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The deep branch (posterior interosseous nerve) winds round the lateral side of the radius between the two planes of fibres of the Supinator to reach the back of the forearm buy generic imuran from india spasms jerking limbs. Before it enters the Supinator muscle it gives a branch to the Extensor carpi radialis brevis and another to the Supinator buy imuran 50mg low cost spasms left abdomen. After it comes out of the Supinator purchase 50 mg imuran with amex muscle relaxant drugs z, it gives off three short branches — to the Extensor digitorum, Extensor digiti minimi and Extensor carpi ulnaris and two long branches one to the Extensor pollicis longus and the Extensor indicis and another to the Abductor pollicis longus and the Extensor pollicis brevis. It must be remembered that it sends off the twigs to supply the three heads of Triceps before it reaches the groove at the back of the humerus. It gives off the three cutaneous branches — the posterior cutaneous nerve of the arm, which arises in the axilla, the lower lateral cutaneous nerve of the arm to supply the skin of the lateral part of the lower half of the arm and the posterior cutaneous nerve of the forearm which supplies back of the forearm and wrist. The radial nerve may be injured (a) in the axilla by the use of a crutch, which is not properly adjusted (crutch palsy) or fracture dislocation of the upper end of the humerus or by attempts for reduction. It may be injured (b) in the radial groove either by fracture of the shaft of the humerus or by pressure on the arm at the edge of the operating table or at the edge of a chair or a pavement after a deep sleep being drunk (Saturday night palsy) or by inadvertent intramuscular injection on the radial nerve at this region. The posterior interosseous nerve may be injured by fracture or dislocation of the upper end of the radius or during operations involving this region. As for example when the radial nerve is injured in the axilla all the muscles supplied by the radial nerve will be paralysed and the cutaneous sensation of the regions supplied by the cutaneous branches of the radial nerve will be abolished. When injury affects the radial nerve at the radial groove the Triceps muscle escapes, similarly the posterior cutaneous nerve of the arm. When the posterior interosseous nerve is injured, all the muscles supplied by the radial nerve itself and the cutaneous branches escape as also the supinator and the extensor carpi radialis brevis which are supplied before the site of injury. The radial nerve through its posterior interosseous nerve is mainly concerned in supplying the extensors of the wrist joint. So the commonest complaint after radial nerve injury is inability of the patient to extend the wrist (Wrist drop) and metacarpophalangeal joints of the fingers. The students must remember that extension of interphalangeal joints is done by interossei through the extensor expansions. These interossei are supplied by the ulnar nerve and hence unaffected by radial nerve injury. If this knowledge of anatomy is lacking, extension of interphalangeal joints may be erroneously interpreted as signs of regeneration. Brachioradialis is supplied by the radial nerve before it divides into the superficial and the deep branches. The muscle is tested by asking the patient to put the forearm in mid-prone position and flexing the elbow against resistance. Bilateral wrist drop may occasionally be due to lead palsy, in which case the brachioradialis may escape and the paralysis of the other muscles is often incomplete. The median nerve descends into the arm lying at first lateral to the brachial artery and at the level of the middle of the arm it crosses in front of the artery and descends on its medial side to the cubital fossa. The nerve enters the forearm between the two heads of the pronator teres crossing from medial to the lateral side the ulnar artery being separated by the deep head of this muscle. At this place the nerve may be compressed in the fibro-osseous canal to produce "carpal tunnel syndrome". A short and stout muscular branch comes out of the median nerve in the palm and supplies the Abductor pollicis brevis, the Opponens pollicis, the Flexor pollicis brevis and rarely the first dorsal interosseous muscle. It ends as palmar digital branches which are 4 to 5 in number and provide digital branches to the thumb, the index finger, the middle and lateral half of the ring finger. These palmar digital branches also supply the first and the second lumbrical muscles. The branches of the median nerve in the arm are only vascular branches to the brachial artery and a muscular branch to the pronator teres. The branches in the forearm are the muscular branches to all superficial flexor muscles e.

