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The pellets smoke blackening anxiety girl t shirt quality prozac 40mg, no tattooing are found en mass with wad and cardboards bipolar depression meds purchase generic prozac line. The pellets spread widely and enter the body hyperaemia or even blister from ame exited from muz as individual missile producing separate injury and will A zle end depression test kind cheap 20 mg prozac free shipping. This is because of welding of pellets amongst circumstances depression icd 9 purchase generic prozac line, exit wound may be present themselves and called as balling effect depression symptoms test online purchase prozac 20 mg mastercard. Detection of Firearm Residue Tests done to detect rearm residue are mentioned in Table 10 depression numbness order prozac australia. This type of injury occurs when people y through Test Used for detection of the air and strike other objects. Atomic absorption Lead spectrophotometer Autopsy Findings on the head happens to be intra-oral followed by under the chin, side of head and forehead. As a result, a primary blast injury almost always affects air-lled structures such as the lungs, ear, and gastrointestinal tract. A tympanic membrane injury with hemorrhage in the middle ear is common ndings 13 in survived victims. Muller D, Levy A, Vinokurow A, Ravreby M, Shelef R, Wolf with injury triad of bruising, abrasions and lacerations. A new type of shotgun ammunition Test Sam ples produces unique wound characteristics. In Urine A Short Textbook of Forensic medicine and Toxicology, 1st Liver reprint edn. Determination Jewelry of lead in forensic samples by atomic absorption spectropho Pocket contents tometer. Special considerations in post Glass or other foreign material A mortem examination of an explosion. Scalp is composed Severe head > 6 hours 8 or less of: injury 220 Principles of Forensic Medicine and Toxicology Contusion of Scalp 7. Tympanic membrane may be ruptured due to hard and blunt impact and causes deafness. It usually suggests External ear may sustain following sort of injuries fracture of base of skull. Due to con Forensic Anatomy of Skull tinued force, the area under the point of impact tries to bend inward. Thus, it can be considered as brain 3, 4 focal impact, the skull undergoes compensatory mecha pan excluding the bones of face. The outer table is twice in thickness that of inner elasticity of skull, both the intruded. Direct Force Fracture planes, if the bones are stretched beyond the limits of skull elasticity (. Fracture due to local deformation pressed between two external objects say for example 2. Fracture due to general deformation 5, 6 between wood plank and wall or between wood log A) Fracture due to local deformation 11. Secondary cessive impacts and meet each other, the later fracture (second fracture in. Force applied to chin: Blow on chin may cause frac With severe local force application say for example ture of glenoid fossa. Force applied below the man hammer; the fracture bone is driven inward into cranial dible may be transmitted through the maxilla to the cavity. Thus also called as signature fracture or fracture base of skull and fracture the cribriform plate. Comminuted [Mosaic (spider web)] Regional Injuries 223 Comminuted Fracture 11. The depression of bone is comparable with distortion produced by squeezing a table-tennis ball or ping-pong ball. If involved both tables, it will cause clean-cut gap corre sponding with the thickness of blade. Fracture of anterior cranial fossa may involve frontal, ethmoidal or sphenoidal air sinuses 4. The cerebral veins cross this 9 occurs due to rupture of: space to reach the sinuses. Subarachnoid space contains blood vessels that enter usually due to trauma and exit the brain and cranial nerves. Gliding type movement between dura and skull causes tearing of one or several bridging veins causing sub dural hemorrhage (. The onset of contu sion indicates pressure on brain and the brain is being Acute Subdural Hematoma 11. The pressure may displace the struc tures around the third ventricle and brainstem. Death may occur as a result of compression of brainstem and downward displacement of cerebellar tonsils. Recent lesions (up to weeks) are red-brown with a gelatinous membrane covering the surface 11. Causes: It may be due to trauma or due to pathological cause Intracerebral Hemorrhage A) Trauma B) Non-traumatic causes (pathological causes) Here the hemorrhage occurs in the cerebral tissue. Retrograde ow of subarachnoid hemorrhage