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The fact that many of the signs and symptoms of hyperthyroidism resemble those of excessive sympathetic activity suggests that the thyroid hormone may heighten the sensitivity of the body to the cadecholamines or that thyroid hormone itself may act as a pseudo catecholamine anxiety symptoms 8 year old boy order venlor 75mg. With the hypermetabolic state, there are frequent complaints of nervousness, irritability, and fatigability. Other manifestations include tachycardia, palpitations, shortness of breath, excessive sweating, and heat intolerance. Even in persons without exophthalmos there is an abnormal retraction of the eyelids and infrequent blinking and patients appear to be staring. The hair and skin are usually thin and have a silky 177 Pathophysiology appearance. Hyperthyroidism can be treated by surgical, radioactive iodine or the use of drugs. The exophthalmos is thought to result from an exophthalmos producing factor whose action is enhanced by anti bodies. Thyroid storm Thyroid storm (crisis) is an extreme and life threatening form of thyrotoxicosis. It is often precipitated by stress, such as infection, by diabetic ketoacidosis, by physical or emotional trauma, or by manipulation of a hyperactive thyroid gland during thyroidectomy. Thyroid storm is manifested by a very high 178 Pathophysiology fever, extreme cardiovascular effects and severe central nervous system effects. Mineralocorticoids may be produced in excessive or insufficient amount, depending on the precise enzyme deficiency. Males are seldom diagnosed at birth, unless they have enlarged genitalia or lose salt and manifest adrenal crisis; in female infants, an increase in androgens is responsible for creating the virilization syndrome of ambiguous genitalia. Most often the underlying problem is ideopathic adrenal atrophy, which probably has an auto immune basis. The adrenal cortex has a large reserve capacity, and the manifestations of adrenal insufficiency do not usually became apparent until about 90% of the gland has been destroyed. Mineralocorticoid deficiency: minerals corticoid deficiency caused increased urinary losses of sodium, chloride, and water along with decreased excretion of potassium. The result is hyponatremia, loss of extra cellular fluid, decreased cardiac out put, and hyper calemia. If loss of sodium and water is extreme cardiovascular collapse and shock will ensue. Gluco corticoid deficiency: Because of a lack of glucocorticoids, the patient has poor tolerance to stress. This deficiency causes hypoglycemia, lethargy, weakness, fever, and gastrointestinal symptoms such as anorexia, nausea, vomiting and weight loss. Secondary adrenal insufficiency Secondary adrenal insufficiency can occur as a result of hypopituitarism or because the pituitary gland has been surgically removed. However, a far more common cause than either of these is the rapid withdrawal of qluco corticoids that have been administered therapeutically. The onset of adrenal crisis may be sudden, or it may progress over a period of several days. The symptoms may also occur suddenly in children with salt losing forms of the adrenogenital syndrome. Massive bilateral adrenal hemorrhage cause an acute fulminating form of adrenal insufficiency. Hemorrhage can be caused by meningococcal septicemia (called water house friderichsen syndrome), adrenal trauma, anticoagulant therapy, adrenal vein thrombosis, or adrenal metastases. In advanced cases, the skin over the forearms and legs becomes thin, having the appearance of parchment. Purple striae (stretch mark), from 183 Pathophysiology stretching of the catabolically weakened skin and subcutaneous tissues, are distributed on the abdomen and hips. Osteoporosis results from destruction of bone proteins and alterations in calcium metabolism. Derangements in glucose metabolism are found in some 90% of patients, with clinically overt diabetes mellitus occurring in about 20%. The gluco corticoids possess mineralocorticoid properties; this causes hypercalemia as a result of excessive potassium excretion & hypertension resulting from sodium retention. Inflammatory and immune responses are inhibited, resulting in increased susceptibility to infection. Cortisol increases gastric secretion, and this may provolce gastric ulceration and bleeding. An accompanying increase in androgen level causes hirsutism, mild acne, and menstrual irregularities in women. Excessive levels of the gluco corticoids may give rise to extreme emotional labiality. Constitutional Disease Bleeding disorders (like platelet abnormality & coagulation factor defect) Hypertension. Emotional disturbance may stimulate hypothalamus and has resultant influence on gonadotrophic hormones. Obstructions in urinary tract (Obstructive Uropathy) Obstructive disorders may cause considerable renal dysfunction, including hemorrhage, renal failure, if they are left untreated. Normally urine is formed by the nephrones in the renal parenchyma, then collected in the renal pelvic to flow through the ureter and reaches urinary bladder. When the bladder becomes full, urethral sphincters are opened then urine passes through urethra to be voided out. Clinical Features Acute urinary retention Symptoms of prostatism (frequency, urgency, dribbling, dysuria, etc) Chronic retention over flow incontinence, and renal insufficiency. Minor trauma to the urethral mucosa may heal by forming strictures years after the procedure. Example: o An increase in tissue volume results from brain tumors, brain edema, or bleeding into brain tissue. The level of consciousness may deteriorate from alertness through confusion, lethargy, obtundation, stupor, and coma. Neurons in vasomotor centre respond directly to ischemia by producing a marked increase in mean arterial blood pressure. Some times up to 270mmHg is accompanied by widening of pulse pressure and a reflex slowing of the heart rate. Types of Brain Edema: 208 Pathophysiology There are two types of brain edema: a) Vasogenic Brain Edema: Increased extra cellular fluid that surrounds brain cells. Infratentorial Herniation Supratentorial Herniation There are three subtypes based on sites.

