By W. Georg. Pacific University.

X-Rays German physicist Wilhelm Röntgen (1845–1923) was experimenting with electrical current when he discovered that a mysterious and invisible “ray” would pass through his flesh but leave an outline of his bones on a screen coated with a metal compound cheap 100mg thorazine amex. In 1895 order 100 mg thorazine amex, Röntgen made the first durable record of the internal parts of a living human: an “X-ray” image (as it came to be called) of his wife’s hand purchase thorazine 100mg mastercard. Scientists around the world quickly began their own experiments with X-rays, and by 1900, X-rays were widely used to detect a variety of injuries and diseases. The X-ray is a form of high energy electromagnetic radiation with a short wavelength capable of penetrating solids and ionizing gases. As they are used in medicine, X-rays are emitted from an X-ray machine and directed toward a specially treated metallic plate placed behind the patient’s body. X-rays are slightly impeded by soft tissues, which show up as gray on the X-ray plate, whereas hard tissues, such as bone, largely block the rays, producing a light-toned “shadow. Like many forms of high energy radiation, however, X-rays are capable of damaging cells and initiating changes that can lead to cancer. This danger of excessive exposure to X-rays was not fully appreciated for many years after their widespread use. Although often supplanted by more sophisticated imaging techniques, the X-ray remains a “workhorse” in medical imaging, especially for viewing fractures and for dentistry. The disadvantage of irradiation to the patient and the operator is now attenuated by proper shielding and by limiting exposure. Modern Medical Imaging X-rays can depict a two-dimensional image of a body region, and only from a single angle. In contrast, more recent medical imaging technologies produce data that is integrated and analyzed by computers to produce three-dimensional images or images that reveal aspects of body functioning. The technique was invented in the 1970s and is based on the principle that, as X-rays pass through the body, they are absorbed or reflected at different levels. It is especially useful for soft tissue scanning, such as of the brain and the thoracic and abdominal viscera. Its level of detail is so precise that it can allow physicians to measure the size of a mass down to a millimeter. In 1970, a physician and researcher named Raymond Damadian noticed that malignant (cancerous) tissue gave off different signals than normal body tissue. This has helped scientists learn more about the locations of different brain functions and more about brain abnormalities and diseases. Ultrasonography Ultrasonography is an imaging technique that uses the transmission of high-frequency sound waves into the body to generate an echo signal that is converted by a computer into a real-time image of anatomy and physiology (see Figure 1. Ultrasonography is the least invasive of all imaging techniques, and it is therefore used more freely in sensitive situations such as pregnancy. Ultrasonography is used to study heart function, blood flow in the neck or extremities, certain conditions such as gallbladder disease, and fetal growth and development. The main disadvantages of ultrasonography are that the image quality is heavily operator-dependent and that it is unable to penetrate bone and gas. In the past, anatomy has primarily been studied via observing injuries, and later by the dissection of anatomical structures of cadavers, but in the past century, computer-assisted imaging techniques have allowed clinicians to look inside the living body. The two disciplines are typically studied together because form and function are closely related in all living things. Therefore, molecules combine to form cells, cells combine to form tissues, tissues combine to form organs, organs combine to form organ systems, and organ systems combine to form organisms. These processes include: organization, in terms of the maintenance of essential body boundaries; metabolism, including energy transfer via anabolic and catabolic reactions; responsiveness; movement; and growth, differentiation, reproduction, and renewal. Although the body can respond to high temperatures by sweating and to low temperatures by shivering and increased fuel consumption, long-term exposure to extreme heat and cold is not compatible with survival. The body requires a precise atmospheric pressure to maintain its gases in solution and to facilitate respiration—the intake of oxygen and the release of carbon dioxide. Homeostasis is regulated by negative feedback loops and, much less frequently, by positive feedback loops. Both have the same components of a stimulus, sensor, control center, and effector; however, negative feedback loops work to prevent an excessive response to the stimulus, whereas positive feedback loops intensify the response until an end point is reached. Regions of the body are identified using terms such as “occipital” that are more precise than common words and phrases such as “the back of the head. Images of the body’s interior commonly align along one of three planes: the sagittal, frontal, or transverse. The body’s organs are organized in one of two main cavities—dorsal (also referred to posterior) and ventral (also referred to anterior)—which are further sub-divided according to the structures present in each area. Serous membranes cover the lungs (pleural serosa), heart (pericardial serosa), and some abdominopelvic organs (peritoneal serosa). A scientist wants to study how the body uses foods and studying all of the structures of the ankle and foot? Which of the following is an example of a normal changes physiologic process that uses a positive feedback loop? The person is standing facing the observer, with upper limbs extended out at a ninety-degree angle 13.

