described, followed by the characteristic features of hae- rouleaux formation and in background staining. Sometimes bacterial infections are associated with pancytopenia as Reactive changes in white cells a result of haemophagocytosis. In overwhelming sepsis, particularly in alcoholics and Bacterial infection neonates, infection can be associated with paradoxi- Acute and chronic bacterial infection cal leucopenia and neutropenia. Neutropenia in bacteraemic In an adult, the usual response to a bacterial infec- patients is indicative of a worse prognosis [1]. Neutro- tion is a neutrophil leucocytosis with a left shift, toxic penia in the course of infections that more often cause granulation, Döhle bodies and, when infection is severe, neutrophilia may be the result of increased margination cytoplasmic vacuolation (Fig. Occasionally, bac- of neutrophils, impaired granulopoiesis or migration teria are seen within neutrophils. In severe infections of peripheral blood neutrophils to tissues more rapidly there may be myelocytes, promyelocytes and even a than they can be replenished by a bone marrow with Fig. In some studies in not specifc for infection, being seen also in pregnancy, neonates, an increased proportion of band cells has in infammatory and autoimmune diseases, following been found more useful than neutrophilia in identify- administration of cytokines and when there is tissue ing infected infants. The presence of neutrophil vacuolation is dicting a positive blood culture than an increase in the more specifc for infection, very commonly indicating absolute neutrophil count [2]. The observation of bacteria within neu- Although neutrophilia is the characteristic response to trophils in a flm made without delay may indicate colo- bacterial infection, this is not invariable. Neutrophilia as a leukaemoid cellosis occasionally causes isolated thrombocytopenia. Infants and young children sometimes also In the neonatal period, neutrophilia may be caused respond to other bacterial infections with lymphocytosis not only by infection but also by hypoxia or stressful rather than neutrophilia. Differential diagnosis Further tests The differential diagnosis of neutrophil changes sugges- Characteristic peripheral blood features are often pre- tive of infection includes other causes of neutrophilia sent in bacterial infection but, since they are neither (see Chapter 6). Toxic granulation and Döhle bodies are specifc nor invariably present, a defnitive diagnosis Fig. In patients with known bacte- Monocytosis occurs in about one quarter of patients. Tuberculosis The haematological manifestations of tuberculosis are Differential diagnosis protean, although some of the abnormalities attributed The haematological manifestations of tuberculosis are to tuberculosis in the past are likely to have been caused so variable that many infective, infammatory and neo- by the coexistence of tuberculosis and a disease such as plastic conditions enter into the differential diagnoses. Further tests Blood flm and count Bone marrow aspiration and trephine biopsy can be Pulmonary tuberculosis causes a normocytic normo- useful in the diagnosis of miliary tuberculosis. Lymphocytosis is present in Viral infections about one quarter of patients and lymphopenia in one Infectious mononucleosis ffth. In contrast to acute pulmonary tuberculosis, tures are fever, pharyngitis, lymphadenopathy (hence Disorders of white cells 419 the common designation ‘glandular fever’), spleno- comprising at least 10% of circulating lymphocytes [8]; megaly and hepatitis. Haematologically, the disease is in one study the former observation had a sensitiv- characterised by ‘atypical mononuclear cells’ or ‘atypi- ity of 66% and the latter a sensitivity of 75% for het- cal lymphocytes’, which are mainly activated T lympho- erophile‐positive disease among patients with suspected cytes produced as part of the immunological response to infectious mononucleosis [9]. Many Blood flm and count are large, with diameters up to 15–30 μm, and have There is often lymphocytosis and leucocytosis as a result abundant strongly