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The long head of biceps takes its origin from the labrum and runs through the joint and in the bicipital groove76 on the front of the humerus anxiety symptoms yahoo cheap 75mg venlor fast delivery, lling the gap between the subscapularis and the supraspinatus tendons. The four muscles act as rotators of the humerus and the combined tendinous structure around the shoulder joint is referred to as the rotator cuff. Tears in subscapularis have been associated with variations in the morphology of the acromion. These changes include pitting, alteration in normal contour and the presence of enthesophytes. If the impingement syndrome was present, eburnation may be found on the superior pole of the humerus and on the undersurface of the acromion. If the bicipital tendon has been involved, new bone may also be found in the bicipital groove. Intervertebral disc disease: the vertebrae are articulated through the medium of the intervertebral disc which is formed from an outer brous part (the annulus brosus) which surrounds a central part (the nucleus pulposus). The annulus is composed largely of type I collagen bres which are laid down obliquely in a series of lamellae, the orientation of the bres alternating between lamellae. A hypomochlion is a structure that forces a tendon or a muscle to change its direction. The cells in the annulus are elongated like broblasts whereas those in the nucleus are rounded, often situated within a capsule. Degeneration of the disc is particularly associated with aging and occurs equally in both sexes. Thechanges within the nucleus and the annulus result in the nucleus bulging outwards and the annulus collapsing88 with joint space narrowing on X ray. It is very common in skeletal assemblages and, as expected, is found especially in the cervical and lower lumbar regions. Thus, it conforms with modern experience extremely well, suggesting that its aetiology has probably not changed much over the years. Note the presence of marginal osteophyte and pitting and new bone formation on the superior surface of C3 and the small osteophyte (white arrow) which is protruding into the intravertebral foramen. If the exiting nerve root had been compressed, symptoms would have been noticed around the neck and in the skin overlying the upper bres of the trapezius muscle. Compression of nerve roots in the cervical region93 may give rise to symptoms in the hand or arm. A knowledge of 92 the intervertebral foramen has been described as the doorway between the spinal canal and the periphery. The nodes may appear in almost any position on the vertebral surface, sometimes extending into the vertebral canal. Radiologically, they are frequently surrounded by a sclerotic margin showing that some degree of remodelling has taken place. A simplied family tree of the joint diseases showing those that are most likely to be found in the skeleton is shown in Figure 4. However, only a small number of the erosive arthropathies are likely to be encountered during the examination of a skeletal assemblage and it is these that will be discussed here. The signs and symptoms differed in a number of ways from those found in other forms of gout, the rubric under which the joint diseases were all included at the time. It was more common in women, involved many joints from the onset and ran a chronic course. The size of this thesis will no doubt astonish those who have presented their own in more recent times! Thus, many considered it a new disease although there have been suggestions that a number of historical gures suffered from it, including Mary Queen of Scots, but most of these attributions are disputed. Cases have been found from the mediaeval and post mediaeval periods in England3 and seventh to ninth century France. Genetic factors are clearly important and contribute substantially to the pathogenesis as judged from twin studies. This occurrence has provoked considerable interest not only because it is a more sensitive indicator of the disease, but their presence during the early stages of the disease is associated with a signicantly greater number of erosions at follow up. It formed as an intermediate in the conversion of ornithine to arginine in the urea cycle. It gained its name from the fact that it was rst extracted from a water melon, the Latin name of which is citrullus. The condition may then either persist or remit, again depending on genetic and environmental inuences. Pannus is the name given to the abnormal synovial membrane which gradually encroaches across the joint, destroying the articular cartilage in its wake. Erosions may be found at the joint margin, in the centre of a joint, or in para articular tissues (Figure 4. Theyarecharacterisedbythefollowingfeatures: r cortical destruction; r undercut edges; r exposed trabeculae; r sharp or scalloped ridges; and r ascoopedoor. The description, together with illustrations of the changes can be found in uvres complete de J. Tome 7 Maladies des vieillards, goutte et rheumatisme, Lescrosnier et Babe, Paris, 1890). Most of the normal joint surface has been destroyed and the joint is heavily eroded. Post mortem damage to a joint may sometimes simulate an erosion but if the damage is recent, the colour of the damaged cortex will be lighter than the rest and this will make the cause obvious. Other destructive processes, including rodent gnawing should also present no difculty. On X ray, a true erosion will often have a sclerotic margin, showing that some remodelling has taken place during life; sclerosis will never be found with a pseudo erosion or other post mortem artefact. Note that the disease cannot be diagnosed with any certainty if the hands and/or the feet are not present. On this account, it diseases of joints, part 2 53 is certain that the true prevalence of the disease in skeletal assemblages is under estimated. Another group of the sero negative arthropathies which share a number of features in common, including sacroiliitis and some degree of fusion of the spine, are known as the spondylarthropathies, a term rst introduced by Moll and his colleagues in 1974. The changes seen radiographically are a mixture of proliferation and erosions, the erosions rst appearing in the central portion of the joints. Radiograph of erosive osteoarthritis with gull wing (small arrow head) and saw tooth (large arrow head) lesions.

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Thelefthipisaffectedaboutfour times more commonly than the right but the condition may also be bilateral anxiety urination order 75mg venlor with amex. In the infant, the acetabulum is shallow and the femoral head is undeveloped with variable degrees of subluxation. In a typical case one or both acetabula will be hypoplastic or obliterated altogether. There are likely to be pseudoarthroses on the ilium, and the femoral heads are likely to be hypoplastic. The pseudarthrosis are often large, surrounded by new bone and they will frequently be eburnated as will the femoral heads. Where secondary osteoarthritis develops this can be taken as an indication that the individual was able to walk, although almost certainly with a waddling gait, and survived for many years into adulthood. It manifests itself around the onset of puberty, particularly in overweight males who are about three times as likely to have the condition as females. The aim of treatment is to stabilise the fracture so that the blood supply to the femoral head is not compromised with the risk of osteonecrosis. The condition has no preference as to side and is bilateral in about a quarter of cases. It is not clear what causes the fracture,88 although trauma and activity are thought to play a part. Whatever the aetiology, the result is that the epiphysis is displaced posteriorly and medially with a reduction in the anteroposterior neck shaft angle. These changes are referred to as a tilt deformity (D Resnick, Patterns of migration of the femoral head in osteoarthritis of the hip. The condition passes through four stages: (1) the onset of avascular necrosis; (2) fragmentation of the head of the femur; (3) revascularisation and regeneration; and (4) healing. In some cases healing and regeneration are complete and it may not be possible to recognise the condition in later life but in others, changes are evident in the proximal femur. These areas are radiolucent on X ray and they are described in life as having a ground glass appearance. Distribution of lesions in different types of brous dysplasia Type of brous dysplasia Sites affected in order of frequency Monostotic Rib, femur, tibia, cranio facial bones, humerus, vertebrae Polyostotic Femur, tibia, ribs, skull, facial bones, upper extremities, lumbar spine, clavicle, cervical spine Cranio facial Frontal, sphenoid, maxilla, ethmoids Cherubism Maxilla, mandible types are recognised: monostotic (only a single bone is affected), polyostotic (several bones affected), craniofacial which may complicate either of the rst two types or occur in isolation, and cherubism, an autosomal dominant condition with variable penetrance that occurs in children and is more severe in males than in females. In life, the condition may cause pain and deformation of the affected bones and pathological fractures are common. X rays of affected bones should showlucent areas with endosteal scalloping and sometimes, a thick sclerotic border, the so called rind sign. However it is brought to light, the help of a skeletal radiologist should always be sought before committing a diagnosis to paper. Kyphosis and Scoliosis Kyphosis refers to a forward curvature in the spine in the anteroposterior plane. There are several causes of scoliosis107 and there is also an association with the Klippel Feil syndrome108 (see below) but the most common type, accounting for up to 80% of all cases, is the so called idiopathic form. The posterior part of the ribs on the convex side are pushed backwards while the anterior part is pushed anteriorly. This results in the characteristic humped back and narrowing of the thoracic cage. The lamina and spinal canal on the concave side are narrower than on the contralateral side and the spinous process is rotated towards the concave side. The lamina and spinal canal on the concave side of thecurvearenarrowerthanonthecontralateralside. Theribsareoftenthinnerthan normal and the vertebrae are wedged towards the concave side and osteophytes are often present together with osteoarthritis of the costo vertebral joints. There are a number of vertebral anomalies that may cause