into called as parenchymatous hemorrhage. Blunt trauma with or without fracture nicating artery and bleeding into anterior portion of temporal horn of lateral ventricle. Infection bone piece may penetrate the dura and enter the cranial cavity thus causing injury to brain by bone fragment as 6. Compression of the constituent units while being forced together Cerebral Concussion 2. Sliding or shear strains which moves adjacent strata of Also called as commotio cerebri or stunning brain shock. In either, acceleration or deceleration, the initial sudden velocity applied to the scalp and skull is then transmitted to the brain. Thus these linear forces tend to produce compressional or rarefactional forces, but these forces do not cause damage to brain since the brain can be distorted but cannot be compressed. The rotational and linear forces cause gliding or shear strain in brain and move adjacent strata of tissue laterally (like playing cards slide one another). At low levels of acceleration/deceleration, anatomic changes of neurons do not occur but physiologic func tions are affected. If unconsciousness persist for hours to days, then there is likely to be structural damage. Vasogenic cerebral edema ratory paralysis with no signicant lesion demonstrated 2. The Autopsy Findings extravasated uid accumulates in extravascular space of At autopsy no visible structural damages are noted in brain.

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Neuroblastoma this is one of the most common tumors of infancy and is found in about 1 per 20 000 births severe depression jesus generic prozac 60 mg mastercard. Usually depression jury duty generic 20 mg prozac with mastercard, the lesion is isolated mood disorder jesse buy genuine prozac line, but occasional metastasis before birth may occur depression symptoms test uk buy 10 mg prozac visa. Sonographically anxiety 9 dpo buy prozac 60 mg on line, the tumor appears as a cystic mood disorder nos 504 plan order 20 mg prozac, solid, or complex mass in the region of the adrenal gland (directly above the level of the kidney and under the diaphragm). The prognosis is excellent if the diagnosis is made in utero or in the first year of life (survival more than 90%), but, for those diagnosed after the first year, survival is less than 20%. Most teratomas are extremely vascular, which is easily shown using color Doppler ultrasound. Prognosis Sacrococcygeal teratoma is associated with a high perinatal mortality (about 50%), mainly due to the preterm delivery (the consequence of polyhydramnios) of a hydropic infant requiring major neonatal surgery. Etiology Hydrops is a non-specific finding in a wide variety of fetal and maternal disorders, including hematological, chromosomal, cardiovascular, renal, pulmonary, gastrointestinal, hepatic and metabolic abnormalities, congenital infection, neoplasms and malformations of the placenta or umbilical cord. With the widespread introduction of immunoprophylaxis and the successfull treatment of Rhesus disease by fetal blood transfusions, non immune causes have become responsible for at least 75% of the cases, and make a greater contribution to perinatal mortality. Prognosis Although isolated ascites, both in fetuses and neonates, may be transitory, the spontaneous resolution of hydrops has not been reported and the overall mortality for this condition is about 80%. Ultrasound Diagnosis Figure 1 longitudinal view, abdnormal accumulation of Figure 2 longitudinal view, abdnormal accumulation of serous fluid at the body cavities (pericardial, pleural, or serous fluid at the body cavities (pericardial, pleural, or ascitic effusions). Figure 3 transverse view, at the stomach and bowellevel, Figure 4 transverse view, at the stomach level, with with abdnormal accumulation of serous fluid at the abdome abdnormal accumulation of serous fluid at the abdome or or ascitic effusion. About 80% of such fetuses are constitutionally small, with no increased perinatal death or morbidity, 15% are growth restricted due to reduced placental perfusion and "utero-placental insufficiency", and 5% are growth restricted due to low growth potential, the result of genetic disease or enviromental damage. Accurate measurements of the head and abdominal circumference, femur length and transverse cerebellar diameter should be taken and their various ratios should be examined. A repeat ultrasound examination in two weeks will demonstrate an increase in fetal measurements and the rate of growth is normal (the lines joining the measurements are parallel