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Metastatic disease in the internal mammary nodes alone has the same prognostic implication as axillary nodal disease generic 50mcg flonase amex allergy symptoms 6 months. But if both internal mammary and axillary nodes are affected the outlook is poorer generic 50mcg flonase mastercard allergy shots not working. Internal mammary group of lymph nodes in the intercostal spaces along the sides of the sternum 50 mcg flonase sale allergy symptoms on the lips, when involved by metastasis is coded as a distant metastasis (Ml) order 50mcg flonase amex allergy shots dust mites, alongwith other groups e. Cancer cells detach as emboli into the venules and are drifted through the venous blood to the lungs first. If they cross the capillaries of the lungs they reach the left atrium and hence to systemic circulation. Even then bony metastasis is more common as probably lots of emboli pass through the lung capillaries without forming metastasis there. Skeletal metastasis is the commonest blood borne metastasis from carcinoma of the breast. This involvement may occur through the left heart or through vertebral veins which communicate through intercostal veins. This latter path explains early involvement of spine in blood borne metastasis even before the lungs. This is mostly through lymphatic spread which involves the subdiaphragmatic and retroperitoneal lymph plexus from the piexus over the rectus sheath by piercing rectus. Cancer cells thus reach the peritoneum and considerable peritoneal dissemination may occur. Seedlings ma drop on the ovary and form ovarian metastasis which is so popularly known as Krukenberg’s tumour. Retrograde lymphatic spread has also been incriminated as the cause of Krukenberg’s tumour as on section it is found that the medulla of the ovary is first involved in Krukenberg’s tumour. A lump in the breast should always be suspected as a carcinoma unless proved otherwise. Sometimes a bigger mass may give rise to a discomfort which is often referred to by the patient as pain. Only inflammatory carcinoma is painful and in majority of cases it is seen in lactational period. Discharge of varying nature may be complained of in case of other carcinomas occasionally. Such symptoms are -— backache, chest pain, haemoptysis, dyspnoea, jaundice, ascites or enlarged axillary or left supraclavicular lymph nodes. The same type of condition may be seen in case of chronic abscess also, (iv) Oedema of the whole arm is sometimes seen as a complication of breast cancer treatment either after radical axillary dissection or after radiotherapy or after both of these. One must exclude neoplastic infiltration of the axilla which may block lymphatic or venous channels as to cause this condition. This condition is susceptible to bacterial infection following minor trauma and requires vigorous antibiotic treatment. Limb elevation, elastic arms stockings and pneumatic compression devices may be used to manage such late oedema, (v) Red eczematous lesion is apparent in Paget’s disease, (vi) Nipple discharge is usually insignificant in scirrhous carcinoma, but bloody discharge is often found in papillary carcinoma. Fibroadenosis and fibroadenoma are much better palpated with the fingers and the thumb. Fibroadenoma has a very definite margin which is regular and the tumour moves inside the breast so freely that it is called ‘breast mouse’. On the other hand the carcinoma has got irregu­ lar surface, harder in feel and is fixed within the breast substance very early. For this the breast should be steadied with one hand and an attempt to move the swelling is made with the other hand. In late cases the tumour becomes fixed to the overlying skin and/or to the pectoral fascia. In very late cases the growth will fungate through the skin and by that time probably the growth has been fixed to the chest wall. The nodes become enlarged and hard which indicate that carcinoma has involved the axillary nodes. The oppo­ site breast should always be palpated methodically — all the quadrants, nipple and areola to ex­ clude presence of any swelling there. Patient must be asked if she has any complaint like chest pain, dyspnoea, haemoptysis, pain in the spine, pain in the hip, pain in the neck or any swelling anywhere in the body. Ribs, spine, sternum, pelvis, upper ends of the femur and humerus should also be exam­ ined for presence of any metastasis. Vaginal examination is necessary to detect Krunkenberg’s tu­ mour of the ovary or presence of peritoneal metastasis in the pouch of Douglas. Cases are on record when a small tumour is associated with supraclavicular lymph node involvement. Whereas microscopic typing and grading are important to understand the prognosis of a breast cancer, clinical staging is a guide to treatment. Over and above there may be extensive oedema of the skin, satellite skin nodules, clinically