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!=;6;.-= V2-10+2 ;8)(?+ 8-@8+2 3)2+-)0+@) %@5.%(@. %2 T()<(@ )<+ 72+?(%/E [ 0%@)2(>>+@ B%2 0%2+ )<-@ = >-9E %2 0-G%2 E/2.+29N T()<(@ U T++JE A%8-*(e+> )+@>+2@+EE -*%@. )<+ >(E)2(1/)(%@ %B )<+ >++7 ?+@%/E E9E)+0 Q@)(2+ *+. ET%**+@ I-*B ET+**(@. i = 80 8%07-2+> )% )<+ -ES *+. 30+-E/2+> 1+*%T )(1(-* )/1+2%E()9: ,())(@. %+>+0- 3.2+-)+2 (@ )<+ E907)%0-)(8 *+.: I%**-)+2-* E/7+2B(8(-* ?+(@E 3@%@?-2(8%E+: ;*)+2@-)(?+ >(-.@%E(E -E *(J+*9 %2 0%2+ *(J+*9 )<-@ )<-) %B >++7 ?+@%/E )<2%01%E(E
H.,+2 ! ! ! ! ! ! ! ! 5#
High Probability: ≥ 3 – )2+-) -E E/E7 HM' -@> 7+2B%20 8%072+EE(%@ Z^6 4%>+2-)+ ,2%1-1(*()9 ! %2 # – )2+-) -E E/E7 HM' -@> 7+2B%20 8%072+EE(%@ Z ^6 Low Probability ≤0 – H5>(0+2 )+E) !!
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H%!"#7(GL (#(@ O?HH>G% Crohn’s Disease (fissure in lateral position) QS)2-57/*0%@-29 'D ;@-* 6c/-0%/E I+** I-@8+2 ;@%2+8)-* ](E)/*F@B+8)(%@E – I4MN R6MN 8<*-09>(- -@> E97<(*(E I(#()%I%#$ FB -^T 2+8)-* 1*++>(@. %BB+2 8%*%@%E8%79 4%E) T(** <+-* 1+8-/E+ %B .%%> 1*%%> E/77*9 3T()<(@ ! >-9 ^ # >-9E: _Od %B 7-)(+@)E <+-* T()< 0+>(8-* )2+-)0+@) ! A(B+E)9*+ 0%>(B(8-)(%@E 3(@82+-E+> B(12+: ! 6()e 1-)(7(@+ %(@)0+@) ! X'$ 7-E)+ ! D%)/*(@/0 )%S%(> (@G+8)(%@E -
If they don’t heal, usually >/+ )% E7-E0 %B (@)+2@-* E7<(@8)+2 0/E8*+ E/2.(8-* 0-@-.+0+@) *-)+2-* (@)+2@-* E7<(@8)+2%)%09 3AF6: 3_Od E/88+EEB/*: Y+8/22+@8+ -@> 0(@%2 (@8%@)(@+@8+ %88/2 (@ r !Od %B 7-)(+@)E
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D1 &;)1<*(&2 4-. MJ )'+7C )*2&7,) EX^<
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* Note: liver function test indicates the ‘ health’ of various components of the liver; transaminases (AST & ALT) indicate hepatocyte health, al kaline phosphatase & γL62'7&<9273&(CJ,3&C, ES=H T BBAF *()*+&7, ;*2, )'+7 ,:*78,2*'< 8,&278K 2*P,3 :317,*(C C'+8 &C &2;'<*( T +2177*(6 J&+713C E<,&C'3,) *( :31Y9 ;9 HA-HAAF C,3P, &C & C,P,3*79 *(),Y 71 *()*+&7, 3,C*)'&2 2*P,3 J'(+7*1( RR S=HU +1(C*C7 1J & 631': 1J *C1L,(b9<,C J1'() *( E!F 2*P,3K E\F ;*2, )'+7K E"F /*)(,9K E]F ;1(,K EeF :2&+,(7&K E`F < &2*6(&(7 7'<1'3 E*_,_ ;31(+8*&2 +&3+*(1<&F 8,&7 *(&+7*P&7*1( +&( C,:&3&7, *7 *(71 8,&7 2*&;2, E;1(,F &() 8,&7 C7&;2, E2*P,3F f;1(, ;'3(CK 2*P,3 2&C7CgK S=H +&( &2C1 P&39 ?*78 &6, ;,*(6 ,2,P&7,) *( :3,6(&(+9 &() +8*2)3,( !"#
%00-'%@* ) ''+#) -A@) "B$:%AC!"@$D @;C73'+7*P, %&'()*+, 3,C'27C J31< ;*2*&39 1;C73'+7*1( ?8*+8 *C ;21+/&6, 1J &(9 )'+7 78&7 +&33*,C ;*2, J31< 2*P,3 71 6&22L;2&)),3 &() 78,( 71 78, C<&22 *(7,C7*(,C %&'()*+, *C ),J*(,) &C 9,221? :*6<,(7&7*1( 1J 78, C/*( &() ,9,C &C & 3,C'27 1J ,Y+,CC ;*2*3';*( *( 78, +*3+'2&7*1(K +2*(*+&229 ),7,+7&;2, ?8,( 2,P,2C &3, X]d'<12-= E(13<&2U h\\'<12-=F
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0812,C7&C*CU ),+3,&C,) ),2*P,39 1J I3 *(71 78, *(7,C7*(, EC';C,a',(7 &++'<'2&7*1( *( 78, 8,:&71+97,C &() *( ;211)F +&( ;, )', 71 ),J,+7 *( 8,:&71+,22'2&3 JY E<,)*+&2 5&'()*+,F 13 1;C73'+7*1( *( ;*2*&39 73,, EC'36*+&2 5&'()*+,F_ 4C*(6 8*C7139K :89C*+&2 ,Y&<*(&7*1( &() 8&,<&71216*+&2 *(P,C7*6&7*1(C E=QAC 717&2 I3K S=HK BBAF +&( 8,2: )*JJ,3,(7*&7, 8,:&7*+ PC_ :1C7L8,:&7*+ 5&'()*+,
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D*JJ,3,(7*&2 E(1(L;*2*&39FU ;&C,) 1( 7*<, &J7,3 1:,3&7*1( E!F ?*78*( ]^ 81'3C – ;3,&/)1?( 1J WI0K E\F eL!d)&9C – C,+1()&39 71 *(73&1:,3&7*P, 89:17,(C*1( - 89:1Y,<*&K E"F nL!d )&9C – <,)*+&7*1( *()'+,) 8,:&7*7*CK E]F Xn )&9C – &-? <&(*J,C7&7*1( 1J C,:7*+ 3,C:1(C,K EeF eL!\ ?,,/C – (1(LS-I-0 P*3&2 8,:&7*7*C &J7,3 73&(CJ'C*1( 1J ;211) :31)'+7C
k8&7 &3, 78, :1CC*;2, +1<:2*+&7*1(Cj
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N&2*6(&(7 - 0812&(6*1+&3+*(1<& E)*C7&2F I,(*6( - N*3*bb* C9()31<, - H&(+3,&7*7*C OY73&<'3&2 N&2*6(&(7 - V,&) 1J :&(+3,&C +&(+,3 - N,7&C7&C,C 71 78, :137& 8,:&7*C E<&2*6(&(7 29<:8 (1),CF