scoliosis including partial or complete unilateral failure of formation, resulting in wedged or hemi vertebrae, and failure of segmentation which may be partial or complete. In this method, the proximal and distal end vertebrae are delineated, these being the vertebrae at the upper and lower limits of the curve and which tilt most towards its concavity. A line is drawn along the upper end plate of the proximal body and the lower end plate of the distal body and the angle of interest is the angle between these two lines. The Cobb angle can easily be determined on skeletons with scoliosisafterthevertebraehavebeenarticulatedandxedinposition. In those with a substantial deformity, severe cardiac and respiratory complications may arise 112 There are various ways of doing this, but one which I have found useful if to cut a section of plastic pipe insulation and pass it up (or down) through the spinal canal. Cases occur in skeletal assemblages and there is no difculty whatsoever in recog nising them for what they are; however, in some assemblages they seem to be somewhat under represented. At Christ Church, Spitalelds, for example, the crude prevalencewaslessthan1% but by contrast, Wells reported on an assemblage of 50 skeletons recovered from the church of St Michael at Thorn in Norwich. Only eight had well preserved spines and of these, two had scoliosis, both females. Klippel Feil Syndrome the original syndrome described by Klippel and Feil in 1912 was a triad comprising a short neck, low hairline and limited movement of the neck. Various other anomalies may be associated with the condition, including scoliosis, as noted above. Cervical rib: the anterior element of the transverse process of the seventh cervical vertebra is the homologue of the rib in the thoracic region and it sometimes develops to form a cervical rib of variable length. If it seems that there are thirteen ribs, however, the seventh cervical vertebra should be examined for an articular facet since cervical ribs are more common than thirteen thoracic ribs. Spina bida occulta: Spina bida occulta is the term used to describe a sacrum in which all the laminae are unfused. The mildest form of the condition in infants is also called spina bida occulta which maybesilentbutmaybeapparentinsomechildrenbythepresenceofatuftof hair or a dimple over the defect in the underlying vertebra. On this account it is strongly recommended that some other term is used to describe the innocuous condition in the sacrum; bid sacrum might be preferable but long usage of the usual phrase suggests it is not likely easily to be abandoned. The prevalence is considerable, 8% in one skeletal assemblage123 and 11% in a series of unselected radiographs. The enlargement may be unilateral or bilateral, and one or both sides may be fused to the sacrum, giving rise to eight variations,125 none of which can be missed in the skeleton. Six lumbar vertebrae: Another aspect of the instability of the lumbro sacral junc tion is the presence of six lumbar vertebrae. This confusion can be easily resolved by articulating the lumbar spine to show that they all t together nicely.

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They do not so much describe their referred source from intra abdominal or pelvic lesions anxiety disorder test 75mg venlor free shipping, such as symptoms as the degree of suffering. They fail to supply rel those of the aorta, and the genitourinary and gastrointestinal evant answers and, if the examiner insists, questions are often tracts. Some of these are briefy During the history the interviewer should obtain specifc discussed here. A good example of this is a patient with backache, followed by sciatica in which the pain in the back worsens Disc lesions causing backache and sciatica are most common instead of diminishes. Sciatica caused by a posterolateral disc protrusion can be expected from adolescence to old age. In elderly patients, lateral recess stenosis is to be more Problem solving frequently expected as the cause of root pain (Table 36. Also, degenerative spinal stenosis is a disease that occurs pre While taking the history, the examiner endeavours to fnd an dominantly in the elderly. Is it obvious that the degree of pain and effect on daily activities tally with Age (years) Disorder appearance and behaviour Most patients do not Pain: important reminders suffer from pain, rather from the disability the pain provokes. Current pain It is obvious that discodural backache will produce more dis Localization ability in a truck driver who has to sit for the whole day than in a patient who does light and varying work. Pain is the most common and important symptom and is usually what forces the patient to seek medical help. Other symptoms are not always mentioned spontaneously but should be asked about: the presence of paraesthesia, numbness, a cold foot or incontinence. Symptoms are usually presented by the patient in a very A psychologically unstable patient never touches the painful area but only points it out vaguely with the thumb. The best approach is chronological, the Back pain may be felt centrally, unilaterally or bilaterally. It is also very useful to obtain information on dication due to thrombosis in the iliac arteries may also create the same factors in previous attacks (Box 36. In disorders of the lower back, pain may be experienced as the level of the pain is also important. In backache with backache, as gluteal pain with or without reference to one or dural reference, pain is usually situated in the lower lumbo both legs, or as typical root pain. Current pain If the patient points to the upper lumbar area, the investigator should immediately be on the alert. Malignant Side and level diseases in the lower back have a great preference for this area Patients are frst asked if they feel any pain at the present time (see p. The method chosen may give In sacral, coccygeal or perineal pain and numbness, com information on emotional status. A stable patient generally pression of the S4 root is a real risk and constitutes an absolute places the palm of the hand at the site of maximal pain and contraindication to manipulation. It is important, though not always easy, to distin back and sooner or later shifts into one leg. If backache gradu tally referred and therefore experienced over a larger area, not ally increases and after some time extends into one leg and restricted to one dermatome. It may even spread upwards to fnally involves the back and both legs, a progressive lesion such the chest or down both thighs, sometimes reaching the ankles. The difference between radicular and dural pain is of the thigh, is very suggestive of a primary posterolateral extremely important in both diagnosis and treatment. The lesion occurs in young effort should therefore be made to obtain a precise description adults and is always nuclear. To a patient, Chronic sciatic pain in the elderly, extending over months a leg is a leg, and most are not precise about whether the pain to years, is typical of radicular pain from a narrowed lateral is in the front or back of the thigh, whether it spreads beyond recess. Less often, it indicates a disc lesion in a very unsta ble lumbar intervertebral joint. The Sequence of backache and root pain: which came patient should identify the frst time that the symptoms frst, backache or root pain However, there are exceptions requires further questioning on whether the problem is con and there is no point in awaiting spontaneous recovery in tinuous or intermittent. All displacements of this nature recurrent, incapacitating backache six times a year. In activity related spinal disorders, it is obvious that there is a Information about the duration of symptoms is also relationship between the symptoms and posture or exertion. There is no limit to the duration of radicular pain resulting from lateral recess Posture and exertion stenosis but in discoradicular interactions a course terminating In a discodural interaction, the ache is increased by stooping, in spontaneous recovery is the rule. Once the protrusion has lifting, sitting or coming upright after sitting and is relieved shifted to one side, symptoms tend to abate; the protrusion during walking and in recumbency. However, there are some has settled itself outside the intervertebral joint and there it characteristic histories that are slightly different from the usual lacks nutrition and shrivels away. For example, a patient between 20 within 12 months of the onset of radicular pain. However, this and 40 years of age may awake without any pain and remain only applies in patients under 60 years of age. Sitting or lying down results in cessation traction is usually the treatment of choice, except in very acute within a minute. In young patients this pattern suggests a cases where it is strongly contraindicated. In a case that is not too acute, manipulation altering the position relieves the pain. This type of disc lesion is best treated by theatre or stand at the cocktail party without low backache epidural local anaesthesia. It should be emphasized that these histories are quite dif this syndrome is typically found in the young. Another factor that may infuence symptoms is raised intra Turning in bed is also mentioned as causing a twinge and is abdominal pressure during coughing and sneezing (Box 36. Pain in these circumstances may be a dural sign produced by Root pain worsening during the night sudden increased intradural pressure, which in turn causes this results from a large protrusion with a high degree of sudden expansion of the dura pressed against the protrusion. For this reason, manipulation and traction will Although it is very often related to a disc protrusion, it is clear be of no help and the patient is best treated by an epidural that any space occupying lesion in the lumbar spinal canal com injection. Often the patient will not If lumbar movements or posture do not infuence the pain, mention it spontaneously, so the investigator must enquire there is certainly no mechanical lesion and the condition may about coughing and sneezing. A neuroma may Duration of pain evoke the same sign but the pain is usually felt more in the leg Lumbago usually recovers spontaneously within a week because than in the back. Because is possible to do fairly heavy work; the pattern is suggestive of of a decrease in intervertebral height, the counterpressure ankylosing spondylitis. The pain is felt centrally in the whole exerted by the posterior longitudinal ligament becomes less lumbar region and varies from day to day.