Stable fractures are those with minimal or no risk of neurological damage whereas unstable fractures are those with a high likelihood of neurological damage coupled with slight movement purchase 100mg thorazine overnight delivery. It has three types which are: type1 cheap thorazine 100 mg amex, type2 buy 100 mg thorazine otc, type 3 (Levine classifcation), type 1 is stable; types 2 and 3 are unstable. Tis is attributed to normally increased elasticity of the spinous ligaments and intervertabral sof tissue in young population. Thoracic Fractures Description: Te thoracic canal is smaller compared to other spinal regions making it more vulnerable to even small compressive lesions. Thoracolumbar Fracture 2 Description: Toracolumber fructure is a transition zone between the rigid thoracic spine and mobile lumbar spine. Cauda Equina Defnition: It is a clinical condition arising from dysfunction of multiple lumbar and sacral nerve roots compression within lumbar spinal canal. Causes - Massive herniated lumber disc - Tumors - Free fat graf following discectomy - Trauma - Spinal epidural hematoma - Infection e. Cerebral Vascular Diseases (Spontaneous Haemorrhage) Intracranial hemorrhage may be subdural, subarachnoid and intracerebral (intra parancyma). Subdural hemorrhage is discussed under traumatic causes of intracranial hemorrhages. Intracerebral Hemorrhage Defnition:It is a hemorrhage within the brain parenchyma, commonly referred to as hypertensive hemorrhage, it is the second most common form of strokes (15-30%) but most deadly. Occurs at common sites for hypertensive bleeds (putaminal, thalamic, cerebellar and lobar). Subarachnoid Hemorrhage Description: It occurs as a result of bleeding from aneurismal rapture in 5% from perimesencephalic. Brain Abscess Defnition: Is a pus containing cavity in brain, it goes through stages. Phenytoin 15-20mg /kg as a loading dose and maintenance dose of 5mg/kg/day for 21 days or as long as seizures are present) - Surgery; excision of the cyst Indications for surgery - Large cysts causing mass efect - Cysts causing abstractive hydrocephalus Surgery Clinical Treatment Guidelines 97 Chapiter 2: Neurosurgery 2. Hydrocephalus in Children Description: It is a condition that results when normal exit and absorption of cerebral spinal fuid in the ventricles are impaired. Tis leads to progressive accumulation of this fuid in the ventricles of the brain, resulting in progressive damage to the developing brain with associated mental retardation and visual impairment. Causes - Congenital abnormality - Intraventricular hemorrhage - Infection - Head trauma - Brain tumor Signs and symptoms - Accelerated head growth - Te baby’s sof spot (anterior fontanelle) is usually full or bulging, or even tense, due to the increased pressure inside the head. Myelomeningocele Defnition: Congenital defect in vertebral arches with cystic dilatation of meninges and structural or functional abnormality of spinal cord or cauda equina. It is broadly classifed into 2 entities: - Open head trauma in which there is a scalp laceration with underlying skull fracture and breached Dura Mater (i. It can also be classifed by severity into mild, moderate and sever head trauma depending on the level of consciousness. Patients with severe maxillofacial injury will also need to be given a tracheostomy. Mannitol should be used with caution in patients with clotting disorders because it afects coagulation, and in congestive heart failure patients it increases intravascular volume before it causes diuresis. Remember steroids (dexamethasone, hydrocortisone) have no place in management of acute head injury. Complications - Post-traumatic seizures - Permanent neurological disability - Post-traumatic hydrocephalus - Post-Concussion Syndrome - Infection e. It is subdivided into acute (< 72hours) Subacute (between 72 hours and 3 weeks) and Chronic ( > 3weeks). Chronic Subdural Hematoma Cause - Minor head injury or fall ofen not remembered by patients or relatives. Epidural Hematoma Defnition: It is the collection of blood between the skull and the Dura Mater caused by a rupture of artery and vein in epidural space, as a result of a fracture of the skull at the moment of the impact in 60-90% of cases. Intracranial Hematoma Defnition: Traumatic intraparancymal hemorrhage is commonly associated with brain contusion. Simple Rib Fracture Defnition: Simple rib fracture is a break in continuity of the rib(s). Flail Chest Defnition: Segmental fracture of rib(s) resulting in paradoxical movement of the chest that may lead to respiratory dysfunction. Pneumothorax Defnition: Collection of air in pleural cavity which can be either simple or under tension resulting in pressure on the mediastinum. Cardiac Tamponade Defnition: Te collection of blood in pericardium causing cardiac dysfunction. Ruptured Diaphragm Defnition: A tear in the diaphragm which allows protrusion of abdominal organs in the chest.

