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Gonococcal urethritis caused by Neisseria gonorrhoeae Nongonococcal urethritis caused by either Chlamydia trachomatis (50%) tadacip 20 mg line, Ureaplasma urealyticum (20%) cheap 20mg tadacip with mastercard, Mycoplasma hominis (5%), Trichomonas (1%), herpes simplex Patients present with purulent urethral discharge; dysuria, urgency, and frequency in urination. Serology (fluorescent antibodies) for chlamydia by swabbing the urethra, or by ligase chain reaction test of voided urine. Single-dose ceftriaxone intramuscularly and single-dose azithromycin orally is now the treatment of choice. Clinical findings include lower abdominal and pelvic pain on palpation of the cervix, uterus, or adnexa; fever, leukocytosis, and discharge are common. If there is fluid in the retrouterine cul-de-sac, a culdocentesis is performed (rare). Ultrasonography of the pelvis may help to exclude other pathology, such as an ovarian cyst or tubo-ovarian abscess. Outpatient therapy is with single-dose ceftriaxone intramuscularly and doxycycline orally for 2 weeks. Outpatient therapy can also be with 2 weeks of oral ofloxacin and metronidazole as a second-line agent. Syphilis is a systemic contagious disease caused by a spirochete; characterized by periods of active manifestations and by periods of symptomless latency. Congenital Early: symptomatic; seen in infants up to age 2 Late: symptomatic, Hutchinson teeth, scars of interstitial keratitis, bony abnormalities (saber shins) Acquired Early infectious syphilis Primary stage: chancre appears by week 3 and disappears in 10–90 days; also, regional lymphadenopathy is painless, rubbery, discrete, and nontender to palpation (primary chancres are found on penis, anus, rectum [men], and vulva/cervix/perineum [women] but may appear on lips, tongue, etc. Latent stage: asymptomatic; may persist for life; 35% of patients develop late or tertiary syphilis Late or tertiary syphilis: most commonly neurologic Figure 7-5. Benign tertiary syphilis develops 3–20 years after the initial infection; typical lesion is the gumma (a chronic granulomatous reaction) found in any tissue or organ, which will heal spontaneously and leave a scar Cardiovascular syphilis and neurosyphilis are the other manifestations of tertiary syphilis. The Argyll Robertson pupil (usually only with neurosyphilis) is a small irregular pupil that reacts normally to accommodation but not to light. Tabes dorsalis (locomotor ataxia) results in pain, ataxia, sensory changes, and loss of tendon reflexes. Neurosyphilis is rare and is essentially the only significant manifestation of tertiary syphilis likely to be seen. A reaction called Jarisch-Herxheimer can occur in >50% of patients (general malaise, fever, headache, sweating rigors, and temporary exacerbations of the syphilitic lesions 6–12 hours after initial treatment). Penicillin-allergic patients receive doxycycline for primary and secondary syphilis, but must be desensitized in tertiary syphilis. Chancroid Lesion Centers for Disease Control and Prevention Patients present with small, soft, painful papules that become shallow ulcers with ragged edges. Diagnosis is made on clinical findings; do a Gram stain initially with culture to confirm. Treatment is azithromycin single dose or ceftriaxone intramuscularly (single dose). Clinical findings include the following: Small, transient, nonindurated lesion that ulcerates and heals quickly Unilateral enlargement of inguinal lymph nodes (tender) Multiple draining sinuses (buboes) that develop (purulent or bloodstained) Scar formation, persistent sinuses; fever, malaise, joint pains, and headaches (all common) Diagnosis is made by clinical examination, history, and a high or rising titer of complement fixing antibodies. Diagnosis is made clinically and by performing a Giemsa or Wright stain (Donovan bodies) or smear of lesion. Lesions of Granuloma Inguinale Due to Calymmatobacterium Granulomatis Infection phil. Vesicles develop on the skin or mucous membranes; they become eroded and painful and present with circular ulcers with a red areola. Lesions are commonly seen on the penis (men) and on the labia, clitoris, perineum, vagina, and cervix (women). They appear as soft, moist, minute, pink, or red swellings which grow rapidly and become pedunculated. Differentiation must be made between flat warts and condylomata lata of secondary syphilis. Treatment includes the following: Destruction (curettage, sclerotherapy, trichloroacetic acid) Cryotherapy Podophyllin Imiquimod (an immune stimulant) Laser removal Clinical Recall Which of the following is the treatment of choice for tertiary syphilis? For the last several days, she has burning on urination