0*.#"@%, $P%/"C%)"'C [*7&2CU *C :&7*,(7 8,<1)9(&<*+&229 C7&;2,j S(9 J,P,3j B,(,3&2 M(C:,+7*1(U 5&'()*+,j S(9 &;)1<*(&2 )*C7,(7*1(j S(9 2,6 C?,22*(6j S;)1<,(U - S(9 C+&3C 1J &;)1<*(&2 C'36,39j - .7*6<&7& 1J +831(*+ 2*P,3 )*C,&C,j – 69(&,+1<&C7*&K C:*),3 (,P*K +&:'7 <,)'C&,K - B,(,3&2*b,) )*C7,(7*1(j E&C+*7,C +1'2) ;, )', 71 <&2('73*7*1(K :,3*71(,&2 <&2*6(&(+9K 13 1;C73'+7*1( 1J :137&2 P,*( ;9 +&(+,3F - V,:&71<,6&29j E01'2) ;, )', 71 <,7&C7&7*+ )*C,&C,K 13 :3*<&39 2*P,3 :&7812169F - O(2&36,) :&2:&;2, 6&22;2&)),3j EW,+&22 Courvoisier’s law – *J 78, 6&22;2&)),3 *C :&2:&;2, *( & :,3C1( ?*78 :&*(2,CC 1;C73'+7*P, 5&'()*+,K 78, +&'C, *C '(2*/,29 71 ;, C71(,CF - .:2,(1<,6&29j EH137&2 89:,37,(C*1( – 78*(/ :3,L8,:&7*+K 8,:&7*+K :1C7 8,:&7*+F DWOU H&2, C7112Cj 0,3P*+&2 &() C':3&+2&P*+'2&3 29<:8 (1),C I1(9 7,(),3(,CC W,C:*3&7139 ,Y&<*(&7*1(
"CB$#)"E%)"'C# +I>>=? Q*3C729 71 +1(J*3< 1;C73'+7*P, 5&'()*+,U !_ =QA – +2&CC*+&2 1;C73'+7*P, :*+7'3, &_ I*2*3';*( 3&*C,) EZ )*3,+7X*()*3,+7o G13<&2 "UnF ;_ W&*C,) S=H E&() BBA– 1(29 13),3,) *J )Y *C &<;*6'1'CK (17 31'7*(,F <13, 78&( S.A &() S=A RR+2&CC*+&2 :*+7'3, <13, 1J7,( C,,( *( 0S 78&( 6&22C71(, )*C,&C, +_ N*2)29 3&*C,) 2*P,3 ,(b9<,C ES=A-S.AF – ;*2*&39 ;&+/:3,CC'3, 2,&)C 71 8,:&71+97, )&<&6, .,+1()29 71 +1(J*3< *(J2&<<&7*1(-*(J,+7*1(U \_ QI0 – ↑TW to suggest bacterial (J,+7*1( i E*<:7 &C C1<, :7C 8&P,(’t <1'(7,) J,;3*2, 3,C:1(C,FK &(,<*& E+133,+7 ;,J13, OW0HFK 7831<;1+971:,(*& E+831(*+ 2*P,3 )*C,&C,K P*3&2 *(J,+7*1(F A8*3)29 71 &CC,CC J13 :17,(7*&2 +1<:2*+&7*1(C "_ 4-O-03 – &CC,CC ),89)3&7*1(K VW.K 03 2,P,2 J13 C'*7&;*2*79 1J 0A *<&6*(6p ]_ S<92&C, – &(9 +1(+1<*7&(7 :&(+3,&7*7*C e_ HA-HAA – &(9 :3121(6,) HA J31< P*7&<*( i <&2&;C13:7*1(K +1&6'21:&789 C,+1()&39 71 2*P,3 )9CJ'(+7*1( E71 ;, 0@WWO0AOD ;,J13, :31+,)'3,C 2*/, OW0H +&( ;, )1(,FK C,:C*C +&'C*(6 DM[0-+1&6'21:&789 `_ A'<1'3 <&3/,3C – 0S !#L#K 0OS E+812&(6*1+&3+*(1<& &() :&(+3,&7*+ +&(+,3F n_ I211) +-C *J J,;3*2, &() 5&'()*+,) EAW@ VI. C,:C*CF ^_ BcN – *( +&C, 1J 1: E*_,_ +812,+9C7,+71<9F
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WV0 7,(),3(,CC ?*78 6'&3)*(6 J1'() 1( +2*(*+&2 ,Y&<*(&7*1( Murphy’s sign positiveE*(C:*3&7139 &33,C7 )'3*(6 ),,: :&2:&7*1( 1J 78, W4rF Boas’s sign – 89:,3&,C78,C*& ;,21? 78, 3*687 C+&:'2& H&2:&;2, BI E"dmF– 1<,(7'< ?3&::*(6 &31'() BIo ?13C7 +&C, C+,(&3*1 *C ,<:9,<& N*2) %&'()*+, <&9 ;, :3,C,(7K *J C,P,3, +1(C*),3 178,3 )*JJ,3,(7*&2C
"CB$#)"E%)"'C# !_ 4273&C1'() VI.– J,&7'3,C 1J &+'7, +812,+9C7*7*C *(+2'),C &F A8*+/,(,) B&22;2&)),3 k&22 ;F Sonographic Murphy’s positive +F H,3*+812,+9C7*+ J2'*) E1,),<& 1J 6&22;2&)),3 ?&22F )F H3,C,(+, 1J 6&22C71(,C *( ;*2*&39 C9C7,< ,F 01(73&+7,) 6&22;2&)),3 EJ31< +831(*+ 6&22C71(, )*C,&C,F \_
0A S;)1<,( &F Q&7 C73&()*(6 &31'() 6&22;2&)),3 (17 C,,( 1( '273&C1'() ;'7 1( 0A ;F OY+2'), +1<:2*+&7*1(C E,<:9,<&K :,3J13&7*1(F
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QI0U 2,'/1+971C*C – *J C,P,3,29 ,2,P&7,) EX\dF – +1(C*),3 +1<:2*+&7*1(C E*_,_ 6&(63,(,K :,3J13&7*1(K +812&(6*7*CF S<92&C, E+&( ;, 3&*C,) <*2)29K *J X!dddK :&(+3,&7*7*CpFK =QA E<*2) 73&(C&<*(*7*CF 4-O-03 E),89)3&7*1(F 0cWK i4I &F W&)*1:&a', 6&22C71(,CK &,31;*2*& E)', 71 J*C7'2&F_ ;F OY+2'), 21?,3 21;, :(,'<1(*&K :,3J P*C+'CK &;(13<&2 3*687 8,<*)*&:8-7813&Y H3,L@:U HA-HAAK O0B
S22 78,3&:,'7*+ 3,6*<,(C 3,7&*(*(6 78, BI 8&P, edm 3,+'33,(+, 1J C71(,C &J7 e93C E(1 =A ;,(,J*7F
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/%C%E$/$C) Assess the patient’s vitals and r ,C'C+*7&7, 78, :&7*,(7 *J (,,),) – M[ J2'*) 3,C'C+*7&7*1( O<:*3*+&2 *(73&P,(1'C &(7*;*17*+C – M[ +,J73*&Y1(, &() <,731(*)&b12, GIN – ;1?,2 3,C7
@'/0,"@%)"'C# F%@A)$ @*',$@.#)")"#G DW *Q=1>5? - 09C7*+ )'+7 1;C73'+7*1( 2,&)C 71 & 7,(C, 6&22;2&)),3 J*22,) ?*78 <'+'C - N&9 2,&) 71 6&22;2&)),3 ?&22 (,+31C*C *J :3,CC'3, ,Y+,,)C +&:*22&39 ;211) :3,CC'3,
0&3,J'2 <1(*713*(6 J13 C*6(C 1J J&*2'3, E:,3*71(*C
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S(&26,C*& D,J*(*7*P, 73,&7<,(7 – 1:,( 13 2&:&31C+1:*+ +812,+9C7,+71<9 S27,3(&7*P, A3,&7<,(7 – :,3+'7&(,1'C +812,+9C71C71<9 !