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Lymphocytic hypophysitis has been diagnosed immunoglobulins 0503 anxiety and mood disorders quiz order venlor cheap online, penicillin or trimethoprim, intrathe C. Any headache fullling criterion C pituitary enlargement and homogeneous contrast B. It is accompanied by be able to cause headache, other than those hyperprolactinaemia in 50% of cases or autoantibodies 1 described above, has been diagnosed against hypophyseal cytosol protein in 20% of cases. Evidence of causation demonstrated by one or the disorder typically develops at the end of preg more of the following: nancy or during the post partum period, but it can also occur in men. Previously used terms: Migraine with cerebrospinal pleo cytosis; pseudomigraine with lymphocytic pleocytosis. The neurological manifestations include sensory disorder resolves spontaneously within three months. Diagnostic criteria: Migraine aura like visual symptoms are relatively uncommon (fewer than 20% of cases). The presence of a viral prodrome in a) hemiparaesthesia at least one quarter of cases has raised the possibility of b) dysphasia an autoimmune pathogenesis of 7. Evidence of causation demonstrated by either or with this disorder supports this view. Most patients with this syndrome have no prior his Description: Headache caused by intracranial neoplasia. Other diagnoses that may share some of its clinical Diagnostic criteria: features include 1. Also to be excluded are to the intracranial neoplasia, or led to its neuroborreliosis, neurosyphilis, neurobrucellosis, discovery! Masses adjacent to the skull or dura mater intracranial neoplasia tend to be more associated with ipsilateral headaches D. Any headache fullling criterion C attacks with thunderclap onset, often triggered by pos B. A space occupying intracranial neoplasm has been tural change or Valsalva like manuvre, and associated demonstrated with reduced level or loss of consciousness. Evidence of causation demonstrated by both of parallel with worsening of the neoplasm the following: b) headache has signicantly improved in 1. Comments: the prevalence of headache in patients with Comments: the vast majority of colloid cysts of the intracranial tumours ranges from 32% to 71%. The third ventricle are discovered incidentally, having likelihood of headache is greater in young patients been asymptomatic. Nevertheless, their position imme (including children), in patients with a history of pri diately adjacent to the foramen of Monro can, on occa mary headache, and with rapid growth of the tumour sion, result in sudden obstructive hydrocephalus, or posterior fossa or midline localization. A low thresh causing headache with thunderclap onset and reduced old for investigation is suggested in any patient with a level or loss of consciousness. The other suggestive symptoms (severe, worse in the morning and associated with nausea and vomiting) are not a classical! Evidence of causation demonstrated by at least two of the following: Description: Headache caused by a pituitary adenoma 1. Hypothalamic or pituitary hyper or hyposecre tion associated with pituitary adenoma has been 1. Headache usually develops within four days after 1 demonstrated intrathecal injection, and is present in both upright C. Evidence of causation demonstrated by both of sole epileptic manifestation and requiring dierential the following: diagnosis from other headache types. The patient has recently had a partial or general More studies are needed to establish the existence of pre ized epileptic seizure ictal headache, and determine its prevalence and clinical C. Evidence of causation demonstrated by both of features, in patients with partial and generalized epi the following: lepsy. Evidence of causation demonstrated by at least Prevalence studies show tonsillar herniation of at two of the following: least 5 mm in 0. Post dural puncture b) headache has signicantly improved in headache: part I diagnosis, epidemiology, etiology and parallel with improvement of the non pathophysiology. Spontaneous spinal cerebrospinal uid for cerebrospinal uid opening pressure in children. Diagnostic uid pressure in normal obese subjects and patients criteria for headache due to spontaneous intracra with pseudotumor cerebri. Cerebrospinal uid for the pseudotumor cerebri syndrome in adults and leakage and headache after lumbar puncture: a pro children. The Idiopathic Intracranial response to the rst epidural blood patch in sponta Hypertension Treatment Trial: Clinical prole at neous intracranial hypotension. Idiopathic intracranial hyper tension: clinical nosography and eld testing of the Holle D and Obermann M. Brain tumour neurological deficits with cerebrospinal fluid headache related to tumour size, and location. A patients with suspected brain tumour: guidance for migrainous syndrome with cerebrospinal uid pleo primary care. Headache in intracranial tosis analyzed by single photon emission computed tumors. Pseudomigraine with temporary neurological symp Valentinis L, Tuniz F, Valent F, et al. Headache attrib toms and lymphocytic pleocytosis: a report of fty uted to intracranial tumours: a prospective cohort cases. Headache in Neuropsychiatric manifestations of colloid cysts: a patients with epilepsy: a prospective incidence review of the literature. Symptomatic colloid ized epilepsy in a tertiary care setting: a cross sectional cysts in the third ventricle of monozygotic twins. Headache Characteristics of headache associated with intract attributed to non vascular intracranial disorder. Treatment of mild cerebellar tonsillar ectopia in idiopathic intracranial traumatic brain injury by epidural saline and hypertension: a mimic of the chiari I malformation. Prevalence of chiari I malformation and cerebellar ectopia in patients with pseudotumor cerebri. Epileptic seizures treatment of chiari malformation with and without and headache/migraine: a review of types of associa syringomyelia: experience with 177 adult patients. Chiari mal associated with epileptic seizures: epidemiology and formation related headache: outcome after surgical clinical characteristics. Comparison of study on post ictal headache in patients with locali operative and non operative outcomes based on zation related epilepsy. International Headache Society 2018 114 Cephalalgia 38(1) Chen P K, Fuh J L and Wang S J. Headache and Chiari cise or sexual activity: a prospective etiological and malformation in young age: clinical aspects and dif clinical study. Non Headache outcomes in children undergoing foramen operative outcomes in chiari I malformation magnum decompression for chiari I malformation. Headache in ship between obesity and symptomatic chiari I mal children with chiari I malformation. Chiari malforma tion type 1: a systematic review of natural history and conservative management.