to the appropriate normal mean for gestation). In starving small fetuses, the fetal measurements demonstrate asymmetry (the greatest deficit is observed in the abdominal circumference, then the femur length and finally the head circumference with the transverse cerebellar diameter being the least affected), there are no obvious fetal anatomical defects, the amniotic fluid and fetal movements are reduced, the placenta is often thickened with translucent areas (placental lakes) and there are abnormal Doppler waveforms in the uterine and / or umbilical arteries. Doppler ultrasound Doppler ultrasound provides a non-invasive method for the study of fetal haemodynamics. Decrease in impedance to flow in the middle cerebral arteries Redistribution of blood flow Descending Aorta and Renal Artery Descending Thoracic Aorta descrease the diastolic flow increase of the impedance Renal artery end diastolic flow increase of the impedance Severe fetal hypoxemia there is decompenation in the cardiovascular system and right heart failure Peripheral vasoconstriction, as seen in fetal redistribution, causes an increase in ventricular afterload and thus ventricular end diastolic pressure increases. In constitutionally small fetuses Doppler studies of the placental and fetal circulations are normal. Similarly in growth restricted fetuses due to genetic disease the results are often normal. These data support the findings from histopathologic studies that in this condition there is failure of the normal development of maternal placental arteries into low resistance vessels (and therefore reduced oxygen and nutrient supply to the intervillous space), and reduction in the number of placental terminal capillaries and small muscular arteries in the tertiary stem villi (and therefore impaired maternal-fetal transfer). These findings suggest that in fetal hypoxemia there is an increase in the blood supply to the brain and reduction in the perfusion of the kidneys, gastro intestinal tract and the lower extremities. Although knowledge of the factors governing circulatory readjustments and their mechanism of action is incomplete, it appears that partial pressures of oxygen and carbon dioxide play a role, presumably through their action on chemoreceptors. This is manifested by the absence or reversal of forward flow during atrial contraction in the ductus venosus and this is a sign of impending fetal death. Chromosomal defects Although low birth weight is a common feature of many chromosomal abnormalities, the incidence of chromosomal defects in small for gestational age neonates is less than 1-2%. However, data derived from postnatal studies underestimate the association between chromosomal abnormalitites and growth retardation, since many pregnancies with chromosomally abnormal fetuses result in intrauterine death. Thus in fetuses presenting with growth retardation in the second trimester the incidence of chromosomal abnormalities is 10-20%. Ultrasonographically, the diagnosis of polyhydramnios or oligohydramnios is made when there is excessive or virtual absence of echo-free spaces around the fetus. Quantitative criteria include: (a) the largest single pocket of amniotic fluid being 1 cm or less, or (b) amniotic fluid index (the sum of the vertical measurements of the largest pockets of amniotic fluid in the four quadrants of the uterus) of less than 5 cm. Nevertheless, the detection of a dilated blader in urethral obstruction and enlarged echogenic or multicystic kidneys in renal disease should be relatively easy. Furthermore, in uteroplacental insufficiency, Doppler blood flow studies will often demomstrate high impedance to flow in the placental circulation and redistribution in the fetal circulation. In the remaining cases, intra-amniotic instillation of normal saline may help improve ultrasonographic examination and lead to the diagnosis of fetal abnormalities like renal agenesis. Prognosis Bilateral renal agenesis, multicystic or polycystic kidneys are lethal abnormalities, usually in the neonatal period due to pulmonary hypoplasia. Quantitatively, polyhydramnios is defined as an amniotic fluid index (the sum of the vertical measurements of the largest pockets of amniotic fluid in the four quadrants of the uterus) of 20 cm or more. In most cases polyhydramnios develops late in the second or in the third trimester of pregnancy. Acute polyhydramnios at 18-23 weeks is mainly seen in association with twin-to-twin transfusion syndrome. Treatment will obviously depend on the diagnosis, and will include better