basophilic cytoplasm. Some have of the presence of atypical lymphocytes, representing large central nucleoli and resemble immunoblasts (i. Nuclei of peripheral blood leucocytes and atypical lymphocytes can be round, oval, reniform, lobulated or, occasionally, (a) Fig. In one study 15% of patients had clover- activity – usually a feature of hairy cell leukaemia. How- leaf nuclei, an observation of low sensitivity but high ever, cytochemistry is not recommended in the diagno- specifcity in patients with suspected infectious mono- sis of infectious mononucleosis. In the same study 30% of patients had Changes in other cell lines are quite common, smear cells, also a highly specifc observation in this although they tend to be overshadowed by the abnor- group of patients [9]. The cytoplasm may be vacu- patients had neutrophil counts of less than 1 × 109/1 olated, foamy or (occasionally) granulated, and moder- [12]. Reduction of It should, however, be noted that both ‘scalloping’ and the eosinophil count is usual; during recovery there is peripheral cytoplasmic basophilia can also be features of eosinophilia. Some cells have a hand‐mirror confor- platelet count being less than 150 × 109/1 in about one mation. Severe thrombocytopenia that some- Apoptotic cells may be present, infectious mononucleo- times occurs is likely to be due to immune destruction sis being the most common cause of apoptosis in circu- of platelets. Large granular lymphocytes body can occur and the blood flm then shows red cell may be increased and there may be some plasmacytoid agglutination, some spherocytes and, later, the devel- lymphocytes and plasma cells. Young children have a greater degree of Infectious mononucleosis (Epstein‐Barr virus infection), lymphocytosis and a lower percentage of atypical lym- cytomegalovirus infection,∗ infectious hepatitis (hepatitis A infection),∗ measles (rubeola), German measles (rubella), echovirus phocytes than older children, but the absolute count infection, adenovirus infection,∗ chicken pox (varicella) and herpes of atypical lymphocytes is similar in children under zoster, herpes simplex infection, human herpesvirus 6 infection∗ and over 4 years of age [14]. Rare patients infection, hantavirus pulmonary syndrome [18] with infectious mononucleosis have severe lympho- Bacterial infections penia [16]. This is associated with severe disease and Brucellosis, tuberculosis, typhoid fever [19], syphilis, rickettsial a worse prognosis. Systemic lupus erythematosus [25] Sarcoidosis [26] Differential diagnosis Graft‐versus‐host disease The differential diagnosis of infectious mononucleosis includes other causes of atypical lymphocytes (Table 9. Hodgkin lymphoma Kawasaki syndrome [27] Further tests Familial haemophagocytic lymphohistiocytosis [28] The fnding of a blood flm suggestive of infectious Transient idiopathic proliferation of monoclonal atypical mononucleosis is an indication to test for a heterophile lymphocytes [29] antibody that agglutinates sheep or horse red cells and ∗ Conditions that can be associated with suffciently large numbers of differs from heterophile antibodies in other conditions in that it is adsorbed by ox red cells but not by guinea pig atypical lymphocytes to be confused with infectious mononucleosis kidney. Rapid commercially available slide tests for het- erophile antibodies are sensitive and very convenient, another series, the percentages of patients with immu- with a false‐positive rate of 1–2%. In adolescents and adults, to more than one virus; 3% of patients had toxoplas- ‘heterophile‐negative infectious mononucleosis’ most mosis. Dys- The acute illness can resemble infectious mononucleosis plastic forms can include hypogranular and pseudo‐ both clinically and haematologically, but in general the Pelger neutrophils and neutrophils with large nuclei number of atypical lymphocytes (Fig. Recurrent infec- tions contribute to the development of anaemia and are associated with increased rouleaux formation and increased background staining. Minor reactive changes in lymphocytes are common and may include clover- leaf forms.