Syndromes

• Cough
• Washing of the skin (irrigation) -- perhaps every few hours for several days
• Estradiol (girls)
• Body odor
• Meat or poultry may come into contact with normal bacteria from the intestines of an animal while it is being processed
• The cream most often used is permethrin 5%.
• Dementia
• Neurosyphilis

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Although anyone can become a victim of trafficking anxiety symptoms breathing problems buy venlor 75 mg low cost, certain populations are especially vulnerable to this form of victimization. Traffickers frequently target the following types of people: Undocumented immigrants Runaway and homeless youth Victims of trauma and abuse Refugees Impoverished individuals Which Countries Are Affected By Human Trafficking Human trafficking affects every country in the world, be they countries of origin, in transit countries, or countries as final destinations. Trafficking typically originates in a developing country and victims are transported to high income countries. Victims are commonly trafficked within their country of origin and across international borders. The Physical Effects Sex trafficking is a complex problem because the victims experience physical and psychological harm. Victims also experience violence and harm from some of the people who are purchasing the sex acts. Victims can also experience gynecologic health problems that stem from forced commercial sex acts. They might suffer from sexually transmitted diseases, menstrual pain and irregularities, miscarriages, and forced abortions, among other problems. Many victims of human trafficking often do not self identify as a victim initially. Additionally, sex traffickers often intentionally misidentify women and girls as "willing" participants in the sex trade, who make a free choice to be there. Finally, victims may not know their physical location and or may not speak or understand the local language. Their traffickers typically exert tight physical and emotional control by doing the following: Confiscating their identification, cell phones, and money Forbidding communication with family or friends Monitoring and restricting movement. Mental Health Recovery for Victims of Sexual Slavery the psychological and physical trauma associated with trafficking and performing sexual acts under duress can be devastating. Understanding the physical and psychological harm that sex trafficking inflicts will help in providing care and support. Building long term, trusting relationships is at the heart of this therapeutic work, which requires time and flexible models of engagement and treatment, including group therapy with peers. The mental health needs of survivors of sex trafficking are among the most complex of crime victims. They often benefit from a multidisciplinary approach to address severe trauma, medical needs, immigration and legal issues, financial problems, safety concerns, shelter, and other basic needs, and re integration with their families of origin or acculturate to the host country. The program was designed to do the following: Empower young sex workers to negotiate for improved working conditions Provide workers with skills to save money Ultimately help them seek alternative employment options. Moreover, it trained women to act as peer educators in order to reach out to other women at risk of being trafficked. Finally, self help groups offer peer counseling on issues such as the following: Self defense from violence and harassment Access to health and legal services Skills to report cases of abuse Access to alternative employment opportunities. Conclusion: Looking Forward Survivors of sex trafficking can and do heal physically and psychologically, if able to access appropriate and culturally sensitive services and resources. In fact, former sex slaves are often the best resources in the fight against human trafficking because they have invaluable information regarding how to combat human trafficking as well as the most effective ways to help victims. They must work towards the goal of reducing sexual slavery and assisting its victims. It is important for them to include former victims in the crafting of mental health, social support, and outreach services. This includes ensuring that the following services are: Appropriate within a specific cultural, linguistic, and/or religious context Gender appropriate Capable of reaching victims. Addressing the sexual exploitation of women and girls is integral to this progress. This resource is for families who are referred to a specialist due to multiple skin spots. Many children who are evaluated for multiple skin spots do not receive a denitive answer at their rst evaluation. This does not necessarily mean an underlying condition does not exist; it simply means a diagnosis cannot yet be conrmed. For many conditions associated with skin spots, features develop over time, so ongoing follow up is necessary. The name cafe au lait spot is derived from the French term for coee (cafe) with milk (lait) because they usually have a light brown color. These spots are always darker than the surrounding skin regardless of ancestry or race. Multiple cafe au lait spots alone do not lead to any health problems but may be associated with a number of dierent conditions that could cause other medical issues. Therefore, your physician may monitor your child and be suspicious in certain situations, such as if the number of spots exceeds ve, additional spots appear over time, or your child has other physical, medical, or developmental concerns. The other associated features may cause symptoms and potential medical issues which need monitoring. They are benign and typically develop on or just underneath the surface of the skin, but may also occur in deeper areas of the body. Although they can appear at any age, neurofibromas most often develop during adolescence and pregnancy. Unlike other neurofibromas, plexiform neurofibromas need to be watched more closely for the increased risk of cancer (malignancy). Plexiform neurofibromas are typically present at birth but may not be visible early on. An eye doctor uses a bright light with a microscope (called a slit lamp) to detect these because they are often too small to be seen on routine exam. Vision loss or an early growth spurt/puberty can be the first sign of an optic pathway glioma. The severity ranges from very mild cases in which the only signs of the condition in adulthood may be multiple cafe au lait spots and a few neurofibromas, to more severe cases in which more serious complications develop. Individuals at risk need to be monitored over time at intervals deemed appropriate by their doctor. Sometimes detailed information can be overwhelming, especially since the internet may have incorrect information or highlight the most severe scenarios. Part 1: the Inflammation Checklist Find out how many inflammatory factors are active in your life at this moment. Part 2: Introduction to Basic Deflaming Concepts Basic conceptual issues are discussed and simple steps to reducing inflammatory food consumption are introduced. Part 3: Why Grains Inflame the truth we must all deal with is that grains are simply not the appropriate food to eat as a staple food. Part 4: Foods and Dietary Suggestions to Fight Inflammation Provided is a thorough list of the foods that are anti inflammatory, as well as suggestions regarding meals. Part 5: Nutritional Supplements to Help Fight Inflammation A simple and clear approach to supplementation is outlined, and supplement programs are presented. Walking 1/2 hour to 1 hour a day is sufficient for many, while more intense exercise is preferred by others.