!
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M(P12P,C :,3+'7&(,1'C +&78,7,3 :2&+,<,(7 *( 78, 6&22;2&)),3 2'<,( '(),3 *<&6*(6 6'*)&(+, E&27,3(&7*P, 71 C'36*+&2 +812,+9C7,+71<9F M()*+&7*1(CU <13*;'() :&7*,(7C ?81 &3, (17 J*7 J13 C'36,39 13 ?8,( ,&329 C'36,39 *C )*JJ*+'27 )', 71 ,Y7,(C*P, *(J2&<<&7*1( D3&*(C 78, 6&22;2&)),3 &() &22,P*&7,C 78, *(J2&<<&7*1( E3,C12P,C &+'7, ,:*C1),F Q1221?,) ;9 ,2,+7*P, +812,+9C7,+71<9 ]L` ?,,/C 2&7,3
04Q?8>I>O896I $LL297? >L @4>I29Q?7297>HQ d W,J2'Y )*C,&C, T ;*2*&39 6&C73*7*C E\ 71 78, 21CC 1J +1(+,(73&7*(6 &+7*1( 1J 78, BI 2,&)*(6 71 *(+3,&C,) J21? 1J ;*2,F S;)1<*(&2 :&*( T )*&3381,& E\ d 71 )*C7'3;,) <*+,22,C J13<&7*1( 2,&)*(6 71 J&7 *(712,3&(+, &() <&2&;C13:7*1(F )8H8L 94>I29Q?7297>HQ D,:,(),(7 1( C,P,3&2 J&+713CU ! ! !
.,P,3*79 1J *22(,CC W,C:1(C, 71 3,C'C+*7&7*1( &() &(7*;*17*+ 78,3&:9 =16*C7*+&2 +1(C*),3&7*1(C E&P&*2&;*2*79 1J @AK C'36,1( ,7+_F
-
H1CC*;*2*7*,C &P&*2&;2,U ! ! !
$H21O2<9QE*<<,)*&7,o *( C*+/ :&7*,(7C ?81 &3, (17 3,C:1()*(6 71 73,&7<,(7F $61IQE?*78*( J,? )&9C 1J 1(C,7F !2I6Q2=d"<721K6I E&J7,3 `L^ ?,,/CF $61IQ
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N,7&L&(&29C*C` 1J ,Y*C7*(6 2*7,3&7'3, C81?C (1 C*6(*J*+&(7 )*JJ,3,(+,C *( ,&329 P,3C'C ),2&9,) :31+,)'3,C ?*78 3,6&3)C 71 <137&2*79K +1(P,3C*1( 3&7,CK ;*2, )'+7 *(5 '39 &() :,3*L1:,3&7*P, +1<:2*+&7*1(C S)P&(7&6,C O&C*,3 71 1:,3&7, &C 78, 6&22;2&)),3 *C 1,),<&71'C W,)'+,) 81C:*7&2 2,(678 1J C7&9 D*C&)P&(7&6,C H1CC*;29 8*68,3 3*C/ 1J 1:,3&7*P, +1<:2*+&7*1(C E+1(731P,3C*&2F – "Y 8*68,3 3*C/ 78&( J13 , 2,+7*P, C'36,39n
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D*C&)P&(7&6,C 08&(+, 1J *(7,3P&2 +1<:2*+&7*1(C 3,a'*3*(6 3,L &)<*CC*1(
-
N1C7 +1<<1( C*7, 1J 1;C73'+7*1( *C 7,3<*(&2 *2,'< E\ J,,7 :31Y*<&2 71 *2,1+,+&2 P&2P,F H:7U '(,Y:2&*(,) 63&)'&2 1(C,7 1J .I 1;C73'+7*1( MYU ScWK I&3*'< J1221? 7831'68 .<&22 C71(,C Eh\L"+
0-'EC'#"# em <137&2*79 G,&329 &22 X`d9,&3CK ?*78 DN 0&'C,CU \t +&3)*1P&C+'2&3 :'2<1(&39 +1<:2*+&7*1(C E12),3FK '(+1(73122,) C,:C*C ?*78 :,3*71(*7*C &() *(73&L&;)1<*(&2 &;C+,CC
I3 % .'36_ \d!do#nU!]! S3+8 .'36_ !##`o!"!U"^\ !]^
@*',$!'@*',") *"%#"# H3,C,(+, 1J 6&22C71(,C *( 78, +1<<1( ;*2, )'+7 E13*6*(&7,) J31< 78, 6&22;2&)),3 &() :&CC 7831'68 78, +9C7*+ )'+7 *(71 78, +1<<1( ;*2, )'+7F 0-$#$C)%)"'C W4r 13 ,:*6&C73*+ :&*( E:&*( 1J7,( <13, :3121(6,) 78&( C,,( ?*78 ;*2*&39 +12*+F G&'C,& &()-13 [1<*7*(6 @;C73'+7*P, %&'()*+, – 7,&L+121'3,) '3*(,K :&2, C7112C 01<:2*+&7*1(CU &+'7, +812&(6*7*C T &+'7, :&(+3,&7*7*C "CB$#)"E%)"'C# +,''!# =QACU ! O&329 ;*2*&39 1;C73'+7*1(U S=A-S.A ,2,P&7,) ! =&7,3U S=H-.,3'< I3 E)*3,+7F-BBA <13, ,2,P&7,) 78&( S.A-S=A E+812,C7&7*+ :&77,3(F QI0U 2,'/1+971C*C E<&9 C'66,C7 +812&(6*7*CF .,3'< S<92&C,U E0ID C71(, <&9 +&'C, :&(+3,&7*7*CF "/%E"CE 4273&C1'() VI. B&22C71(,C *( 6&22;2&)),3 B&22C71(, *( 0ID – )'+7&2 C71(,C P*C*;2, qedm 1?*(6 71 1;C+'3*(6 6&C *( 78, )'1),('< D*2&7,) 0ID ^ ! e<< *C (13<&2 *( 78, edC &() `<< *( 78, `dC &() C1 1( ! M( 12),3 :&7*,(7CK :1C7L+812,+9C7,+71<9K 13 :&7*,(7C 1( =A 1:*&7,CK 78, 0ID <&9 ;, 2&36,3 @78,3 N1)&2*7*,CU NW0HK O4.