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It is wise to consult an urologist before ordering any x-ray procedure to help decide which is the most cost-effective approach generic 90mg dapoxetine otc erectile dysfunction oil. Exploratory surgery Case Presentation #28 A 46-year-old male executive was found to have a large right flank mass 359 on routine physical examination buy dapoxetine 30 mg otc impotence from alcohol. Visualizing the anatomy of the right flank and cross- indexing each structure with the etiology classification cheap dapoxetine 90 mg without prescription impotence at 37, what would be your list of possible causes at this point? Further history reveals the patient has noted painless hematuria on a couple of occasions but is otherwise asymptomatic cheap 30 mg dapoxetine amex erectile dysfunction medications in india. Physical examination is unremarkable aside from the large nontender mass in the right flank. As is shown in Table 29, however, jumping to that conclusion in any given case may be hazardous. In addition to the kidney (pyelonephritis and perinephric abscess), inflammation of the skin (herpes zoster), the colon (diverticulitis and colitis), the gallbladder (cholecystitis), and the spine (epidural abscess and Pott disease) may also cause flank pain. Neoplasms of the kidney and colon are less likely to produce pain unless they are complicated by infection. However, trauma of the kidney and spine and renal calculi—whether due to hyperparathyroidism, idiopathic etiologies, or hyperuricemia—are important causes. If these are negative, bone scans, arteriogram, and other tests listed below may be 362 required. Protein electrophoresis (multiple myeloma) Case Presentation #29 A 36-year-old black woman complained of severe left flank pain for 3 days. Utilizing the methods discovered above, what would be your list of possibilities at this point? Physical examination is unremarkable except for hyperesthesia and hyperalgesia in the distribution of T12 dermatome on the left. Retina: Conditions of the retina to be considered in this symptom are exudative choroiditis, retinal detachment, venous thrombosis, and embolism. Optic cortex: Transient ischemic attacks in the posterior cerebral circulation and epileptic auras may cause this symptom. Arterial circulation to the eye and brain: Migraine, cerebral thrombosis, and emboli present with this symptom. Approach to the Diagnosis This is similar to the workup of blurred vision (see page 76). The increase of gas in the intestinal tract depends on three physiologic mechanisms: 1. Increased intake of air: This is probably one of the most frequent causes of flatulence and borborygmi. However, compulsive eating, compulsive drinking, excessive smoking, or excessive talking may produce the same effect. When we overeat, however, or when we drink too much, the amount of gas taken in may exceed our ability to absorb it. Salesmen and public speakers have an additional problem because talking increases salivation and swallowing, and frequently air is swallowed between sentences. Some people have a particular beverage they are fond of, such as cola, coffee, or alcohol. In addition, some of these beverages release gas after ingestion (carbonated beverages especially), which causes flatulence. Increased production of gas in the intestinal tract: In acute bacterial gastroenteritis (e. The diarrhea or vomiting associated with these disorders usually makes 364 the diagnosis easy. A more obscure cause of increased production of gas is chronic mild intestinal obstruction leading to excessive bacterial overgrowth. Adhesions, intestinal polyps, regional ileitis, and the various causes of paralytic ileus (e. Gas production is also increased when bacteria are allowed to accumulate in large numbers in chronic intestinal disorders. The blind loop syndrome, diverticulitis, and Meckel diverticulum fall into this category. Some types of irritation in the intestinal tract cause a mild paralytic ileus and allow bacteria to multiply and ferment: Esophagitis and hiatal hernia, chronic gastritis, ulcers, regional ileitis, and ulcerative and mucous colitis may cause mild paralytic ileus on this basis. When the amount of digestive juices is insufficient to digest food, more food is available for bacterial fermentation. Thus, in chronic atrophic gastritis, the reduced level of hydrochloric acid leaves undigested food for bacterial action. In cholecystitis and partial bile duct obstruction or liver disease, there are insufficient bile acids for digestion and more food is left for bacterial fermentation. In chronic pancreatitis, the reduction in pancreatic enzymes causes the same problem. In celiac disease, the atrophied villi cannot pick up food and gas, and these are passed through the