supraclavicular node involvement, parasternal metastasis, oedema of the ipsilateral arm and distant metastasis. It is based on Clinical observation related to the tumour (T), regional lymph nodes (N) and distant me­ tastasis (M). Tl : Tumour of 2 cm or less; skin is not involved or involved locally in Paget’s disease. T4 : Tumour of any size with any of the following : Skin infiltration, ulceration, skin oedema, Peau d’ or­ ange, pectoral muscle or chest wall attachment. N1 : Clinically palpable axillary nodes (Nla — metastasis not suspected, Nib — metastasis suspected). N3 : Homolateral supra- or infraclavicular nodes consid­ ered to contain metastasis; oedema of the arm. Its presence M1: Clinical and radiologic evidence of metastasis ex­ is invariably associated with progressive disease. Appearance of septal thickening is similarly of cept those to homolateral axillary or infraclavicular lymph grave prognostic significance. It should be remembered that the tumours do not generally become palpable until they are bigger than 1 cm in diameter. The accuracy of diagnosis of breast cancer on physical examination is only 70% among the most experienced clinicians. Views are taken of each breast from the superior and medial aspects, with the inferior and lateral surfaces of the breast respectively against the cassette. It is particularly useful in high-risk populations (relatives of the patients who suffered from breast cancer), (b) It is particularly useful in older patients with large and fatty breasts where palpation is rather difficult to make the diagnosis. Younger women have dense and active breast stroma which obscures lesions in mammography, (c) Mammog­ raphy is very important in examining the opposite breast in women who have already been treated for breast cancer.

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When the viability of the midgut is doubtful the volvulus is reduced and returned to the abdomen generic 50mcg flonase with mastercard allergy eyes. After 24 to 36 hours a ‘ second look’ has to be made to see the condition of viability ofthe bowel purchase 50 mcg flonase otc allergy medicine cream. Any necrotic bowel should be resected and primary anastomosis should be made to restore continuity order flonase 50mcg otc allergy shots gerd. This condition is usually associated with cystic fibrosis and lack of pancreatic enzymes which leads to viscosity of the meconium order 50 mcg flonase with amex allergy symptoms phlegm. The colon is usually small, beaded and relatively empty containing only dry mucus. Occasionally there may be ascites either due to inflammatory response to the ischaemic over distended small intestine or to meconium spillage from perforation. If distension is absent at birth, it develops rapidly with failure of passage of meconium. Small bubbles of gas are trapped in the inspissated meconium in the terminal ileum and thus produce the characteristic ‘ground glass’ appearance. A Contrast enema preferably with gastrografin will show a microcolon and terminal ileum filled with pellets of meconium. Dilute gastrografin is passed through the colon under fluoroscopic control into the meconium filled ileum. Since gastrografin is hyperosmolar and acts by absorbing fluid from the interstitial fluid into the intestinal lumen maintaining adequate hydration, so that meconium will be soft and will be rejected naturally. The enema may be repeated at 12 hour intervals over several days until all the meconium is evacuated pier rectum. Large volumes of intravenous balanced salt solutions are needed to amend the fluid loss. If this technique fails resection of the distended terminal ileum is performed and the distal bowel is flashed with the N-acetyl cysteine. The proximal segment is anastomosed to the distal segment in end-to-side fashion just within the peritoneum. One should not attempt at ‘milking’ the meconium at the time of operation lest this should damage the bowel. Through the ileostomy wash out of inspissated meconium should be carried out with Gastrografin or Mucomyst. The peritoneum provides a friction-less surface over which the abdominal viscera can freely move, and the mesothelial lining secretes fluid that serves to lubricate the peritonea] surfaces. The peritoneum covers the inner side of the parietes, which is known as parietal peritoneum. Peritoneum also covers the outer surface of the abdominal viscera which is known as visceral peritoneum. Between these two layers lies the potential space, which is known as peritoneal cavity. The quality and quantity of this fluid may change with various pathological conditions. Beneath the peritoneum, supported by a small amount of areolar tissue, lies a network of lymphatic vessels and reach plexus of capillary blood vessels from which absorption and exudation occur. The parietal peritoneum is reinforced by the transversalis (endoabdominal) fascia which lies external to it. The