b /%C%E$/$C) #;1O21Q =&:&31C+1:*+ 0812,+9C7,+71<9 E=0F &() *(73&L1:,3&7*P, +812&(6*163&:89 EM@0F J1221?,) ;9 =&:_ 0ID ,Y:213&7*1( E*J C71(,C &3, C,,(F ! Z 1:,( 0ID ,Y:213&7*1( 13 :1C7L1: OW0H E*J =&:_ 0ID ,Y:213&7*1( J&*2C 71 +2,&3 C71(,F $<=>?9>589 OW0H ?*78 C:8*(+7,3171<9 &() C71(, 3,<1P&2 M(7,3P&2 =0 ?*78 M@0
k8,( 71 )1 1:,3&7*P, 3,<1P&2 1J C71(,C E*_,_ (17 C'*7&;2, J13 OW0HF .71(, X\e<< M(73&8,:&7*+ C71(, =&36, ('<;,3 1J C71(,C M<:&+7,) C71(, D'&2 :&7812169 A137'1'C )'+7 H3,P*1'C I*223178 MM E'(C'*7&;2, &(&71<9 J13 OW0HF
@*',%CE") "# S 2*J,L783,&7,(*(6 ;&+7,3*&2 *(J,+7*1( 1J 78, ;*2*&39 73,, &CC1+*&7,) ?*78 :&37*&2 13 +1<:2,7, 1;C73'+7*1( 1J 78, )'+7&2 C9C7,< S ),2&9 *( 73,&7<,(7 +&( 3,C'27 *( <'27*L136&( J&*2'3, C,+1()&39 71 C,:7*+&,<*& 0-$#$C)%)"'C
Charcot’s triad U W*687 4::,3 r'&)3&(7 EW4rF :&*(K *(7,3<*77,(7 J,P,3 ?*78 +8*22C &() 5&'()*+, E1(29 edLndm 1J :&7*,(7C 8&P, 78, +2&CC*+ 73*&)F Reynold’s pentad : Charcot’s triad l <,(7&2 1;7'()&7*1( l 8,<1)9(&<*+ *(C7&;*2*79 – C,,( *( 2,CC 78&( !dm 1J :&7*,(7CK <13, :3,P&2,(7 *( 78, ,2),329 S C'36*+&2 ,<,36,(+9p
0%)*','E. 4C'&229 3,C'27C J31< 1;C73'+7*1( 71 78, ;*2*&39 C9C7,< ?*78 *(J,+7*1( 1J C7&6(&(7 ;*2, N1C7 +1<<1( +&'C, *C +812,)1+812*78*&C*C E`dmFo 01(C*),3 ;,(*6( C73*+7'3,C E*(C73'<,(7&7*1(FK <&2*6(&(+9 E:&(+3,&7*+K ;*2*&39FK J13,*6( ;1)9 E:3,P*1'C *(C73'<,(7&7*1(FK H.0K 0812,)1+8&2 +9C7CK Mirizzi’sK 8&,<1:8*2*&K ;*2*&39 ,(7,3*+ &(&C71<1C*C 01<<1( +&'C&7*P, 136&(*C
.,:C*C O2,+731297, &;(13<&2*79 E),89)3&7*1(F M(J,+7*1( 01&6'21:&789 E[*7 iF
"CB$#)"E%)"'C# DW $?76MI8?4 742 !86O<>?8? &_ 4273&C1'() )*2&7,) ;*2, )'+7C ;_ =QAC +812,C7&7*+ :*+7'3, +_ I211) - I*2, 0'27'3, *C12&7*1( 1J +&'C&7*P, 136&(*C<
k8,( 71 )1 OW0H 3,<1P&2 1J C71(,C G17 C'36*+&2 +&()*)&7,C V&) :3*13 +812,+9C7,+71<9 H&7*,(7C ?*78 &+'7, +812&(6*7*C ^ #
4273&C1'() r'&37,329 \d!do\`U`n>n] A8, k&C8*(671( N&('&2 1J .'36,39 E`78 ,)*7*1(F – :6"`^ !]#
/%C%E$/$C) A8, <&*( 61&2C 1J 73,&7<,(7 *C )*3,+7,) 71?&3)C 73,&7*(6 78, ;*2*&39 *(J,+7*1( &() 1;C73'+7*1( !"