intestines. Intestinal parasites may preempt food from absorption and produce excessive gas in their own digestive processes. Approach to the Diagnosis If excessive food, beverages, or air swallowing from nervous tension or talking can be excluded, reflux esophagitis and diverticulitis must be considered. If these findings are questionable, a more definitive diagnosis may be made with endoscopy. When the outcome is still 365 uncertain, evaluation of the adequacy of the intestinal digestive secretions is worthwhile. Gastric analysis with Histalog and duodenal analysis for bicarbonate, bile, and pancreatic enzymes is done. If the digestive secretions are adequate, a small-bowel biopsy may be necessary to exclude a malabsorption syndrome. Therapeutic trial of proton pump inhibitors (reflux esophagitis) Case Presentation #31 A 46-year-old white woman complained that for the past year she has had increasing episodes of flushing of the face and neck, especially during exercise or stress. What diagnosis should you entertain considering the physiology involved in this symptom? Further history reveals that she has had chronic diarrhea for a couple of years as well. Physical examination revealed telangiectasias of the face and neck and mild hepatomegaly. A flushed face may result from an increased amount of circulating blood (polycythemia) or from any factor that may dilate the blood vessels in the face. Polycythemia may be primary, as in polycythemia vera, or secondary, as in Cushing syndrome, unilateral renal disease, hypernephroma, and pulmonary or cardiovascular disease associated with chronic anoxia. It is less commonly found in the use of belladonna, alkaloids, histamine headaches (usually unilateral), and cirrhosis of the liver, but it is common in chronic skin diseases of the face such as acne rosacea. A flushed face with a heart murmur would suggest mitral stenosis or a right to left shunt with polycythemia.

Fat-suppressed or gadolinium-enhanced sequences may show high signal at the anterior disc vertebral end-plate junctions order dapoxetine 60 mg on line erectile dysfunction treatment by food. Urea and creatinine are also important as hypercalcaemia buy 60 mg dapoxetine amex erectile dysfunction treatment south africa, and acute renal impairment have prognostic significance in this condition buy dapoxetine 90mg on line erectile dysfunction utah. Treatment of low back pain: adults (See also Chapter 21 for greater detail) • An important therapeutic intervention in the case of acute pain is to take the patient seriously purchase dapoxetine 60mg with amex injections for erectile dysfunction treatment, take a positive view, and in the absence of sinister signs, e. Low back pain in children and adolescents Synopsis Children and young people present with a combination of back pain, deformity, limp, systemic or neurological features. Many of the features of adolescents overlap with young adults and the reader is referred to the assessment of adults on pp. Taking a history of low back pain in children • It is important to consider back pain in relation to age and development. Loss of developmental milestones, refusal to walk, or irritability in a non-verbal child, especially if <4y, warrants immediate investigation. Examination of back pain in adolescents • Be opportunistic with a young child, observe play and review findings in context of developmental stage. The femoral head is stabilized in the acetabulum by the acetabular labrum and strong pericapsular ligaments. Anatomy of pelvic musculature • Three groups of muscles move the hip joint: the gluteals, the flexor muscles, and the adductor group. It inserts into the lateral greater trochanter and abducts and internally rotates the hip. It runs anteriorly over the iliac rim, across the pelvis, under the inguinal ligament, and inserts into the lesser trochanter. The iliacus (L2–L4) arises from the ‘inside’ of the iliac blade, passes under the inguinal ligament medially to the lesser trochanter. Retroperitoneal or spinal infections that track along soft tissue planes sometimes involves the psoas sheath and can cause inflammation in the psoas bursa, which separates the muscle from the hip joint. The adductor longus and gracilis are the most superficial; they arise from the pubis and insert into the femoral shaft and pes anserinus (‘goose’s foot’) below the knee, respectively. The adductor magnus (L4/5) is the largest of the deeper adductors; it inserts into the medial femoral shaft. Body weight is transferred onto one leg during this action and, therefore, adductors need to be strong, especially for running. Functional anatomy of the hip • With a flexed knee, the limit of hip flexion is about 135°. Tibial torsion can compensate but this and hip anteversion results in a toe-in