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If acute parenchymatous tonsillitis shows markedly swollen congested oedematous tonsils and enlarged tender cervical lymph nodes anxiety medication generic 75 mg venlor overnight delivery. The upper arm is flexed and the hand is placed under his cheek and a small pillow is placed in front of his chest. In the first day, the diet consists of nd th cold fluids and semi solids and from the 2 to the 7 day, avoid hard, spicy and hot food. It is usually due to bad selection of the patient, bad dissection or injury of blood vessels. If this fails re anaesthize the patient and suture the tonsillar pillars and pack the tonsillar fossa. Its boundaries are: Anteromedial is buccopharyngeal fascia of lateral pharyngeal wall. It may be due to extension of the oedema to the larynx or direct compression on the larynx. Trans oral drainage should be avoided as it causes secondary bacterial infection and T. Initial therapy in the early stages is tried with parenteral broad spectrum antibiotics, hydration and analgesics. This is done through an external submandibular incision below and parallel to the body of the mandible. Diseases of the Hypopharynx Foreign Body Impaction Incidence: usually in children and elderly. Definition: Chronic inflammation of the mucous membrane of the hypopharynx and upper oesophagus. Aetiology: Unknown, may be iron deficiency anaemia, vitamin deficiency or autoimmune. Aetiology: neuromuscular incoordination causing premature closure of the cricopharyngeal sphincter during the act of swallowing. At the inlet of the oesophagus (the strong circular muscular fibers which act physiologically with cricopharyngeus as one unite) the most narrow part in the alimentary tract. The arch of the aorta crossing and compressing the oesophagus in the superior mediastinum. It is commonly seen in children, in mentally retarded and in elderly over 50 years of age who get obstruction with meat or bones impacting due to lack of teeth. The narrowest part of the oesophagus is the upper oesophageal sphincter (cricopharyngeus muscle) and two thirds of the F. Associated coughing or choking if the foreign body is impacted at or just below the laryngeal inlet. The patient is often able to point at the exact site particularly if it is lodged in the upper part of the oesophagus. No loss of weight despite the long standing dysphagia; due to intermittent course. Barium swallow: Marked dilatation of the lower 2/3 of the oesophagus with smooth tapering lower end (parrot peak appearance). It extends from the root of the tongue to the trachea, lying opposite the third, fourth, fifth and sixth cervical vertebrae.

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A mutant recessive allele anxiety 3000 order venlor with a visa, such as the allele that causes sickle cell anemia (see Figure 7. They do not have the disorder themselves, but they carry the mutant allele and can pass it to their offspring. The mutation that causes the disorder affects just one amino acid in a single protein, but it has serious consequences for the affected person. This photo shows the sickle shape of red blood cells in people with sickle cell anemia. This is the failure of replicated chromosomes to separate during meiosis (the animation at the link below shows how this happens). Some of the resulting gametes will be missing a chromosome, while others will have an extra copy of the chromosome. The X and Y chromosomes are very different in size, so nondisjunction of the sex chromosomes occurs relatively often. Therefore, people with a genetic disorder in their family may be concerned about having children with the disorder. Professionals known as genetic counselors can help them understand the risks of their children being affected. In this procedure, a few fetal cells are extracted from the fluid surrounding the fetus, and the fetal chromosomes are examined. Treating Genetic Disorders the symptoms of genetic disorders can sometimes be treated, but cures for genetic disorders are still in the early stages of development. At the following link, you can watch the video "Sickle Cell Anemia: Hope from Gene Therapy," to learn how scientists are trying to cure sickle cell anemia with gene therapy. A number of companies now makes it easy to order medical genetic tests through the Web. Frameshift mutations are additions or deletions of nucleotides that cause a shift in the reading frame. The majority of mutations are neutral in their effects on the organisms in which they occur. Special permission is granted to Alberta educators only to reproduce, for educational purposes and on a non proft basis, parts of this document that do not contain excerpted material. This material, along with the program of studies and the Science 30 Information Bulletin, can assist you with instructional programming. They may be used by the classroom teacher as an examination, a quiz, or a review for students. A common heart defect occurs when a hole between the left and right sides of the heart does not close before birth. The hole results in abnormal blood fow between chambers, as shown in the diagram below. Which of the following rows identifes the affected heart chambers in the diagram above and describes a result of the heart defect Ventricles Mixing of oxygenated and deoxygenated blood Alberta Education, Provincial Assessment Sector 7 Science 30 Use the following information to answer questions 2 to 4. A researcher makes the following hypothesis: Athletes who have trained at a high altitude before competing at a low altitude will have greater endurance because they are able to use oxygen more effectively. Experimental Designs of Some Circulatory System Studies I the average red blood cell count of a group of people living at a high altitude was compared with the average red blood cell count of a similar group of people living at a low altitude. V the concentration of antibodies in a group of people living at a high altitude was compared with the concentration of antibodies in a similar group of people living at a low altitude. Two of the studies described above helped to establish that altitude has an effect on immunity. Blood Vessel Description of Blood Vessel Function of Blood Vessel 1 Pulmonary 4 Walls are only one cell thick 7 Carries blood from the artery heart to the lungs 2 Aorta 5 Carries blood with a relatively 8 Allows nutrients and high pressure and high oxygen wastes to be exchanged content 3 Capillary 6 Carries blood with a relatively 9 Carries blood from the high pressure and a low oxygen heart to the rest of the content body Numerical Response 1. Using the numbers above, choose one blood vessel and match it with the description of that blood vessel and the function of that blood vessel. In a study investigating the effects of caffeine on the circulatory system, heart rate and blood pressure readings of study participants were measured after the participants were given either a caffeine pill or a placebo (sugar pill). Effects of Caffeine on the Circulatory System Time (h) 0 1 3 5 8 Average Heart Rate (beats/min) Caffeine 72 77 72 72 72 Placebo 72 72 71 71 72 Average Systolic Pressure (mmHg) Caffeine 121 128 126 126 123 Placebo 120 119 120 120 120 Average Diastolic Pressure (mmHg) Caffeine 80 83 81 81 80 Placebo 79 80 79 80 80 5. After a person has been vaccinated against a particular pathogen, he or she often needs to receive injections of the same vaccine, called booster shots, in the future in order to maintain a suffcient level of immunity against that pathogen. Booster shots increase the length of time that the person is immune to that particular pathogen. In some varieties of pea plants, the trait for drought tolerance is controlled by a single dominant allele represented by D. If a pea plant having the genotype Dd is crossed with a pea plant having the genotype dd, what percentage of the offspring would be expected to be drought tolerant Marfan syndrome is an autosomal genetic disorder that affects connective tissue in the body. Dominant Unaffected mm Alberta Education, Provincial Assessment Sector 13 Science 30 Use the following information to answer numerical response question 2. Some Biological Molecules 1 Proteins 2 Enzymes 3 Hormones 4 Amino acids 5 Nitrogen bases 6 Deoxyribose sugars 7 Phosphate molecules Numerical Response 2. Match the descriptions of each protein numbered above with its classifcation below. Some scientists are researching the possibility of using viruses to treat genetic disorders caused by a mutated gene. Three Erlenmeyer fasks were set up for an experiment to compare the properties of three different acids of equal concentration. A few drops of bromocresol green were added to each fask prior to experimentation. Which of the following rows identifes the colour of the acid solution within each fask Green Blue Yellow Alberta Education, Provincial Assessment Sector 18 Science 30 Use the following information to answer question 15. A student plans to perform a titration on lake water near her house where acid rain has been reported. Steps of the Titration 1 Rinse the burette with distilled water and then with standardized sodium hydroxide. Alberta Education, Provincial Assessment Sector 19 Science 30 Use the following information to answer numerical response question 4. A student wants to compare the buffering capacity of soil samples collected from four different locations. She records the initial pH of the soil, adds 10 mL of a strong acid solution to each sample, and after 24 hours records the pH of each soil sample. Comparison of Soil pH Before and After Addition of 10 mL of a Strong Acid Soil Source of Soil pH After Sample Soil Sample Initial Soil pH Addition of Acid 1 Nova Scotia beach 7. When the soil samples listed above are placed in order from greatest buffering capacity to least, the order is Greatest Least (Record all four digits of your answer in the numerical response section on the answer sheet. Which of the following pairs of substances could regulate changes in pH by acting as a buffer NaCl(aq)/Cl (aq) Alberta Education, Provincial Assessment Sector 20 Science 30 Use the following information to answer numerical response question 5. Much of this site is contaminated with creosote that was used to preserve wood in railway ties. One concern regarding the release of creosote into the river ecosystem could be the resulting A.