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-2?;?987678><– “M( P*,? 1J +812&(6*7*C ;,*(6 & C'36*+&2 ,<,36,(+9K M ?*22 2*/, 71 3,C'C+*7&7, 78, patient who may be in septic shock”. S(7*+*:&7, 3&:*) ),7,3*13&7*1(_ M(J13< C,(*13C @;7&*( 611) *(73&P,(1'C &++,CC &() J2'*) 3,C'C+*7&7, &C &::31:3*&7, A&/, ;211)C J13 *(P,C7*6&7*1(C – +'27'3,C ,C:,+*&229 021C, <1(*713*(6 1J P*7&2C *( VD-M04 V329 :&3& l .:@\ i,,: NSH X `e<789? M[ +,J73*&Y1(, &() <,731(*)&b12,o *<*:,(,< *J 78, :&7*,(7 *C *( C81+/ $H21O2<7 M8I861Q =29>H512??8>< A*<*(6 'C'&229 ),J,33,) '(7*2 \]L]^8 &J7,3 &)<*CC*1( ?8,( :&7*,(7 *C C7&;2, &()-13 8&C *<:31P,) ?*78 C9C7,<*+ &(7*;*17*+C O<,36,(+9 *J ),7,3*13&7*(6 - S;Y (17 *<:31P*(6 *(J,+7*1( E!emF I*2*&39 ),+1<:3,CC*1( &F D,+1<:3,CC*1( +1<<1(29 :,3J13<,) 'C*(6 OW0H ,()1C+1:*+ C:8*(+7,3171<9 l C7,(7*(6 13 ,Y7,3(&2 )3&*(&6, E(&C1;*2*&39 )3&*(U ;*2, )'+7 71 (1C, J13 +1(7*('1'C )3&*(&6,F .'++,CC 3&7, #dm MJ +&'C, 1J 1;C73'+7*1( +&( ;, 73,&7,) *( 78, C&<, C,77*(6 E,_6_ C71(,C 71 ;, 3,<1P,)F 78,( 73,&7 78, +&'C, &2C1 @78,3 <,781)C 71 ),+1<:3,CCU :,3+'7&(,1'C 73&(C8,:&7*+ )3&*(&6, E,C:_ *J (,1:2&C7*+ 1;C73'+7*1(F 1:,3&7*P, ),+1<:3,CC*1( !2L8<878K2 )42165Q 081*+,C J13 ),J*(*7*P, 73,&7<,(7U E&F @:,( +812,+9C7,+71<9 ?*78 0ID ,Y:213&7*1( E;F =&:&31C+1:*+ +812,+9C7,+71<9 E+F =&:&31C+1:*+ +812,+9C7,+71<9 ?*78 0ID ,Y:213&7*1(
@+! $P0,'-%) "'C @4>I6O16H >1 94>I2=>94>?9>5Q 8? 521L>1H2= 0812&(6*163&< *(P12P,C *(5,+7*1( 1J )9, – +&( *<&6, 8*68,3 )'+7C 0812,)1+81C+1:9 *(P12P,C 'C*(6 & C+1:, 71 P*C'&2*C, 78, 2&36, ;*2*&39 )'+7C – +&((17 *<&6, 8*68,3 )'+7CK 78'C (17 &C C,(C*7*P,K ;'7 +&( ;, 'C,) 71 3,<1P, C71(,C P*C'&2*C,) *( 78, )'+7 081*+, 1J *<&6*(6 ),:,()C 1( C*7, 1J 1;C73'+7*1( &() 78, +&'C,
-2H>K6I >L ?7><2? N&('&2 3,<1P&2 ?*78 C71(,L63&C:*(6 J13+,:C Q2'C8*(6 1'7 C71(,C D3,)6*(6 C71(,C 1'7 'C*(6 ;&2211( +&78,7,3 13 D13<*& ;&C/,7 =*78173*:C9
@>L M8I861Q ?72<7 >1 )37;M2 6L721 12H>K6I >L ?7><2F?G
MJ 78,3, *C & 217 1J *(C73'<,(7&7*1( 1J 78, ;*2*&39 C9C7,< )'3*(6 78, 1:,3&7*1(K 1(, C81'2) &(7*+*:&7, C?,22*(6 &() 1,),<& 1J 78, ;*2*&39 C9C7,< 3,C'27*(6 *( :1C7L1:,3&7*P, 1;C73'+7*1( &() ;'*2)L': 1J ;*2, 8*68,3 3*C/ 1J ;*2*&39 2,&/&6, E&F #72<7– 3,<1P,) 2&7,3 ;9 ,()1C+1:9 E;F )37;M2 F;?;6IIQ 8
Functions as a “pressure release valve” as most of the bile will flow through the 813*b1(7&2 2*<; 1J 78, 7';, *(71 78, )*C7&2 :&37 1J 78, 0IDo 1(29 ?8,( 78,3, *C 1;C73'+7*1( 71 J21? ?*22 ;*2, ;, )*P,37,) 1'7 7831'68 78, P,37*+&2 2*<; S221?C J13 :1C7L1: +812&(6*163&< 71 +8,+/ J13 3,<&*(*(6 C71(,C E&7 H@D #L!dF ;,J13, 3,<1P&2 – J3,, J21? 1J +1(73&C7 *(71 )'1),('
+","%-.+.0%## FAC@'//'CG 01(C*),3 ;*2*&39 ;9:&CC *J 78,3, &3, *_ N'27*:2, C71(,CK **_ A8, 0ID *C <13, 78&( \+< *( )*&<,7,3K 13 ***_ A8,3, &3, C73*+7'3,C -
.*(+, 78, 0ID 8&C ;,,( +831(*+&229 )*2&7,)K a'*7, '(2*/,29 78&7 *7 ?*22 J'(+7*1( (13<&229 ,P,( &J7,3 3,<1P&2 1J 78, 1;C73'+7*1( N1C729 3,:2&+,) ;9 ,()1C+1:*+ C7,(7*(6 0812,+9C715,5'(1C71<9 :3,J,33,) 1P,3 W1'YL,(L> +812,)1+815,5'(1C71<9
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N&<<&39 )'+7&2 ,+7&C*& E(1(L:',3:,3&2 <&C7*7*CF
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I211) C7&*(,) EC:17 1( ;3&F
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-
I,(*6( 01()U 2&+7*J,31'C )'+7C 6,7C C?122,( &() ;2 1+/,) A3,&7<,(7U (1(,K 'C'&229 C,2JL2*<*7*(6 H3,)*C:1C,) 71 (1(L:',3:,3&2 &;C+,CC ?8*+8 ?1'2) 3,a'*3, &(7*;*17*+C Z C'36*+&2 )3&*(&6, - =&+7&7*1(&2 N&C7*7*C EC?122,(K 3,) &() 7,(),3 ;3,&C7F – 'C'&229 +&'C,) ;9 C7&:8921+1++'C &'3,'C E:'3'2,(7 )*C+8&36, *C '(+1<<1(F - I3,&C7 &;C+,CC *C 78, <1C7 +1<<1( +1<:2*+&7*1( - A3,&7<,(7U &(7*;*17*+C T +1(7*(', ;3,&C7J,,)*(6K *J J&*2 71 *<:31P, 13 &;C+,CC +&P*79 C,,( 1( '-C 73,&7 ?*78 C'36*+&2 )3&*(&6, - S(9 <,)C 78&7 <*687 &JJ,+7 89:178&2&<*+L :*7'*7&39 &Y*C - E!F ),:2,7, )1:&<*(, E*_,_ 73*L+9+2*+ &(7*),:3,CC&(7K <,7892)1:&K ;,(b1)*&b,:*(,CF - E\F )1:&<*(, 3,+,:713 ;21+/,3 E*_,_ 8&21:,3*)12F - E"F ,C7316,(*+ ,JJ,+7 E*_,_ )*6*7&2*CF - A3,&7<,(7U <,)*+&7*1( +&( ;, 7&:,3,) - +8&(6,) - 3-1 :*7'*7&39 :312&+7*(1<& - N,&C'3, C,3'< :312&+7*( 2,P,2 T (,'31*<&6*(6 E0A - NWMF - A3,&7<,(7U ;31<1+3*:7*(, 13 3,C,+7*1( 1J :312&+7*(1<& G1 73,&7<,(7 .,, ;,21? - A3,&7<,(7U C8137L7,3< +1'3C, ?*78 C7,31*) +3,&<