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The presence of fever would suggest that the mass is an abscess such as subphrenic abscess buy imuran uk spasms under belly button, perinephric abscess safe 50mg imuran spasms with broken ribs, diverticular abscess purchase imuran cheap muscle relaxant names, appendiceal abscess, or pyosalpinx. At this point, before ordering more expensive tests, a surgeon or gastroenterologist should be consulted. An abdominal ultrasound will be helpful in differentiating cholecystitis and other cystic masses of the pancreas, kidneys, and reproductive organs. Endoscopic procedures will help diagnose carcinoma of the stomach and colon and diverticulitis. Gallium scans will help uncover subdiaphragmatic, perinephric, diverticular, and pelvic abscesses. Peritoneal taps will help differentiate ascites, pancreatitis, and peritoneal bleeding. Needle biopsy of the liver or any mass lesion under laparoscopic guidance may be diagnostic. Ultimately, exploratory laparotomy is still an excellent way of establishing a diagnosis. If there is hepatomegaly, one should suspect congestive heart failure, emphysema, constrictive pericarditis, hepatic vein thrombosis, and cirrhosis of the liver. If there is dyspnea or cardiomegaly, one should suspect congestive heart failure or emphysema. The presence of hypertension or proteinuria should arouse suspicion of nephritis or nephrosis. These findings are suggestive of tuberculous peritonitis, ruptured viscus, pancreatic cyst, advanced intestinal obstruction, mesenteric thrombosis or embolism, acute pancreatitis, and ruptured ectopic pregnancy. If peritoneal fluid is established, a peritoneal tap is done and the fluid analyzed and cultured. The fluid may be spun down and a Papanicolaou (Pap) smear made or cell block study done. Contrast radiographic studies may identify a primary neoplasm or primary source for infection. A general surgeon or gastroenterologist should be consulted early in the diagnostic evaluation. On physical examination, his blood pressure is 110/80, but he demonstrates weak dorsalis pedis, tibialis, popliteal, and femoral pulses in both lower extremities. Following the algorithm, you suspect a Leriche’s syndrome and you would be correct. Diminished pulse in the upper extremities should suggest dissecting aneurysm, embolism, fracture, arteriovenous fistula, coarctation of the aorta, aortic aneurysm, thoracic outlet syndrome, and subclavian steal syndrome. Diminished pulse in the lower extremities should suggest embolism, fracture, arteriovenous fistula, peripheral arteriosclerosis, Leriche’s syndrome, and coarctation of the aorta, as well as dissecting aneurysm. Diminished pulses in all four extremities would suggest shock or constrictive pericarditis. The presence of unilateral absent or diminished pulse should suggest dissecting aneurysm, embolism, fracture, arteriovenous fistula, some cases of coarctation of the aorta, aortic aneurysm, thoracic outlet syndrome, and subclavian steal if it is in the upper extremity. In the lower extremities, unilateral decrease in the pulse may be caused by arteriosclerosis or arterial embolism. Bilateral diminished pulses would suggest Leriche’s syndrome, saddle embolism, dissecting aneurysm, and coarctation of the aorta if it is in the lower extremity; and if it is in the upper extremity, it may also be related to a dissecting aneurysm and rarely arteriosclerosis. The presence of a sudden onset in diminished pulse should suggest an embolism or dissecting aneurysm regardless of where the diminished or absent pulse may be. However, if it is just the lower extremities, it could be Leriche’s syndrome as well.

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This ulcer is elongated imuran 50 mg for sale spasms in lower left abdomen, often presents a slough at its base and surrounded by a zone of erythema and induration 50mg imuran with amex ql spasms. Tuberculous ulcer — is shallow buy 50mg imuran amex spasms below breastbone, often multiple and greyish yellow with slightly red undermining margin. Carcinomatous ulcer is painless to start with and only becomes painful in late cases. There is little pain in the tongue; in late cases one may complain of pain and it may be referred to the ear since irritation of the lingual nerve is referred to the auriculotemporal nerve. Profuse salivation is common and an elderly man sitting in the surgical out-patient department with handkerchief continuously pressed at the mouth to soak saliva, is probably suffering from this condition. This is partly due to irritation of the nerves of taste and partly due to difficulty in swallowing due to ankyloglossia, that means the patient cannot protrude the tongue out of the mouth. This indicates that the carcinomatous process has infiltrated the lingual musculature and even the floor of the mouth. Growth at the posterior third of the tongue often escapes the notice and in these cases alteration of the voice and dysphagia are the important symptoms. Diagnosis is made by palpating the growth which has been described in the section of "palpation" and by laryngoscopy. Lymph node enlargement becomes more conspicuous in carcinoma of posterior 3rd of the tongue where growth is relatively out of sight, (iii) Blood spread is exceptional and only seen in cases of growth situated in the extreme posterior part of the tongue. Bimanual palpation will reveal cross fluctuation between the floor of the mouth and its cervical extension. Thus ranula which is an acquired condition, becomes the most important condition in differential diagnosis. Though median variety is more common yet lateral sublingual dermoids are not unseen. While the median variety develops from inclusion of ectoderm between the two halves of the developing mandible, the lateral variety develops from the 2nd branchial cleft. It is an opaque and non- translucent swelling in the floor of the mouth when situated above the mylohyoid. When situated below the mylohyoid, a cystic swelling develops either just below the chin, giving rise to a double chin or in the sub-mandibular region giving rise to a cystic swelling there. It is filled with sebaceous material and unlike other dermoid cysts does not contain hair. In dehydrated patient with poor oral hygiene if he complains of sudden increase in size of both the parotid glands with considerable pain, the case is probably one of acute parotitis. If there is brawny oedematous swelling of the parotid region with pain, this is probably a case of parotid abscess. A slow growing tumour having duration for years or months of the parotid gland is the pleomorphic adenoma. When such a tumour suddenly starts growing rapidly and becomes painful, it is highly suggestive of malignant transformation of this adenoma (mixed parotid tumour). Site is important as adenolymphoma, which is also a slow-growing painless tumour, arises in the lower part of the parotid gland at the level of the lower border of the mandible slightly lower than the usual site of pleomorphic adenoma. It must be remembered that mumps is the commonest cause of bilateral parotitis (See Fig. Excruciating pain, slight swelling and redness in the region of the parotid gland are characteristic features of parotid abscess. In case of obstruction of the parotid duct with a stone or stricture patient will complain of colicky pain during meals when the swelling of the parotid gland will also be increased.