with increased frequency and urgency to urinate. Roughly the same as for pyelonephritis Any cause of urinary stasis or any foreign body predisposes Tumors/stones/strictures/prostatic hypertrophy/neurogenic bladder Sexual intercourse in women (“honeymoon cystitis”) Catheters are a major cause, and the risk is directly related to the length of catheterization (3–5% per day). Common presenting symptoms include dysuria, frequency, urgency, and suprapubic pain. Less common symptoms include hematuria, low-grade fever; foul-smelling and cloudy urine. Urine culture with >100,000 colonies of bacteria per mL of urine confirmatory but not always necessary with characteristic symptoms and a positive urinalysis. Treatment For uncomplicated cystitis, 3 days of trimethoprim/sulfamethoxazole, nitrofurantoin, or any quinolone Seven days of therapy for cystitis in diabetes Quinolones should be avoided in pregnancy. Predisposing factors include obstruction due to strictures, tumors, calculi, prostatic hypertrophy, or neurogenic bladder, vesicoureteral reflux Women > men More common in childhood, during pregnancy, or after urethral catheterization or instrumentation E. Pathology shows polymorphonuclear neutrophils and leukocytes (in interstitial tissue and lumina of tubules). Clinical findings include chills, fever, flank pain, nausea, vomiting, costovertebral angle tenderness, increased frequency in urination, and dysuria. Antibiotics for 10–14 days (fluoroquinolone), or ampicillin and gentamicin, or a third-generation cephalosporin are all acceptable. Most patients can be treated as outpatients, though pregnant women who appear very ill and those unable to tolerate oral medication due to nausea or vomiting should initially be hospitalized. Although any factor predisposing to pyelonephritis is contributory, stones are the most important and are present in 20–60%. Other structural abnormalities, recent surgery, trauma, and diabetes are also important. Pathophysiology Arises from contiguous pyelonephritis that has formed a renal abscess Rupture occurs through the cortex into the perinephric space Microbiology: 1) The same coliforms as in cystitis and pyelonephritis; 2) E. Fever and pyuria with negative urine culture or polymicrobial urine culture are suggestive. Antibiotics for gram-negative rods Third-generation cephalosporins, antipseudomonal penicillin, or ticarcillin/clavulanate, often in combination with an aminoglycoside, for example Antibiotics alone are unlikely to be successful. Over the last 4 days, he developed an ulcer over the proximal portion of his tibia just below the knee. He has a sinus tract in the center of the red, inflamed ulcer that is draining purulent material. Osteomyelitis is an infection of any portion of the bone including marrow, cortex, and periosteum. Acute hematogenous occurs mostly in children in the long bones of the lower extremities and is secondary to a single organism 95% of the time. The most commonly involved bones are the tibia and femur, and the location is usually metaphyseal due to the anatomy of the blood vessels and endothelial lining at the metaphysis. In adults, hematogenous osteomyelitis accounts for about 20% of all cases and the most common site is the vertebral bodies (lumbar vertebrae are most frequently involved). Secondary to contiguous infection can occur in anyone with recent trauma to an area or placement of a prosthetic joint. Although this is secondary to a single organism most of the time, a higher percentage is polymicrobial in origin. Vascular insufficiency is mostly seen age >50, with diabetes or peripheral vascular disease, resulting in repeated minor trauma that is not noticed because of neuropathy and decreased sensation. With vascular insufficiency, there is often an obvious overlying or nearby ulceration or wound. Plain x-ray: Usually the initial test because it is more easily obtained, easily read, and inexpensive. The disadvantage is that 50–75% of bone calcification must be lost before the bone itself appears abnormal, which usually takes at least 2 weeks to develop. Bone biopsy and culture: This is the best diagnostic test but also the most invasive. Acute hematogenous osteomyelitis in children can usually be treated with antibiotics alone; however, osteomyelitis in adults requires a combination of surgical (wound drainage and debridement, removal of infected hardware) and antibiotic therapy. Antibiotic therapy depends on the specific isolate obtained, which must be as precise as possible because empiric treatment for 6–12 weeks would be undesirable. Chronic osteomyelitis must be treated for as long as 12 weeks of antibiotic therapy, and in some cases, even longer periods of antibiotics may be required.