H&781216*+&2 G*::2, D*C+8&36, - D*C+8&36,U .,31'C E9,221? - +2,&3FK C&(6'*(,1'C E;211)9FK C,31C&(6'*(1'C E;211)L7*(6,)F - 4(*2&7,3&2K '(*)'+7&2K :,3C*C7,(7 &() C:1(7&(,1'C 631CC29 ;211)9 )*C+8&36, C'66,C7 :&781216*+&2 :31+,CC *( 78, ;3,&C7 - H&7*,(7C ?*78 ;211)9 (*::2, )*C+8&36, 8&C 8*68,3 3*C/ 1J ;3,&C7 +&(+,3 Ee\mF 78&( :&7*,(7C ?*78 (1(L;211)9 )*C+8&36, E!#mF!e H89C*1216*+&2 G*::2, D*C+8&36, - D*C+8&36,U ?8*7, 13 +2,&3K 9,221? EC73&?L+121'3,)FK 63,,(K ;31?( 13 63,9 - D*C+8&36, *C 'C'&229 ;*2&7,3&2K *(P12P*(6 <'27*:2, )'+7C
*"#)'-. FC"00,$ !"#@*%-E$G[ DW "? 742 =8?9461O2 71;IQ L1>H 742 <855I2f -
Exclude eczema, dermatitis or Paget’s disease (common complaint: staining of the bra
?*781'7 1;P*1'C (*::2, )*C+8&36,F \W "? 742 =8?9461O2 H>12 I8g2IQ 7> M2 5674>I>O896If - G&7'3, 1J )*C+8&36, – 631CC29 ;211)9 <13, C*6(*J*+&(7 - 4(*2&7,3&2 13 ;*2&7,3&2 )*C+8&36, – '(*2&7,3&2 <13, C*6(*J*+&(7 - 4(*)'+7&2 13 <'27*L)'+7&2 )*C+8&36, – '(*)'+7&2 <13, C*6(*J*+&(7 - .:1(7&(,1'C 13 1(29 1( :3,CC*(6– C:1(7&(,1'C <13, C*6(*J*+&(7 - H,3C*C7,(7 13 *(7,3<*77,(7 – :,3C*C7,(7 <13, C*6(*J*+&(7 TW "? 74212 6;MI8
V&P, 78, :&7*,(7 C1'687 73,&7<,(7 ,2C,?8,3,j
"CB$#)"E%)"'C !_ Mammography (≥ 3593CFK 4-. 13 NWM 1J ;178 ;3,&C7C 71 ),7,+7 &(9 '(),329*(6 <&2*6(&(+9 \_ V*C712169 1J ;*1:C*,) 2,C*1( E+13, ;*1:C9 ?*78 +2*: :2&+,<,(7F *J J1'() 1( *<&6*(6 – +2*: *C :2&+,) 71 &221? C';C,a',(7 21+&2*b&7*1( *J C'36,39 *C 3,a'*3,) "_ D'+7163&:89 – )'+7 *C +&(('2&7,) &() 3&)*1:&a', +1(73&C7 *C *(5,+7,) ]_ D'+71C+1:9 – !<< 3*6*) P*),1LC+1:, 71 :,3J13< *(7,3(&2 ,Y:213&7*1( 1J )'+7 R D*C+8&36, J13 +9712169 71 ),7,+7 <&2*6(&(7 +,22C E3&3,29 8,2:J'2K (17 3,+1<<,(),)F
/%C%E$/$C) F#A//%-.G - MJ M(73&)'+7&2 :&:*221<& – <*+31)1+8,+71<9 ?*78 :3,L1: )'+7163&
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%??2??H2<7 >L @6<921 -8?g M(+3,&C,) 3*C/U E!_e 71 ] J12)C *(+3,&C,F - O&329 <,(&3+8, Eh!\93F – *(+3,&C,) 1,C7316,( ,Y:1C'3, - =&7, <,(1:&'C, EXee93F – *(+3,&C,) 1,C7316,( ,Y:1C'3, - =&7, &6, &7 J*3C7 J'22 7,3< :3,6(&(+9 EJ*3C7 ;*378 &J7,3 "d &-? )1';2*(6 1J 3*C/ &C +1<:&3,) 71 J*3C7 ;*378 ;,J13, 78, &6, 1J !^F - V1? <&(9 + 8*2)3,(j E('22*:&3*79 *(+3,&C,) 3*C/F - V13<1(, W,:2&+,<,(7 A8,3&:9 Ed_\m &7 e93CK d_`m &7 !d93 T !_\m &7 !e93 1J +1(7*('1'C VWAF – 3*C/ )*C&::,&3 ?*78*( e 9,&3C 1J +,&C*(6 VWA!` - @,C7316,( ;&C,) @0H
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'7421 18?g L697>1? L>1 96<921 - S6, - Q&<*29 8*C7139 E&7 2,&C7 \ 6,(,3&7*1(F 1J ;3,&C7 +&(+,3 13 69(&,+1216*+&2 +&(+,3 S6, &7 )*&6(1C*C Q*3C7 ),63,, 3,2&7*P, ?*78 ;3,&C7 +&(+,3 s 3*C/ )1';2,C W*C/ *(+3,&C,) *J 3,2&7*P, 8&) ,*78,3 ,&329 1(C,7 +&(+,3 Eh]d93F 13 ;*2&7,3&2 )*C,&C, S(9 &CC1+*&7,) +&(+,3C – 1P&39K +121(K :31C7&7,K 6&C73*+K :&(+3,&7*+ - H3,P*1'C ;3,&C7 )*C,&C,U H3,P*1'C29 73,&7,) ;3,&C7 +&(+,3 H3,P*1'C ;3,&C7 ;*1:C9 ! G1 *(+3,&C,) 3*C/ – &),(1C*CK +9C7CK &:1+3*(, <,7&:2&C*& ! S79:*+&2 )'+7&2 89:,3:2&C*& ESDVF 13 &79:*+&2 21;'2&3 89:,3:2&C*& ES=VF +&33*,C & ]L5 fold ↑ 3*C/ E3*C/ ↑ to 10LJ12) *J 78,3, *C :1C*7*P, J&<*29 8*C7139F H3,P*1'C <&<<163&< 3,C'27C - OY:1C'3, 71 *1(*C*(6 3&)*&7*1( E*_,_ WA J13 :3,P*1'C ;3,&C7 )*C,&C, 13 81)6/*( 29<:81<&F - D&*29 S2+1812 *(7&/,K ,C:,+*&229 ;,J13, &6, 1J "d E2*(/ 8&C ;,,( C81?(F #Q?72H89 12K82J =@SK =@k E+1(C7*7'7*1(&2F Q,P,3 E*(J,+7*P, +&'C,F I1(, :&*(K .@I E<,7&C7&C*CF
IW0S! SGD IW0S\ --
I3,&C7 0S C'C+,:7*;*2*79 6,(, &-? ^dm 1J 8,3,)*7&39 ;3,&C7 0S ;'7 &++1'(7C J13 1(29 em 1J &2 2 ;3,&C7 0S S'71C1<&2 D1<*(&(7 *(8,3*7&(+, IWS0 ! <'7&7*1(!n – 2*J,7*<, 3*C/ E;9 &6, ndF 1J enm J13 ;3,&C7 0S T ]dm J13 1P&3*&( 0S IW0S \ <'7&7*1( – 2*J,7*<, 3*C/ E;9 &6, ndF 1J ]#m J13 ;3,&C7 0S T !^m J13 1P&3*&( 0S 03*7,3*& J13 3,J,33&2 J13 6,(,7*+ +1'(C,22*(6 &F Q&<*29 V*C7139 ≥ 2 relatives with breast cancer, one under 50 ≥ 3 relatives with breast cancer, any age H3,P*1'C29 *),(7*J*,) IWS0 ! - \ <'7&7*1( *( 78, J&<*29 H&(+3,&7*+ +&(+,3 ?*78 ;3,&C7 &()-13 1P&3*&( *( C&<, C*), 1J J&<*29 SC8/,(&b* %,?*C8 &(+,C739 ;F H,3C1(&2 V*C7139 I3,&C7 +&(+,3 )Y &7 &6, ed 13 91'(6,3 @P&3*&( +&(+,3 N&2, ;3,&C7 +&(+,3 A3*:2, (,6&7*P, ;3,&C7 +&(+,3
R I,C*),C M126?7 @%NIW0S! 6,(, <'7&7*1( ↑3*C/ 1J >K6186586< 7;M2 6<= 51>?7672 96<921?