visceral peritoneum is identical with the serosa or capsule of the intra-abdominal organs. It must be remembered that peritoneal cavity is a completely closed sac except the ends of the fallopian tubes in case of females through which it is communicated with the exterior. The lesser sac lies behind the stomach and lesser omentum, whereas the greater sac covers the whole of the abdomen including the pelvic cavity. This absorption occurs primarily through fenestrated lymphatic channels on the undersurface of the diaphragm. There is a tendency that the peritoneal fluid moves upward probably due to decreased intra-abdominal pressure, the upward movement of the diaphragm duing expiration and by capillary attraction. In a few minutes coloured particles which are left in the peritoneal cavity reach the lymph vessels underneath the diaphragm. This upward movement of peritoneal fluids is responsible for the subphrenic collection of many intra-abdominal infections. The surface area of the peritoneum is about 2 m ,2 which is approximately identical to the area of the skin. The peritoneum acts as a semipermealile membrane and permits transport ofwater, electrolytes and peptides in both directions according to theosmotic concentration. Absorption from the peritoneal cavity of particulate matter takes place when the size is less then 10 (im. Such particulate matters may include bacteria, formed blood elements, proteins etc. These lymphatic channels are also responsible for the appearance of the so-called sympathetic pleural effusions whenever transabdominal inflammatory process takes place as invariably subdiaphragmatic lymphatic plexus is involved early. The bi-directional transfer property of the peritoneum is used in peritoneal dialysis. By adjusting the composition of the dialysate, excess water, sodium, potassium and products of metabolism can be removed from the blood stream. The majority of cells involved in healing of the peritoneal wound are derived by differentiation of stem cells present within the subperitoneal tissues in the surrounding area. The adhesions may be transient, eventually resolving as delyed healing becomes complete or they may be permanent in nature. Fibrins elaborated from the inflamed peritoneal mesothelium are the scaffold upon which adhesions are built. Formation of adhesions is a protective response helping to localise the peritonea] insult and is also an adaptive healing response which helps to bring additional blood supply to the ischaemic injured areas of the peritoneum. The anterior parietal peritoneum is most sensitive, while the pelvic peritoneum is the least sensitive. Local injury or inflammation of parietal peritoneum leads to protective voluntary muscular guarding and later on to reflex muscular spasm, the signs which are indicative of such insult. In contrast to the parietal peritoneum, the visceral peritoneum receives afferent innervation only from the autonomic nervous system and hence is insensitive. However visceral afferent nerves respond well to traction or distension and less to pressure, but no receptors for pain or temperature. Peritonitis may be either septic or aseptic, bacterial or viral, primary or secondary, acute or chronic. Most surgical peritonitis is secondary to bacterial contamination from the gastrointestinal tract.

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Some surgeons try to form a jejunal pouch to be attached to the oesophagus buy 50 mcg flonase visa milk allergy symptoms 6 month old, but its acceptance has not been great as there is little functional advantage flonase 50mcg lowest price allergy forecast in nyc. Nutritional deficiencies may occur flonase 50 mcg online allergy forecast nc, particularly vitamin B12 deficiency due to loss of the parietal mass and routine replacement is required generic flonase 50 mcg without a prescription allergy forecast api. If the surgery is performed early with proper clearance of lymph nodes, the result is quite encouraging. Yet, chemotherapy so far could not attain the overall popularity due to morbidity associated with this regime. The perito­ neal lymphatics take up this chemotherapy and probably yield better result. Leiomyosarcoma — It usually arises as malignant change of leiomyoma, which is the second benign tumour of the stomach. Metastasis is quite late, and if detected it is usually the liver which is involved. The treatment is again partial gastrectomy and the result is much better than carcinoma (about 50% survive more than 5 years after operation). Simultaneously fluid balance should be maintained by intravenous infusion of dextrose saline and normal saline. In very occasional cases massive haemorrhage or rupture of the stomach may occur requiring immediate operative repair. The mortality Figures have remained constant at 10% or more despite advances in methods of diagnosis and treatment. Bv convention, when the source