glycemic control of maternal diabetes mellitus, antiarrhythmic medication for fetal hydrops due to dysrrhythmias, thoracoamniotic shunting for fetal pulmonary cysts or pleural effusions. For those measurements where the standard deviation increased or decreased with gestation, logarithmic or square root transformation was applied to stabilize variance. If the quadratic or cubic terms did not improve the original linear model (an independent correlation with p < 0. Withhold for moderate and progressed following treatment with a fuoropyrimidine, oxaliplatin, and irinotecan, as permanently discontinue for severe or life-threatening adrenal insuffciency. Continued approval for this indication may be contingent for new-onset moderate to severe neurological signs or symptoms and permanently upon verifcation and description of clinical beneft in confrmatory trials. This indication is approved under accelerated approval based on involvement of lymph nodes or metastatic disease who have undergone complete overall response rate and duration of response [see Clinical Studies (14. Continued approval for this indication may be contingent upon verifcation and description of clinical beneft in Unresectable or confrmatory trials. Adjuvant treatment of or recurrence or this indication is approved under accelerated approval based on overall response rate melanoma unacceptable toxicity 480 mg every 4 weeks for up to 1 year [see Clinical Studies (14. Continued approval for this indication may be contingent (30-minute intravenous infusion) upon verifcation and description of clinical beneft in confrmatory trials. Continued approval for this weighing less than 40 kg: indication may be contingent upon verifcation and description of clinical beneft in confrmatory trials. This indication is approved under accelerated approval based on overall response rate and duration of response [see Clinical Studies (14. Review the Prescribing Information for ipilimumab for recommended (30-minute intravenous infusion) ipilimumab for a maximum dose modifcations. Permanently discontinue adverse reaction Monitor patients for signs with radiographic imaging and for symptoms of pneumonitis. Other Grade 3 myocarditis Permanently discontinue Administer corticosteroids at a dose of 1 to 2 mg/kg/day prednisone equivalents for moderate (Grade 2) or more severe (Grade 3-4) pneumonitis, followed by corticosteroid Requirement for 10 mg per day or taper. Immune-mediated a Resume treatment when adverse reaction improves to Grade 0 or 1. Complete resolution of symptoms following corticosteroid taper occurred in 67% of patients. Discard if cloudy, discolored, or contains extraneous particulate matter other than a few translucent-to-white, proteinaceous particles. Administration Approximately 8% required addition of infiximab to high-dose corticosteroids. Two patients required the addition of corticosteroid-refractory immune-mediated colitis. In cases of corticosteroid-refractory mycophenolic acid to high-dose corticosteroids. Complete resolution occurred in 74% colitis, consider repeating infectious workup to exclude alternative etiologies. Approximately 91% of patients with withheld for hepatitis, 13 reinitiated treatment after symptom improvement; of these, colitis received high-dose corticosteroids (at least 40 mg prednisone equivalents per day) 8% (1/13) had recurrence of hepatitis. All patients with hepatitis required systemic corticosteroids, 3 mg/kg every 3 weeks, including three fatal cases. Median time to onset was including 94% who received high-dose corticosteroids (at least 40 mg prednisone 1. Approximately 19% of patients with immune-mediated hepatitis required addition of mycophenolic acid to high-dose corticosteroids. All patients with colitis required systemic corticosteroids, including 92% who received high-dose corticosteroids (at least 40 mg prednisone equivalents 5. All patients with colitis required systemic corticosteroids, including 80% who hypophysitis received hormone replacement therapy and 33% received high-dose received high-dose corticosteroids (at least 40 mg prednisone equivalents per day) for a corticosteroids (at least 40 mg prednisone equivalents per day) for a median duration of median duration of 21 days (range: 1 day to 27 months). Twenty-three patients received high-dose corticosteroids (at least 40 mg prednisone equivalents for moderate (Grade 2) transaminase elevations. Approximately 40 mg prednisone equivalents per day) for a median duration of 23 days (5 to 29 days). Ten patients received