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Alcoholic cirrhosis the most common cause of cirrhosis is excessive alcohol consumption At least 75% of alcohol related deaths are attributed to cirrhosis anxiety nursing interventions buy generic venlor line. Stage of fatty change Excessive accumulation of fat with i n l i v e r c e l l s c a u s e s l i v e r enlargement Alcohols replace fat as a fuel for liver metabolism and impair mitochondrial ability to oxidize fat. Stage of Alcoholic Hepatitis It is an intermediate stage between fatty changes and cirrhosis It is characterized by inflammation and necrosis of liver cells, thus is always serious and some times fatal. Stage of cirrhosis o Cirrhosis is the direct result of liver injury caused by fatty liver and alcoholic hepatitis. Clinical Manifestations of cirrhosis The Manifestations of cirrhosis are variable, ranging from asymptomatic Hepatomegally to hepatic failure. Accumulation of metabolic bi products and toxins like bilirubin, ammonia and other substances in the circulation since the liver loses its detoxification capacity. While Gastric 140 Pathophysiology ulcers tend to affect the old age group with peak incidence in the 6th 7th decade. Inability of the mucosal barrier to resist the destructive action of the gastric secretions (enzymes & acids). B: It is more likely that both of the above factors contribute to the development of peptic ulcer diseases. Inability of the mucosal Barrier to Resist Gastric Secretions the defense of the mucosal surface depends on an adequate blood flow and intact mucosal barriers. W hich colonize the mucus secreting epithelial cells of stomach and duodenum and digest the protective mucus secreting membranes. Pain, which is described, as waning, gnawing or crampy like, is usually rhythmic and frequently occurs when the stomach is empty. The Pain is usually over small area near the mid line in the epigastrium and may radiate below the costal margins in to back or rarely to the right shoulder. An ulcer may penetrate only 144 Pathophysiology the mucosal surface or it may extend in to the smooth muscle layer. Healing of muscularis layer involving replacement with scar regeneration is often less than perfect in which repeated episodes of ulceration occur. Epigastric fullness, heaviness after meal with severe case of obstruction vomiting of undigested food. The presence of an over night gastric residual of 50ml of undigested food indicates severee obstruction. Mechanical obstruction Classifications o Extrinsic factor: Adhesions of peritoneum Hernias 146 Pathophysiology Volvulus (Twisting of the bowel lumen) o Intrinsic factors, which encroach on the patency of the bowel. Intestinal obstruction interfiles with reabsorption of 7 to 8 liters of electrolyte rich extra cellular fluid in small bowel. Lost in the vomitus of 7 liters to 8 liters which represent about half of the extra cellular fluid volume of an average adult can occur in 24hours or less following acute intestinal obstruction. If untreated, the distention resulting from bowel obstruction tends to perpetuate itself by causing atony of the bowel & further distension is aggravated by the accumulation of gases. Clinical Manifestations of Intestinal Obstructions the manifestation of intestinal obstruction depends on the degree of obstruction and its duration. With acute obstruction the onset is usually sudden and dramatic but with chronic one onset is more gradual. It is due to increased peristalsis as the intestine attempts to move the content forward. A b d o m i n a l d i s t e n t i o n: d u e t o g a s e s accumulations and atonia of the Smooth muscles in the intestinal lumen 4. Signs of Gangrenous Changes or Strangulations: If an acute intestinal obstruction left untreated for long duration, usually above 72 hours, strangulations and gangrenous change is the rule. The following are clinical signs of gangrenous changes: the patient becomes weak and prostrated. Structural classification Hormones have diverse structures ranging from single modified amino acids (epinephrine and thyroxine), poly peptides (growth hormone and insulin), and glycoproteins (follicle stimulating hormone and luteinizing hormone) to lipids (steroid hormones such as cortisol). Function Hormones do not initiate reactions; rather they are modulators of body and cellular responses. For example, thyrotropin acts selectively on the thyroid gland, where as epinephrine affects the function of many body systems. Synthesis Protein and peptide hormones are synthesized in the rough endoplasmic reticulum and stored in granules or vesicles within the cytoplasm of the cell until secretion is required. The lipid soluble steroid hormones are released as they are synthesized (smooth endoplasmic reticulum). Transport 154 Pathophysiology Hormones are delivered from cells of the endocrine gland to target cells: 1. Paracrine Metabolism Hormones secreted by endocrine cells must be continuously inactivated to prevent their accumulation. Both intracellular and extra cellular mechanisms participate in the termination of hormone function. Some hormones are enzymatically inactivated at receptor sites where they exert their action. Mechanisms of action Hormones exert their action by binding to specific receptor sites located on the surface of the target cells. The function of these receptors is to recognize a specific hormone and translate the hormonal signal into a cellular response. In this respect, the hypothalamus and the pituitary (hypophysis) act as an integrative link between the central nervous system and the many endocrine mediated functions of the body. Feedback mechanisms the level of many of the hormones in the body is regulated by negative feedback mechanisms. It can also be seen in two ways: Hypofunction and hyper function 156 Pathophysiology Hypofunction of an endocrine gland can occur for a variety of reasons. Primary defects in endocrine function originate with in the target gland responsible for producing the hormone. Diagnostic methods 157 Pathophysiology There are a number of techniques for assessing endocrine function and hormone levels. Growth hormone is stimulated by hypoglycemia, fasting, starvation, increased blood levels of amino acids and stress conditions. Growth hormone is inhibited by increased glucose levels, free fatty acid release, cortisol, and obesity. Since the problem develops after epiphyseal closure in adults, the bones are unable to grow longer. The enlargement of the bones and cartilage may cause symptoms that range from mild joint pain to deforming, crippling arthritis. Changes in physical appearance occur, with thickening and enlargement of bony and soft tissues on the face and head. The paranasal and frontal sinuses enlarge, as does the bony tissue of the forehead. Enlargement of soft tissue around the eyes, nose, and mouth results in a coarsening of facial features. Sleep apnea may also occur and is related to upper airway narrowing and obstruction resulting from increased amounts of pharyngeal soft tissues. Individuals with acromegaly are more likely to develop polyps in the colon and colon cancer. Effects on the cardiovascular system include cardiomegaly, left ventricular hypertrophy, angina pectoris and hypertension. Other systems that under go change include the respiratory, gastrointestinal, genitourinary, musculoskeletal, and nervous systems. Prolactinomas (prolactin secreting adenomas) are the most frequently occurring pituitary tumor. Common manifestations experienced by women with prolactinomas include galactorrhea, a dysfunction (anovulatory, infertility), menstrual dysfunction (oligomenorrhea or amenorrhea), decreased libido, and hirsutism. Since prolactinomas do not typically progress in size, drug (Dopamine agonist) therapy is usually the first line treatment. A deficiency of only one pituitary hormone is referred to as selective hypopituitarism.