H317,+7*P, J&+713CU - k8,78,3 :&7*,(7 ;3,&C7J,) 8,3 +8*2)3,(K &() *J C1K J13 81? 21(6 - H89C*+&2 &+7*P*79 E8,&2789 2*J,C792,F
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0*.#"@%,$P%/"C%) "'C 012I8H8<6182? F*$,0G - *8[ M(731)'+, 91'3C,2J T &C/ J13 521H8??8><71 ,Y&<*(, 78, ;3,&C7 E&2?&9C 8&P, & 946521><271 &++1<:&(9 91' *J 91' &3, <&2,F - $R5>?2:&7*,(7 &),a'&7,29 J31< 78, ?&*C7 ': ?*78 ,Y:1C'3, 1J &Y*22&, - ,8O478?878><78, :&7*,(7 &7 ]e1 13 C*77*(6 :1C*7*1( *J & ;,) *C (17 &P&*2&;2, "< - B,(,3&2 &::,&3&(+, – +&+8,Y*+K 5&'()*+,)K :&2213K ;3,&782,CC(,CC - Patient’s hands relaxed at her sides – 211/ J13U &(9 6?QHH271Q*( 78, ;3,&C7 +1(71'3CK &(9 2'<:C &(9 C+&3C 1J :3,P*1'C 1:,3&7*1( 13 :31+,)'3, ,_6_ :'(+8 ;*1:C9 - =11/ J13 1P,329*(6 C/*( +8&(6,C EQ l H4WOF Q*Y&7*1( 1J C/*( 71 78, 2'<:
Peau d’orange 42+,3&7*(6K J'(6&7*(6 +&(+,31'C 2'<: W,73&+7*1( 1J C/*( – '(),329*(6 +&(+,31'C 2'<: O3978,<& - =11/ J13 <855I2 946
- @461697218?2 742 I;H5[ .8&:, – 8,<*C:8,3*+&2 13 1P&2 .*b, – <,&C'3, uu+< ;9 uu +< .*7, – ?8*+8 ;3,&C7K ?8*+8 a'&)3&(7K 2,(678 E+ 742 ?g8< – 739 71 :*+/ ': 78, C/*( &;1P, 78, 2'<: (8R678>< 7> ;<=21IQ816I8? H;?9I2 – &C/ :&7*,(7 71 :3,CC 8,3 8&()C &6&*(C7 8,3 8*:C 71 +1(73&+7 78, :,+713&2*C <&513 <'C+2,K 78,( 739 71 <1P, 78, 2'<: *( \ :,3:,()*+'2&3 )*3,+7*1(CK 78,( &C/ :&7*,(7 71 3,2&Y &() 739 71 <1P, 78, 2'<: &6&*( N1;*2*79 1J 2'<: E<1;*2, *( &22 )*3,+7*1(K (17 <1;*2,F
D*C+121'3&7*1( D*C:2&+,<,(7 D,3<&7*7*C E,+b,<& 2*/, 3&C8 ?*78 +3'C7*(6F – Paget’s Disease - SC/ :&7*,(7 71 3&*C, 8,3 &3
06I5678>< - H&7*,(7 C81'2) ;, 29*(6 )1?( &7 ]e ),63,,C 71 78, 813*b1(7&2 ?*78 8,3 *:C*2&7,3&2 8&() 7'+/,) ;,8*() 8,3 8,&)– 78*C C:2&9C 78, ;3,&C7 1'7 C1 *7 +&( ;, :&2:&7,) :31:,329 - .7&37 ?*78 78, (13<&2 C*), J*3C7p - SC/ J13 &(9 :&*( ;,J13, C7&37*(6 71 :&2:&7, - 4C, 1(, 8&() 71 3,73&+7 &() C7&;*2*C, 78, ;3,&C7 &() :&2:&7, ?*78 78, 178,3 - H&2:&7, *( & C9C7,<&7*+ <&((,3 ,_6_ a'&)3&(7 ;9 a'&)3&(7 J31< +,(73, 1'7?&3)C - OY&<*(, 78, ,(7*3, ;3,&C7 *(+2')*(6 78, &Y*22&39 7&*2 - k8,( 78, 2'<: *C 21+&7,)K +8,+/ ?*78 78, :&7*,(7 ?8,78,3 78*C *C 78, C&<, 2'<: - 01(7*(', 71 ,Y&<*(, +&3,J'229 J13 178,3 2'<:C E<'27*:2, 2'<:C &3, '(2*/,29 <&2*6(&(7K 'C'&229 J*;31&),(1<& 13 J*;31&),(1C*CF - SC/ :&7*,(7 *J C8, +&( C81? 91' 78, )*C+8&36, ;9 ,Y:3,CC*(6 *7 8,3C,2J EGO[OW Ca',,b, 78, (*::2, 91'3C,2JpFo *J :&7*,(7 +&((17 )1 *7K 78,( &C/ 78, +8&:,31(, 71 8,2:
%R8II61Q IQH54 <>=2? - H&2:&7, 78, (13<&2 C*), J*3C7
- Rest the patient’s right forearm on your right forearm and use your left hand to palpate the 3*687 &Y*22& EP*+, P,3C& J13 78, 2,J7 C*),F - H&2:&7, 6,(729K C21?29K &() C9C7,<&7*+&229K +1P,3*(6 78, J*P, <&513 631':C 1J (1),CU &(7,3*13K :1C7,3*13K <,)*&2K 2&7,3&2K &() &:*+&2 - MJ &(9 29<:8 (1),C &3, J1'() 71 ;, ,(2&36,)K (17, 78, ('<;,3 1J 29<:8 (1),CK 78,*3 C*7,K C*b,K
7,(),3(,CCK +1(C*C7,(+9 EJ*3
)> 9>H5I272 742 2R6H8<678>< - OY&<*(, 78, C':3&+2&P*+'2&3 =GC T +,3P*+&2 =GC - OY&<*(, 78, 2'(6C J13 &(9 :2,'3&2 ,JJ'C*1( - H,3+'CC 78, C:*(, J13 ;1(9 7,(),3(,CC - OY&<*(, 78, &;)1<,( 211/*(6 J13 8,:&71<,6&29 - )46K21 ;5