high-dose corticosteroids (at least 40 mg prednisone equivalents per day) for a median duration of 8. Monitor thyroid function prior to and Monitor patients for elevated serum creatinine prior to and periodically during treatment. Immune-mediated (at least 40 mg prednisone equivalents per day) for a median duration of 27 days nephritis and renal dysfunction led to permanent discontinuation or withholding of (19 days to 1. For any suspected immune-mediated adverse reactions, exclude assessment and treatment. Based on the severity of the adverse reaction, permanently discontinue [see Dosage and Administration (2. Upon improvement to Grade 1 or less, initiate For immune-mediated rash, administer corticosteroids at a dose of 1 to 2 mg/kg/day corticosteroid taper and continue to taper over at least 1 month. Approximately 16% of patients with syndrome, hypopituitarism, systemic inflammatory response syndrome, gastritis, rash received high-dose corticosteroids (at least 40 mg prednisone equivalents per day) duodenitis, sarcoidosis, histiocytic necrotizing lymphadenitis (Kikuchi lymphadenitis), for a median duration of 12 days (range: 1 day to 8. In animal reproduction studies, discontinued for adverse reactions in 9% of patients. Grade 3 and 4 adverse through delivery resulted in increased abortion and premature infant death. There were more patients in the 194 to 197 patients) and dacarbazine group (range: 186 to 193 patients). Grade 3 and 4 adverse reactions occurred in previously untreated, unresectable or metastatic melanoma [see Clinical Studies (14. The most common adverse reactions (reported in 20% of patients and at a higher incidence than in the dacarbazine arm) were fatigue, musculoskeletal pain, rash, Patients were randomized to receive: and pruritus. Skin and Subcutaneous Tissue c Serious adverse reactions (74% and 44%), adverse reactions leading to permanent Rash 28 1. Includes back pain, bone pain, musculoskeletal chest pain, musculoskeletal discomfort, myalgia, neck pain, pain in extremity, pain in jaw, and spinal pain. The most common (20%) adverse reactions d Includes rhinitis, viral rhinitis, pharyngitis, and nasopharyngitis. Respiratory, Thoracic and Mediastinal Adjuvant Treatment of Melanoma Cough/productive cough 27 0. The most common b Includes pustular rash, dermatitis, acneiform dermatitis, allergic dermatitis, atopic adverse reactions (at least 20%) were fatigue, diarrhea, rash, musculoskeletal pain, dermatitis, bullous dermatitis, exfoliative dermatitis, psoriasiform dermatitis, drug eruption, pruritus, headache, nausea, upper respiratory infection, and abdominal pain. The most exfoliative rash, erythematous rash, generalized rash, macular rash, maculopapular rash, common immune-mediated adverse reactions were rash (16%), diarrhea/colitis (6%), morbilliform rash, papular rash, papulosquamous rash, and pruritic rash. Tables 10 and 11 summarize the adverse reactions and laboratory abnormalities, d Includes upper respiratory tract infection, nasopharyngitis, pharyngitis, and rhinitis. The trial excluded patients with General untreated brain metastases, carcinomatous meningitis, active autoimmune disease, or a medical conditions requiring systemic immunosuppression. The population characteristics were: median age Constipation 10 0 9 0 64 years (range: 26 to 87); 48% were 65 years of age, 76% White, and 67% male. The most common (20%) adverse Infections reactions were fatigue, rash, decreased appetite, musculoskeletal pain, diarrhea/colitis, Upper respiratory tract 22 0 15 0. The most frequent c Includes autoimmune dermatitis, dermatitis, dermatitis acneiform, dermatitis allergic, (>2%) serious adverse reactions were pneumonia, diarrhea, febrile neutropenia, anemia, dermatitis atopic, dermatitis bullous, dermatitis contact, dermatitis exfoliative, dermatitis acute kidney injury, musculoskeletal pain, dyspnea, pneumonitis, and respiratory failure. The most common f Includes colitis, colitis microscopic, colitis ulcerative, diarrhea, enteritis infectious, (>20%) adverse reactions were fatigue, musculoskeletal pain, nausea, diarrhea, rash, enterocolitis, enterocolitis infectious, and enterocolitis viral. Chemotherapy Chemotherapy k Includes autoimmune thyroiditis, blood thyroid stimulating hormone increased, Adverse Reaction (n=358) (n=349) hypothyroidism, primary hypothyroidism, thyroiditis, and tri-iodothyronine free decreased. All Grades Grades 3-4 All Grades Grades 3-4 l Contains blood thyroid stimulating hormone decreased, hyperthyroidism, and (%) (%) (%) (%) tri-iodothyronine