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Before giving the drugs to make the patient sleep you should let him/her breathe 100% oxygen buy thorazine 100mg low price, which will be used as a reserve during the time of intubation buy discount thorazine 100 mg. Induction can be performed: • With intravenous anesthetic agents: Ketamine + Atropine or Thiopentone • With inhalation agent (e generic 100mg thorazine visa. Halothane) After the patient is induced, the anesthesia can be continued with intubation or with out (mask ventilation or spontaneous breathing). Endo tracheal intubation: It is a technique of passing an endotracheal tube into the trachea of the patient for securing the airway, and to make easier ventilation. For Intubation the patient should be adequately relaxed with inhalation agent or muscle relaxant. The relaxant used for intubation is Suxamethonium, which has fast onset of action and short effect. Monitoring: During anesthesia it is important to do strict monitoring of heart beat, blood pressure, respiration, temperature, fluid balance and urine output. The carrier gas for volatile anesthetic agent can be atmospheric air or oxygen from compressed source depending on the type of Anesthesia machine in use. Recovery and Extubation: During recovery phase the patient recovers from: • Inhalation agents by exhalation and/or metabolism • Ketamine by excretion and metabolism • Muscle relaxants by excretion and/or metabolism and/or reversal with neostigmine Before extubation • Be sure that the patient is breathing adequately (reversed from relaxant) • Suck oropharyngeal secretion • Deflate the cuff (which is used for adults) and remove the endotracheal tube Transportation and immediate postoperative care: • Transport in the recovery position • Check and observe closely the pulse rate, blood pressure, respiratory rate, urine output hourly, any abnormal and continuing blood loss and presence of pain. Because of these reasons it can be used alone for short procedures and surgery, which does not require relaxation and intubation. Dose and route of administration: ƒ Intramuscular: 5-10 mg/kg ƒ Intravenous: 1-2 mg/kg The effect of one single dose lasts for about 15 min. Treatment of systemic toxicity • The best treatment of systemic toxicity is prevention by meticulous attention to technique and recognition of intravascular injection. Commonly used local anesthetic drugs 118 Lidocaine (Xylocaine) 1%, 2% or 5% with or without Adrenaline in dose of: With Adrenaline: 7 mg/kg Without Adrenaline: 3 mg/kg • Bupivacaine (Carbosthesin, Marcain) 0. The level of lumbar puncture is at the rd th interspaces between the 3 and 4 lumbar vertebrae. Turn the patient to a supine position with pillow under the head in the case of heavy (hyperbaric) local anesthetic drug. Complications of spinal anesthesia and measures to take • Drop in blood pressure-due to high spinal block - Give Oxygen - Make faster the drip if that does not help. Commonly performed nerve blocks: o Digital nerve block o Axillary block of the brachial plexus o Wrist-block 122 C) Field block Field block is injection of local analgesic so as to create a zone of analgesia around the operative field. It can be used for: o Repair of an inguinal hernia o Caesarean section o Circumcision D) Infiltration Infiltration is direct injection of drugs into the area to be incised and between bone ends in fractures. E) Topical anesthesia This can be performed simply by applying 4% lidocaine to the mucus membrane, for minor surgery and instrumentation of: o Nose o Mouth o Eye o Pharynx and larynx o Urethral procedures 123 Review Questions 1. After evaluation by the surgeon, it is decided to take him to the operating theater. A 17 year old girl is brought to the Emergency department with polytrauma after a car accident. L Bartholomeusz: Safe Anesthesia: A Training manual, where facilities are limited. Outline management options for thyroid carcinomas Thyroid Enlargement: Goiter Goiter refers to a generalized enlargement of the thyroid gland which is normally impalpable. Inflammatory • Autoimmune (chronic lymphocyte thyroiditis, Hashimoto’s disease) • Infectious • Acute (bacterial thyroiditis, viral,) • Chronic (tuberculous, syphilitic) 126 Simple Goiter Patho-physiology: Simple Goiter is enlargement of the thyroid gland as a result of stimulation of the thyroid gland by high levels of circulating thyroid stimulating hormone. Defective hormone synthesis also cause goiter and it accounts for many sporadic goiters. In endemic goiter, it usually occurs at puberty when metabolic demands are high, this is reversible if stimulations cease. As a result of fluctuating stimulation of the thyroid gland, areas of active lobule and inactive lobules will develop. Active lobules become more vascular and hyperplasic until hemorrhage occurs causing necrosis. These necrotic lobules coalesce to form nodules filled with either iodine free colloid or inactive follicles. Secondary changes like cystic degeneration, hemorrhage and calcification occur at late stages. Diagnosis Clinical presentation: Discrete swelling in one lobe with no palpable abnormality else where is called solitary (isolated) nodule. The Goiter is painless and freely moves with swallowing and usually patients are euthyroid. Complications • Tracheal obstruction can occur due to gross lateral displacement or compression. Prevention and treatment Prevention In endemic areas the incidence of goiter can be significantly reduced by the introduction of iodized salt. In early stages, a hyper-plastic goiter may regress if thyroxin is given in a dose of 0. Operation might be indicated • On cosmetic grounds • Tracheal compression and • When malignancy cannot be excluded The options of surgical treatment are • Near total thyroidectomy • Subtotal thyroidectomy Toxic goiters Thyrotoxicosis - is a condition in which there is increased metabolic rate due to high level of circulating thyroid hormone. Clinical features The most significant symptoms are • Loss of weight in spite of good appetite, • A recent preference of cold • Palpitation.