gait. Femoral neck retroversion (if the angle is posterior to the femoral intercondylar plane) allows greater external rotation of the hip, usually resulting in a toe-out gait. Neuroanatomy • The femoral nerve is formed from L2–L4 nerve roots and supplies mainly muscles of the quadriceps group and some deeper hip adductors. This is at a foramen formed by the ilium (above and lateral), sacrum (medial), sacrospinous ligament (below), and sacrotuberous ligament (posteromedial). Nerve entrapment and trauma at this site may give rise to piriformis syndrome, and may benefit from physical therapy. Taking a history Age Age is a risk factor for some conditions: • Unless there has been previous hip disease (e. Distribution and type of bone and soft tissue pain • All mechanical lesions of the lumbar spine can result in referred pain around the pelvis and thighs. Tendonitis of the adductor longus, osteitis pubis, a femoral neck stress fracture, osteoid osteoma, or psoas bursitis can give similar symptoms. If the pain appears to be ‘catastrophic’ consider pelvic bone disease (tumours, infection, Paget’s disease, osteomalacia, osteoporotic fracture) (see Chapter 16) or an unstable pelvis (chronic osteitis pubis with diastasis/laxity of the symphysis pubis and sacroiliac joints). It is often sudden or subacute in onset, associated with stiffness, and may give similar symptoms to those caused by sacroiliitis but invariably occurs for the first time in a much older age group. When it does occur, it is unlikely to be confined to pelvic musculature or to be unilateral, but should be considered where acute or subacute onset diffuse pelvic girdle/thigh pain accompanies weakness. Quality and distribution of nerve pain • Nerve root pain is often clearly defined and sharp. It may be burning in quality and is often accompanied by numbness or paraesthesias. L5 or S1 lesions generally cause pain below the knee, but can also cause posterior thigh pain. Symptoms may be referred to this area with L2 or L3 nerve root lesions, since this is where the nerve originates. Always consider lower spinal, muscle, or neurological pathology when assessing weakness and pain around the pelvis. Observation and palpation For observation and palpation, the patient should be supine on a couch: • Look for leg length discrepancy (hip disease, scoliosis) and a leg resting in external rotation (hip fracture). The pubic tubercle is found by palpating slowly and lightly downwards from umbilicus over the bladder until bone is reached. Tests generally help to discriminate articular and extra- articular disease, but not the causes of articular disease: • Measure and determine actual or apparent leg length discrepancy: measure from the anterior superior iliac spine to the medial tibial malleolus; by flexing hips and knees, the site of shortening should become apparent. The patient flexes the hip and knee on one side until normal lumbar lordosis flattens out (confirmed by feeling pressure on your hand placed under their lumbar spine during the manoeuvre). If the other hip flexes simultaneously, it suggests hip extension loss on that side (Thomas’ test). Patients without intra-articular pathology should have a pain-free range of movement. Also, variations in femoral neck anteversion contribute to variations in rotation range. Occasionally, pain at the end of abduction or internal rotation occurs with a bony block (solid ‘end- feel’). In an older patient this might suggest impingement of a marginal joint osteophyte. Flex and adduct the hips exerting an axial force into the posterior ‘acetabulum’ to demonstrate posterior dislocation. The slip (usually inferoposterior) is thought to occur in association with a period of rapid growth. Muscle activation tests Specific muscle activation against resistance can be used to elicit pain, but results need to be interpreted cautiously in the context of known hip disease: • Hip adduction against resistance (sliding their leg inwards towards the other against your hand) reproducing pain is a sensitive test for adductor longus tendonitis, but may be positive in osteitis pubis, hip joint lesions, and other soft tissue lesions in the adductor muscles. Psoas bursitis or infection tracking along the psoas sheath is likely to give intense pain with minimal resistance. Palpate posterolateral structures Ask the patient to lie on their side and palpate the posterolateral structures (Fig. There may be tenderness as a result of soft tissue lesions or trauma causing sciatic nerve entrapment (piriformis syndrome), which can lead to foot drop. It can also be palpated (and the sacrococcygeal joint moved) from a bi-digital examination, though this requires the index finger to be placed inside the rectum, the thumb outside, the two digits then holding the joint.