free increased. Across both trials, the most common adverse pain, and gastrointestinal pain reactions (20%) were fatigue, musculoskeletal pain, cough, dyspnea, and e Includes acne, dermatitis, acneiform dermatitis, allergic dermatitis, atopic dermatitis, decreased appetite. These trials excluded patients with active autoimmune disease, medical conditions requiring systemic immunosuppression, or with symptomatic interstitial lung disease. The most common (20%) adverse reactions were fatigue, decreased appetite, musculoskeletal pain, dyspnea, nausea, a Includes fatigue and asthenia. The most frequent (2%) serious adverse reactions were pneumonia, pyrexia, diarrhea, pneumonitis, pleural effusion, dyspnea, acute kidney injury, pain, lower abdominal pain, and upper abdominal pain. Anemia 39 8 69 16 Chemistry Rate of death on treatment or within 30 days of the last dose was 4. The most common adverse reactions (20%) were fatigue, cough, nausea, rash, dyspnea, diarrhea, Hypocalcemia 23 0.

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An associated frail chest leads to paradoxical breathing and may require assisted ventilation depression tattoos prozac 20mg visa. Causes include trauma depression definition finance order genuine prozac online, post surgical bleeding klinische depression test discount prozac 20mg with visa, and tumours of the chest cavity and chest wall mood disorder following cerebrovascular accident order 40 mg prozac overnight delivery. Clinical Features Depending on the magnitude of the blood collection depression without meds purchase prozac now, there could be hypovolaemic for massive bleeding anxiety in spanish discount prozac 20 mg with amex, or symptoms similar to those associated with pneumo thorax, except for the percussion note, which is dull for haemothorax. However, haemopneumothorax is the more common presentation following chest trauma. Erect posteroanterior view and lateral Look for fractured ribs, collapsed lung(s), fluid collection in the pleural space (air fluid level), position of mediasternum, and diaphragm. Management Resuscitation if needed Small haemothorax (blunting of the costophrenic angle), will resolve spontaneously. For large clotted haemothorax, perform thoracotomy to drain clot or refer to a more specialized unit. Patients with maxillofacial injury require immediate referral to higher levels for appropriate management. Category Specific function Score l Eye opening (E) Spontaneous 4 To voice 3 To pain 2 Nil 1 2 Best verbal response (V) Oriented, converses 5 Converses but confused 4 Inappropriate words 3 Incomprehensible words 2 Nil 1 3 Best motor response (M) Obeys 5 Localizes pain 4 Flexion withdrawal 3 Flexion abnormal 3 Extension 2 Nil 1 Glasgow Coma Score Score = E + M + V (the higher the score the better the prognosis). Resuscitation Arrange transport with adequate resuscitation equipment if at level 4. Secondary Survey At levels 5 and 6, management should be as above plus secondary survey to detail all injuries and to do specific investigations. Thorough debridement of necrotic tissues and surgical toilet; all vital structures that are injured such as the parotid duct, facial nerve, and naso lacrimal duct should be repaired. Primary closure if there is adequate tissue for approximation; plan for wound cover with skin graft or flaps if there is tissue loss. The nose, zygoma, and mandible are the most prone to injury, with maxillary bone injuries being relatively less common and more complicated. Check for missing teeth/fragments/fillings to rule out inhalation (take chest x ray, abdominal x-ray). For alveolar fractures, reduce and splint with composite resin, dental wires (figure of 8), arch bar, or acrylic resin splints. They may also be displaced or undisplaced, depending on the pull of the muscles attached to the mandible. Treatment Semi-rigid fixation with trans-osseous wires (osteosynthesis) Lag screws Plates and screws; load sharing plates or load bearing plates (for edentulous atrophic mandible, comminuted and defect fractures). Early and proper management is critical in order to avoid death and long-term morbidity. Document accurately the neurological status with the Glasgow Coma Scale (Table 49. Review regularly every 15 to 30 minutes while awaiting transportation if at level 4 and are not able to manage. Arrange immediate referral to a Specialized unit, and provide appropriate transportation and personnel to accompany the patient during transportation. Rehabilitate as appropriate: Physiotherapy, occupational