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If blood is seen coming through the pylorus discount 20 mg tadacip visa, there is every possibility that duodenal ulcer is bleeding buy tadacip 20 mg amex. Bleeding from the stomach and duodenum can be treated with a number of haemostatic measures. Gastroduodenoscopy with fibreoptic instrument is essential to find out duodenal bleeding point. If endoscopy does not give any clue to the diagnosis, a barium meal examination should be performed on the following morning. A decision should be made within 48 hours of commencement of bleeding, whether surgery should be undertaken or not. Experience has shown that when operation is delayed beyond that time the mortality rises sharply. In a few cases operation should be undertaken quickly after preliminary resuscitation. Indications for immediate operations are :— (i) Those patients who rebleed after admission to hospitals. In case of chronic duodenal ulcer the treatment of choice is probably underrunning the bleeding point, pyloroplasty and vagotomy. In case of gastric ulcer, gastrotomy and underrunning of the bleeding vessels should be performed. At this time four-quadrant biopsy of the ulcer should be taken to prove it to be benign. If the bleeding vessel is near the pylorus, a wide pyloroplasty should be made alongwith direct suturing of the bleeding vessel at the ulcer base. If no ulcer is found, the gastrotomy is extended to detect erosions or vascular malformations. If erosions are found to cover a wide distal area of the stomach, a Billroth I partial gastrectomy should be performed. Diagnosis and finding out of the bleeding vessels are extremely important in case of upper G. Chronic Stenosis Mainly three types of stenosis are seen as complications of peptic ulcer. After months of intermittent obstruction it may suddenly cause complete obstruction of the pylorus. Though the patient can usually take breakfast and lunch, yet rejects afternoon tea and never takes dinner. If this symptom is not present, the diagnosis of pyloric stenosis should be reconsidered. This usually takes place in the evening and the vomitus contains undigested particulate matter taken on that day or one or more days earlier. Visible peristaltic waves passing from left to right is quite characteristically noticed after giving anything to drink. A succussion splash is often heard on shaking the patient and keeping the clinician’s ear very near to the patient’s abdomen. On ausculto-percussion the greater curvature can be delineated and the stomach is found grossly distended. Gastric function tests will show huge quantity of fasting content due to stagnation of old food. There is low acid content due to chronic gastritis from fermentation of stagnant food in the stomach. Absence of bile in all the samples and copious amount of mucus due to chronic gastritis are detected in aspirated samples. Barium meal examination will show a large and low stomach and presence of barium even after 6 hours. Emptying of stomach is much below normal and in the first plate while the stomach is full of barium yet the duodenal bulb is not full with barium. Gastric juice contains 10 mEq/ litre of potassium so potassium deficiency is also obvious. To replenish this loss, administration of sodium chloride and potassium chloride solution usually suffice. When a patient with gastric outlet obstruction is admitted to the hospital, any significant acid base and electrolyte abnormality must be corrected. Polythene Ryle’s tube or large bore Ewald tube should be introduced into the stomach. Due to technical reasons gastrojejunostomy or gastroenterostomy is more preferred to pyloroplasty. Since duodenal ulcer is almost always associated with high acid secretion and this condition is a complication of chronic duodenal ulcer the treatment should always be vagotomy alongwith antrectomy or more often gastrojejunostomy. Periodicity is lost k H a n d the symptoms practically fplrcontinue without any remission. It may be confused with pyloric stenosis when the second pouch fails to fill with barium. Gastroscopy will reveal the upper chamber and the scarred channel leading to the lower compartment. This will produce stagnation and may mimic in many ways the symptoms of pyloric stenosis. Note the ulcer crater with malignant guide lines Penetration to pancreas from a posteriorly placed gastric or that no longer run straight and are be­ duodenal ulcer may take place. Ulcers near the greater curvature and near the lesser curvature below the angulus are more prone to malignant change. Ulcers in the characteristic situation near the lesser curvature are very rare to undergo carcinomatous change. It is due to this prone to malignancy that treatment of gastric ulcer is different from that of duodenal ulcer. Endoscopy and even four quadrant biopsy will definitely give a clue whether malignant change has involved in an ulcer or not. When periodicity is lost and vomiting does not relieve pain in gastric ulcer, malignancy may be suspected. Residual Abscess Subacute perforation or leaking perforation or chronic perforation may cause residual abscess formation. Benign tumours are mostly (i) Polyps, (ii) Leiomyoma, (iii) Lipoma; (iv) Neurofibroma and (v) Ectopic pancreas. While the former is an inflammatory lesion and much more common (20% of benign tumour and 90% of benign polyps), the latter is the true tumour. Besides the two varieties mentioned above, adenomatous polyps may arise in the stomach in conjunction with multiple small bowel polyposis (Peutz-Jeghers syndrome) or the familial polyposis of Gardner’s syn­ drome. These are usually asymptomatic, except when they are adjacent to the pylorus and prolapse through it causing symptoms of pyloric obstruction to appear. These polyps are usually associated with atrophic gastritis, megaloblastic anaemia, achlorhy- dria and intestinalisation of gastric mucosa. Intense interest has existed and conflicting opinions have been expressed regarding the malignant potentiality of hyperplastic polyp of the stomach. Approximately 30% of these polyps may coexist in stomachs with invasive carcinoma. The possibility may be that achlorhydric patient with intestinalisation of gastric mucosa are responsible for development of both cancer and hyperplastic polyp. This adenoma also develops in achlorhydric patients with atrophic gastritis and intestinalisation of gastric mucosa. Fibreoptic endoscopy has facilitated the diagnosis and treatment of gastric polyps. Pedunculated lesions can be totally excised by use of the snare and cautery and the histology of the lesion is established. Further surgical treatment is indicated (a) when the polyp is more than 2 cm in diameter and one is not sure from the histological report that the tumour is benign and (b) when the sessile lesion is more than 2 cm in diameter. A solitary sessile lesion is best removed by wedge excision with a margin of surrounding gastric wall and submitted for frozen section examination.

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Q. Iomar. University of the District of Columbia. 2019.

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