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The infections anxiety symptoms body buy cheap venlor line, ovarian disorders, uterine fibroids, and prognosis for most cases of low backache is good. For 90% endometriosis among others, can cause pain referred to of people, even those with nerve root irritation, their the back. Normal pregnancy can cause back pain in many symptoms will improve within two months no matter ways, including stretching ligaments within the pelvis, what treatment is used, and even if no treatment is given. Additionally, An historic review shows that there is no change in the the effects of the female hormone estrogen and the pathology or prevalence of low back pain: What has ligament loosening hormone relaxin may contribute to changed is our understanding and management. These changes in the disc and the joints produce o Fractures symptoms and can be seen on an X ray. A person with o Leg length difference spinal stenosis may have pain radiating down both lower o Restricted hip motion extremities while standing for a long time or walking even o Misaligned pelvis pelvic obliquity, anteversion or short distances. Disc material z Inflammatory: expands into the spinal canal, which compresses the o Seronegative spondylarthritides. A person would experience pain, possible loss of spondylitis) sensation, and bowel or bladder dysfunction. Relief of pain is often reported when the involved o Chondrocalcinosis muscle group is stretched. Fibromyalgia results in z Psychosomatic widespread pain and tenderness throughout the body. Ankylosing spondylitis typically due to a herniation (or bulging) of the disc between the begins in adolescents and young adults. Inflammation of nerves from the spine can occur with infection of the nerves with the herpes zoster virus that Herniated discs develop as the spinal discs degenerate or causes shingles. The jelly like central portion of the disc upper back pain or in the lumbar area to cause low back bulges out of the central cavity and pushes against a nerve pain. Herniated discs are found in one third of As can be seen from the extensive, but not all inclusive, adults older than 20 years of age. Only 3% of these, list of possible causes of low back pain, it is important to however, produce symptoms of nerve impingement. Psychological and emotional factors, Spondylosis occurs as intervertebral discs lose moisture particular depression, can play a role14. Even minor trauma under these circumstances can cause Back pain is also classified into three categories based on the duration of symptoms13: inflammation and nerve root impingement, which can produce classic sciatica without disc rupture. The focus of these red flags is to detect fractures (broken bones), infections, or ii. Recent significant trauma such as a fall from a height, Pain in the lumbosacral area (lower part of the back) is motor vehicle accident, or similar incident. The pain may become age: A fall down a few steps or slipping and landing worse with activity. Occasionally, the pain may be worse on the buttocks may be considered mild trauma. One may have numbness or weakness in the part of the leg that receives its nerve supply from a compressed 4. Any person older than 70 years of age: There is an sacral nerve is compressed or injured. Another example increased incidence of cancer, infections, and would be the inability to raise the big toe upward. The Agency for Healthcare Research and Quality has identified 11 red flags32 that doctors look for when 9. Low back pain worse at rest: this is thought to be z Examination of the back: associated with an infectious or malignant cause of Palpation Range of motion or painful arc pain, but can also occur with ankylosing spondylitis. The presence of any acute nerve dysfunction should also Physical examination prompt an immediate visit. These would include the inability to walk or inability to raise or lower your foot at As part of the initial evaluation, the physician should the ankle. Also included would be the inability to raise perform a thorough neurologic examination to assess the big toe upward or walk on the heels or stand on the deep tendon reflexes, sensation, and muscle strength toes. Under certain circumstances, this may be the abdomen should be palpated to search for an acute emergency. The physician should assess joint and including difficulty starting or stopping a stream of urine, muscle flexibility in the lower extremities, examine the or incontinence, can be a sign of an acute emergency and entire spine and assess stance, posture, gait, and straight requires urgent evaluation in an emergency department. Pain with forward flexion is the most common response and usually reflects mechanical causes. If pain is If the patient cannot manage the pain using the medicine induced by back extension, spinal stenosis should be currently prescribed, this may be an indication for a re considered. In this equivalent to being exposed to daily chest radiograph for situation, further psychological testing and/or behavioural more than one year17. Laboratory tests Two major drawbacks to radiography are difficulty in the comprehensive evaluation may include a complete interpretation and an unacceptably high rate of false blood count, determination of erythrocyte sedimentation positive findings. Plain films provide following specific rate and other specific tests as indicated by the clinical information: evaluation. Chronic changes include decreased inter vertebral height, vacuum Why we need imaging Plain films have high sensitivity and specificity for bony Plain film radiography pathologies like acute fractures, spondylosis, or Plain film radiography is rarely useful in the initial spondylolisthesis, scoliosis, kyphosis, gross degenerative evaluation of patients with acute onset low back pain. They have a low or no sensitivity and specificity least two large retrospective studies have demonstrated for soft tissue pathologies like disc herniation, marrow the low yield of lumbar spine radiographs4, 5. It is an X ray study in which a radio opaque dye is injected the other study found that oblique views of the spine directly into the spinal canal. Exposure to study disc herniation and/or arachnoiditis in post unnecessary ionising radiation should be avoided. It is also issue is of particular concern in young women because useful when clinical findings are compelling and are not 34 Journal, Indian Academy of Clinical Medicine z Vol. Their routine use is however unable to differenciate disc herniation from bony, discouraged in acute back pain unless a condition is mal alignment, infectious or other extradural lesions. The present that may require immediate surgery, such as with most important limitation of myelography is its inability cauda equina syndrome or when red flags are present and to visualise entrapment of nerve root lateral to the suggest infection of the spinal canal, bone infection, termination of nerve root sheath. Rarely used less sensitive to patient movement and is also less nowadays as better non invasive radiological expensive. Complications are headache, of symptoms to rule out more serious underlying nausea, vomiting, back pain, and seizures. In addition, radiation exposure limits the amount of lumbar spine that can be scanned, Bone scintigraphy, or bone scanning, can be useful when and the results are adversely affected by patient radiographs of the spine are normal but the clinical movement. They are also useful in localising a lesion, images of tissues with no known biohazard effects. In addition, the timing of the pain are frequently of questionable clinical significance. Hence, electrodiagnostic studies than 60 years of age, and in 33 per cent of those more have only a limited role in the evaluation of acute low than 60 years of age11.