ofbleeding lies above the duodenojejunal flexure it is referred to as upper G. This may cause mild, moderate or even massive bleeding contributing about 5 to 15% of upper G. Haemorrhage usually occurs from ulcers situated in the posterior wall of the first part of the duodenum. Mostly the ulcers in the lesser curv ature and posterior wall of the stomach bleed. Patients often over-estimate the amount lost and the stated volume of haematemesis may be misleading unless the blood is collected and measured objectvely. The initial haemoglobin value after an acute bleeding is unhelpful because it is many hours before dilution occurs and the haemoglobin drops to a representative level. However, when bleeding has occurred over a prolonged period, the haemoglobin value may be a more accurate reflection. If one gets low haemoglobin level immediately after an acute bleeding, this probably means that there has been chronic occult loss previously. Probably the degree of shock is some indication with the thready pulse and low blood pressure. Again when the patient is at rest in bed his pulse rate and blood pressure may be reasonably normal despite a fairly large bleeding. Assessment of the cause — A careful history is highly important to assess the probable cause of bleeding. A history of long standing heavy alcohol intake may point towards hepatic cirrhosis and a possible variceal bleeding. Dysphagia or discomfort on swallowing suggests either a benign or malignant oesophageal lesion or a hiatus hemia with oesophagitis. A Mallory-Weiss tear presents classically as a small haematemesis following an episode of prolonged vomiting, frequently caused by alcoholic gastritis. However in many instances of the Mallory-Weiss lesion haematemesis may occur with the first vomit and not following prolonged vomiting and retching. A previous history of peptic ulcer is also suggestive of bleeding from chronic peptic ulcer. On examination, epigastric tenderness on palpation will suggest chronic peptic ulceration as a probable cause of bleeding. It must be cautioned that bleeding may occur from other site despite a pathology detected on clinical examination. As for example a tenderness in the duodenal point may suggest chronic duodenal ulcer but probably bleeding is coming from a Mallory-Weiss tear or even oesophageal varix. A careful assessment of the history and a physical examination may yield no definite cause in above 50% of patients with upper G. But it must be remembered that emergency endoscopy in a bleeding patient is more difficult than routine endoscopy. A little preparation is always required before endoscopy apart from starving the patient for at least 4 hours. The necessity for preliminary gastric lavage is debatable and has one major disadvantage in that the mucosa of the stomach may be damaged. It probably helps to empty the stomach of blood and certainly does lead to sufficient peristalsis to interfere with the examination. It is also sensible to render the gastric contents alkaline with cimetidine before the examination, although the value of this drug is still to be proved. Treatment with cimetidine may however help prevent bleeding from chronic peptic ulcers. Sedation is difficult since excessive drowsiness increases the risk of inhalation. Some endoscopists therefore never use any sedation, but this often leads to a difficult examination. But endoscopy should better be performed under sedation with intravenous diazepam, which should be administered slowly in anaemic and shocked patients and dose should better not to exceed 5 mg. If necessary, the gastroscope can be withdrawn into the oesophagus (to stop the tip becoming obscured by blood) and the patient is rolled on to his right side so that the blood clot moves to the antrum, the fundus can then be seen. If no bleeding point can be found out with a forward-viewing endoscope, the second and third parts of the duodenum and ampulla should be examined using a side-viewing instrument if necessary Contraindications to endoscopy. Endoscopy is a good vagal stimulus and can precipitate heart block in these patients. So ideally endoscopy should be performed on all patients between 12 to 48 hours after admission. It should always be performed by experienced endoscopist in the endoscopy room preferably in the operation theatre. Occasionally indirect pointers to the source of bleeding may be revealed, for example an enlarged spleen in portal hypertension, a soft tissue mass in an intussusception, a gastric carcinoma calcification or metastasis on the chest radiography. The source of active bleeding may remain undetected by barium studies in 50% of patients or even more. Nevertheless, if endoscopy has proved impossible barium studies are worth attempting. The accuracy of a barium meal in detecting lesions such as erosions, small ulcers or early tumour is greatly increased by the use of the double-contrast technique.