therapy, and counselling. Regular neurological assessments performed less often than hourly are of no use for interpretation. It is important for primary assessment to establish the presence of an injury and initiates immediate treatment to avoid worsening either the primary or the secondary injury. The injury could be a compression fracture with retropulsion of bone fragments into the spinal canal, causing spinal cord compression or complete transection of the cord. Clinical Features Condition may present as part of the multiply injured patient and caution is needed not to overlook this condition. Neurogenic shock refers to the haemodynamic triad of hypotension, bradycardia, and peripheral vasodilatation resulting from autonomic dysfunction and the interruption of sympathetic nervous system control in acute spinal cord injury. Investigations Plain spinal radiographs: It is critical to maintain cervical stability during transfer and examination. Transfer should be made even if the clinical manifestations of spinal injury are minor. For level 6: Bone injuries addressed through surgery or other means Spinal decompression as appropriate for the individual case. Rehabilitation with physiotherapy, occupational therapy, prosthetic and orthotic fittings, etc. It is critical in these patients that a variety of conditions be suspected and diagnosed or clearly excluded before definitive treatment is initiated. Clinical Features Meticulous history and physical examination are very important in establishing the diagnosis. The clinical features include abdominal pain, abdominal distension, abdominal guarding and rigidity, altered bowel sounds, and alteration of bowel habits. Caution: As a result of organ displacement associated with pregnancy, clinical examination of the abdomen for abdominal pain in a pregnant female can be confusing. Investigations Haemoglobin, white blood cell count, packed cell volume Urea and electrolytes Urinalysis Plain abdominal radiograph (erect and dorsal decubitus), chest radiograph Other investigations as the condition dictate. Arrange transfer to a suitable surgical facility as soon as possible if not able to handle case (level 4 without a surgeon). Maintain resuscitation during transfer, nasogastric suction, fluids, and input output chart. Manage conservatively if found appropriate: Nil by mouth, nasogastric suction, correct fluid and electrolyte imbalance by intravenous fluids Re-evaluate with the appropriate investigations. In older children and adults, suspect bowel obstruction if: There is constipation. Obstruction due to adhesions from previous surgery may open under conservative treatment. Appreciate that peritonitis could be due to tuberculosis and could also be aseptic. The aseptic type is usually due to chemical irritants like pancreatic juices, etc. Peritonitis usually ends up producing adhesions that may cause future bowel obstructions of varying degrees. Clinical Features Presentation is with an acute tender abdomen, abdominal distension, altered bowel sounds, guarding, rigidity, rebound tenderness, and fever. These are usually disturbed by the movement of fluid and electrolytes into the third space. Consider nasogastric suction, which is usually necessary because of organ hypotonia and dilatation. The pain may be relieved briefly after perforation but is accentuated by the ensuing diffuse perito nitis. There is localized tenderness in the right lower quadrant, rebound tenderness, muscle guarding, cutaneous hyperaesthesia, and pelvic tenderness 351 Clinical Guidelines in the right iliac fossa on rectal examination. Starve the patient before surgery Give premedication when there is time (atropine 0. Failure of this process during any stage may result in intestinal atresia, which can affect any section of the bowel and can have varying degrees of severity. Management at Levels 4 to 5 Initiate resuscitation measures with intravenous lines, nasogastric suction and fluid charts. Through this opening abdominal content can herniate to varying extents into the inguinal canal and scrotal sac. The communicating type is the most common form and extends down into the scrotum; the non communicating one is less common. There may be associated pain and discomfort, or it may present as an acute abdomen. Examination findings reveal a reducible mass but cases of irreducible incarceration may occur. Management Inguinal hernias do not heal and must be corrected by elective herniorraphy for uncomplicated cases, to avoid complications. Gastrochesis, which is a herniation