The countries Cuba thorazine 100mg overnight delivery, France buy 100mg thorazine mastercard, Italy and Japan operate sentinel networks for surveillance order thorazine 100mg mastercard. Trend data from Germany and from the United Kingdom are evaluated from 2001 because surveillance methods changed in that year. Sentinel surveillance reports annual data from the same sites, with the exception of Japan, which conducts sentinel surveys every three years. Surveys are periodic, and reflect the population of registered pulmonary smear-positive cases. Depending on the area surveyed, a cluster-sampling technique may be adopted, or all diagnostic units may be included. While some countries, such as Botswana, repeat surveys every 3–5 years, for the purposes of this report they are considered as repeated surveys and not surveillance. Survey areas In both survey and surveillance settings, the coverage area is usually the entire country, but in some cases, subnational units are surveyed. Large countries, such as Brazil, China, India, Indonesia, the Russian Federation and South Africa, tend to survey large administrative units (e. Some countries have opted to limit surveys or surveillance to metropolitan areas, as in the case of Azerbaijan, China and Uzbekistan. Cuba, France, Italy and Japan) conduct sentinel surveillance, and some other countries have restricted surveys to subnational areas, either because of the remoteness of certain provinces or to avoid conflict areas. Separate sample sizes should be calculated for new cases and previously treated cases. However, the number of sputum-positive previously treated cases reported per year is usually small, meaning that a long intake period needed to achieve a statistically adequate sample size. Therefore, most countries have obtained an estimate of the drug-resistance level among previously treated cases by including all previously treated cases who present at centres during the intake period. While this may not provide a statistically adequate sample size, it can nevertheless give a reasonable estimate of drug resistance among previously treated cases. Surveys in Armenia, Baku City (Azerbaijan), Georgia, Gujarat state (India) were designed with separate sample sizes for re-treatment cases. Once fully implemented, these routine data will provide estimates of drug resistance in these populations. Survey protocols The quality of survey protocols has improved over the last 10 years. Most protocols reviewed in Phase 4 of the project were complete, and included detailed budgets, timelines and plans for quality assurance at several levels. Most of the protocols reviewed were submitted through a local ethics review board or through the ethics review board of a technical partner supporting the project. Survey data were reported from 35 countries or geographical settings, and surveillance data from 48 countries or geographical settings. Data from laboratory registers from South Africa were reported but not included in any analyses. These settings were Cuba, Honduras, Latvia, the Russian Federation (Tomsk Oblast), Spain (Barcelona and Galicia), Ukraine (Donetsk Oblast) and Uruguay. Among these settings, seven were able to report information for more than one year. Most countries cross-checked patient history collected in the survey with medical records, but fewer countries re- interviewed a percentage of patients. All new data reported have been returned to countries for verification before publication. The global project requests that survey protocols include a description of methods used for the quality assurance of data collection, entry and analysis. In surveillance settings, a combination of smear and culture was used for initial diagnosis. Some laboratories inoculated sodium hydroxide decontaminated specimen directly onto Ogawa medium without centrifugation. Laboratories in high-income countries generally used liquid medium or agar-based medium. The proportion method was most frequently used in all phases of the global project. Resistance was expressed as the percentage of colonies that grew on recommended critical concentrations of the drugs tested; that is, 0. The criterion used for drug resistance was growth of 1% or more of the bacterial population on media containing the critical concentration of each drug. Quality assurance of laboratories Proficiency testing and retesting of a proportion of survey strains are two components of external quality assurance of laboratories17. The percentage of isolates sent for checking is determined before the beginning of the survey.