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In females the diagnosis is often not made unless it presents as Cushing’s syndrome buy discount flonase 50mcg line food allergy testing new zealand. There is marked increase in urinary oestrogen generic flonase 50mcg allergy blood test results, 17-hydroxycorticosteroids and 17-ketosteroids buy generic flonase 50mcg on line allergy symptoms natural remedies. Oestrogen secreting tumours in men are often malignant and radical resection with lymphadenectomy should be the treatment of choice as this tumour is relatively insensitive to irradiation and chemotherapy generic flonase 50mcg amex allergy treatment delhi. This condition is due to progressive destruction of the three zones of the adrenal cortex and medulla with lymphocytic infiltration. Though the cause is still not very clear, yet autoimmune disease is held responsible for 60% of cases. Other autoimmune diseases such as thyroiditis (Hashimoto’s disease), pernicious anaemia, hypoparathyroidism and gonadal failure are seen associated with this condition. Hyperpigmentation is the form of irregular dusky pigmentation of the skin due to deposits of melanin are noted in approximately 90% of cases. It occurs mostly on the extensor surfaces, on the palmar creases and on the buccal mucosa. Patients are usually hypotensive with low sodium level and elevated potassium level. When the condition goes to chronic stage, it requires administration of corticosteroids in the form of cortisone acetate 25 mg in the morning and 12. Most cases occur in infants, though adults are also involved particularly in bums. Profound vascular collapse resulting from endotoxaemia and acute corticosteroid deficiency is very lethal. Petechial haemorrhages in the skin which coalesce to form purpuric rashes may be seen. Bilateral tenderness 2 inches (5 cm) below the costal margin with clear urine and absence of any sign in the lungs is confirmatory of this condition. The petechial spot in the skin may be punctured and the smear should be examined for diplococcus. Hydrocortisone sodium succinate should be administered intravenously, or intramuscularly if the veins are not available, in the dose of 100 mg every 8 hours. Mainly 3 catecholamines are found in adrenergically innervated human tissues—dopamine, norepinephrine and epinephrine. These catecholamines are synthesised in the brain, the nerve endings of sympathetic neurones, chromaffin cells of the adrenal medulla and certain other extra­ adrenal neural crest tissues. Dopa is decarboxylated to L-dihydroxy phenylethylamine (Dopamine) by aromatic L-aminoacid decarboxylase. Epinephrine accounts for 80% of total catecholamines in the human adrenal medulla, norepinephrine accounts for approximately 20% and dopamine represents a very small fraction. There are cytoplasmic granules which are storage vesicles for dopamine, epinephrine and norepinephrine in the cells of adrenal medulla and sympathetic nerve endings. Excitation of these cells stimulates expulsion of the granular contents into the extracellular fluid and circulation. These are available in the urine and can be measured for diagnostic purpose in pheochromocytoma. The term is derived from the Greek word Phaios which means dark and chroma means dusky as this tumour stains deep brownish colour when exposed to chromium salts. This tumour is derived from primitive cells originating in the neural crest, which can differentiate to form pheochromocytes. This tumour has a tendency to produce large amount of catecholamines, primarily norepinephrine. When treated with solution of chrome salts, this tumour turns dark brown to almost black. The cells are large polyhedral or irregular pheochromocytes, many of which show pleomorphism. The tissues are traversed by thin walled vessels, the walls of which are lined by the cells of the tumour. This tumour presents a clinical picture in a bizarre fashion which is often referred to as adrenal-sympathetic syndrome. The most constant feature of this syndrome is paroxysmal or persistent arterial hypertension. Occasionally pheochromocytoma may present in a relatively asymptomatic patient as only diastolic hypertension detected during routine evaluation. The signs and symptoms of pheochromocytomas are due to increased secretion of epinephrine and norepinephrine. The secretion may be constant or intermittent accounting for persistent or paroxysmal nature of the symptoms. Usually patients with paroxysmal hypertension are more symptomatic than those with sustained hypertension. In small doses norepinephrine stimulates arteriolar tone and causes increased vascular resistance and diastolic pressure. When the secretion is mainly epinephrine, the effects include sweating, tachycardia and hyperglycaemia. Measurement of plasma epinephrine and norepinephrine is generally not useful, though particularly with paroxysmal hypertension these levels may be raised. Provocative test by intravenous administration of histamine, a drug that provokes secretion of catecholamines into the circulation of patients with pheochromocytoma, thereby evokes a hypertensive episode. Unfortunately false-negative and false-positive reactions occur with these tests in approximately 20% of cases. Conventional urography may show downward displacement of the kidney if a large adrenal mass is present. This technique offers great promise in the identification of both primary and metastatic adrenal lesions. The place of medical treatment is restricted to (i) in preoperative preparation, (ii) for patients who refuse surgery and (iii) for patients who have functioning metastases. Oral administration of phentolamine (Regitine) may be used to control symptoms in the dose of 25 mg every 3 hours. Intravenous phentolamine has been proposed for difficult cases to control hypertension. More recently phenoxybenzamin (Dibenzyline), an a- adrenergic receptor blocking agent has been used to achieve reduction of chronic blood pressure in patients with pheochromocytoma with good result, a-methyl dopa is also been used with some success. The dose used in these cases is about 60 mg per day by mouth in 3 or 4 divided doses. This approach is probably good considering that pheochromocytomas may be bilateral and may occur in extra-adrenal sites.

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