of small bowel contents with no covering at all and is often paraumbilical. Umbilical hernia, which is a mild condition as a result of a defect in the linea alba. Clinical Features There is protrusion of bowel contents through the abdominal wall to varying extents with or without other organs. Management Conservative management for small umbilical hernias with expectant observation. Surgery for strangulations or other surgical complications arising from the hernia. Clinical Features There is failure to pass meconium, or may pass meconium per urethra or vagina. Investigation Invertogram Check for other anomalies Management Surgical management best at specialized facility even for apparently simple malformations. Definitive surgical intervention, which may range from minor anuloplasty (dilatation, incision) to more complicated pull through procedures at the appropriate facility. This invagination may cause strangulation that leads to gangrene formation in the affected portion of the bowel. Clinical Features There is onset of acute abdominal pain sometimes associated with red currant jelly stools. Clinical examination reveals a mass of the interssuceptus in the right hypochondrium. Investigation Plain abdominal radiograph may show evidence of obstruction but misses still in identifying intussusceptions in early disease. Complications Complications of this condition include obstruction (when a hollow viscus goes through a ring of variable size and cannot be reduced), and incarceration (when non-hollow organ for example omentum, goes through a ring of variable size and cannot be reduced). Strangulation is a process in which blood flow into the obstructed viscus is compromised, and if not corrected culminates in ischaemia of the viscus supplied by the involved blood vessels. Clinical Features Protrusion in the groin region, initially on straining and later may be spontaneous. There may also be a nagging or painful sensation in the groin or a strangulated, painful groin mass. Examination Observation of the bulge with the patient coughing while standing and when lying down, and with a finger invaginated into the external ring, repeating the same examinations. There is no great advantage of differentiating indirect from direct inguinal hernia, pre-operatively. Emergency surgery after resuscitation (if emergency surgery is not possible at the hospital refer to next level). In strangulation, with obstruction of viscus, especially bowel the usual resuscitative measures are carried out/continued before and after surgery. Umbilical, incisional, and lumbar hernias require similar treatment as above in Section 50. Common causes are: Haemorrhoids Anal fistulae and fissures Tumours: Benign (leiomyoma, fibromas, polyps) or malignant Trauma Aiigiodysplasia Bleeding disorders Investigations Haemoglobin, white blood count, packed cell volume. Barium enema (double contrast) Proctoscopy/Sigmoidoscopy and biopsy Management Do blood group cross match and transfuse if necessary. Painless bleeding is commonly due to haemorrhoids but may be due to colorectal carcinoma. A patient with a perianal mass complains of feeling a mass (usually prolapsed haemorrhoids or anal tags) or has anal discharge that is associated with itching and is commonly associated with tumours, proctitis, and helminthic infestations. Perineal discharge, on the other hand, is usually due to fistilae and is common in obese people. The following have been associated with anal incontinence: Congenital abnormalities. Trauma to the sphincters and anorectal ring, injuring them (obstetric, operative, abuse and accidental). Refer to the appropriate level facility according to the primary pathology if not able to manage at the present level. It is a common occurrence in children and the elderly (especially females, who form 85% of affected adults population) but may occur at any age Clinical Features Clinically there are three types, categorized as follows: Primary prolapse with spontaneous reduction. Most patients present with reducible prolapse, which often occurs during defecation and is associated with discomfort, bleeding, and mucus discharge. When uterine prolapse compounds rectal prolapse, urinary incontinence may also be a feature. Rectal prolapse is also associated with benign prostatic hypertrophy, constipation, malnutrition, old age, and homosexuality/anal intercourse. Anorectal carcinomas should always be suspected if there are also ulcers, indurations, or masses in this area.

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