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"CB$#) "E%) "'C# “The evaluation of a breast lump is via the )-"0,$ %##$##/$C) ” E!F 02*(*+&2 OY&<*(&7*1( E\F S W&)*1216*+&2 SCC,CC<,(7 – <&<<163&< 13 '273&C1'() E"F S V*C71:&781216*+&2 SCC,CC<,(7 – +9712169 13 ;*1:C9 S22 " <'C7 ;, +1(+13)&(7 J13 ;,(*6( 71 8&P, X##m C:,+*J*+*79 71 3-1 <&2*6(&(+9
F\G +126?7 "H6O8O1654Q - N1C7 C,(C*7*P, 1J 78, :31P,( ;3,&C7 *<&6*(6 <1)&2*7*,C - 4C'&229 :,3J13<,) *( &C9<:71<&7*+ 12),3 ?1<,( EX]d>@F f;3,&C7 7*CC', *( 91'(6,3 ?1<,( *C ),(C,3o <13, )*JJ*+'27 71 :*+/ ': &;(13<&2*7*,CgK ;'7 X"e>@ *( C9<:71<&7*+ ?1<,( -
-
%M<>1H6I L267;12?[ F6G /891>96I98L89678>1 ?72II672 I2?8>< J874 5>>1 >;7I8<2 >1 9>H27 ?8O< bYZ 1J C:*+'2&7,) <&CC,C 1( <&<<163&:89 &3, )', 71 <&2*6(&(+9 .7,22&7, 2,C*1( *C & 21+&2*C,) )*C7137*1( 1J 78, ;3,&C7 :&3,(+89<& ?*781'7 :,3+,:7*;2, <&CC 2,C*1( – 8*68 +8&(+, 1J *7 ;,*(6 <&2*6(&(7 0&'C,CU M(P&C*P, +&(+,3K 3&)*&2 C+&3 E;,(*6(FK J&7 (,+31C*CK &;C+,CCK ,7+_ F9G %19487297;16I =8?7>178>< F>L 742 9><7>;1GN 72<7 ?8O< N <855I2 9463=21 6?QHH27189 =2
G13<&229K \ P*,?C &3, )1(,U 916<8>96;=6I F@@G W*687 -=,J7 ndm 7'<1'3C *( 2&7,3&2 a'&)3&(7 E'::,3F H2=8>I67216I >MI8j;2 F/,'G 0&:7'3,C 78, 7&*2 W*687 -=,J7 ^dm 7'<1'3C *( 1;2*a', <*2/9 ?&9 S))*7*1(&2 C:,+*&2*C,) P*,?CU <&6(*J*+&7*1( &() +1(,) +1<:3,CC*1(o )1(, 1( 3,a',C7 71 8,2: <&6(*J9 &3,&C 1J &;(13<&2*79 71 J'378,3 +8&3&+7,3*b, &(9 2,C*1(_ =11/ &7 78, &Y*22& 1( 78, N=@ P*,? J13 &(9 2=2?
N&2*6(&(7 N&<<163&:8*+ Q*()*(6C G,? 13 C:*+'2&7,) <&CC,C 02'C7,3,) <*+31L+&2+*J*+&7*1(C *( 2*(,&3 13 ;3&(+8*(6 &33&9 S3+8*7,+7'3, D*C7137*1( - I,(*6( N&<<163&:8*+ Q*()*(6C W&)*&2 .+&3 Q&7 G,+31C*C – +8&3&+7,3*C7*+ 1*2 +9C7 N*2/ 1J 0&2+*'< – +8&3&+7,3*C7*+ <*+31+&2+*J*+&7*1(C &::,&3 )*C+1*) 1( 00 P*,? &() C*+/2, C8&:,) 1( N=@ P*,? -
+"3-%!# F+126?7 "H6O8178< - 0&7,6139 dU G,,) &))*7*1(&2 *<&6*(6 ,P&2'&7*1( - 0&7,6139 !U G,6&7*P, E(178*(6 71 +1<<,(7 1(K d_demK ! *( \ddd 3*C/ C7*22 :3,C,(7F - 0&7,6139 \U I,(*6( – 1>;78<2 ?9122<8HH2<=2= - 0&7,6139 "U H31;&;29 ;,(*6( EX #^mF K `-!\ J1221?L': C'66,C7,) - 0&7,6139 ]U .'C:*+*1'CK M8>5?Q ?4>;I= M2 9>
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AI716?>;<=!^ E.7&P31C .7')9F - 4C'&229 !C7 *(P,C7*6&7*1( *( 91'(6 :&7*,(7C Eh"e 9,&3C 12)F 13 :3,6(&(7K 2&+7&7*(6 :&7*,(7Co - G17 78, 612) C7&()&3) J13 C+3,,(*(6 - .,(C*7*P*79 s #^_]mK G,6&7*P, H3,)*+7*P, [&2', s ##_em :,3<*7C *<&6*(6 3&78,3 78&( ;*1:C9 J13 ;,(*6( 2,C*1(C 1( '-C -
4C,CU
-
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OP&2'&7*1( *( <&<<163&:8*+&229L)*JJ*+'27 &3,&C ,_6_ +8,C7 ?&22K &Y*22& H*7J&22CU @:,3&713 ),:,(),(7K (1(LC7&()&3)*C,) 7,+8(*a',CK :113 3,C12'7*1(K 4(&;2, 71 ),7,+7 <1C7 <*+31 +&2+*J*+&7*1(C
Q,&7'3,C 1J <&2*6(&(+9 f +")@*g I13),3C s C:*+'2&7*1(K <*+3121;'2&7*1(K &(6'2&3 <&36*(C M(7,3(&2 0&2+*J*+&7*1( A&22,3 78&( ?*), EJ*3L73,, &::,&3&(+,o *(P&C*1( 1J J&C+*&F 0,(73&2 [&C+'2&3*79 - 01<:3,CC*;*2*79 E<&2*6(&(7 2,C*1(C )*C:2&+, ;3,&C7 7*CC', ?-1 +8&(6, *( 8,*687F V9:1,+81*+ (1)'2, - H1C7,3*13 &+1'C7*+ C8&)1?*(6 I,(*6( Q,&7'3,C
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D*JJ,3,(7*&7,C ;178 :&2:&;2, &() <&<<163&:8*+ 2,C*1(C &C ,*78,3 +9C7*+ 13 C12*) .';C,a',(7 +8&3&+7,3*b&7*1( &() +2&CC*J*+&7*1( 1J C12*) (1)'2,C EC,, ;,21?F B'*), :31+,)'3,C ,_6_ I*1:C9K )3&*(&6, 1J &;C+,CCK &C:*3&7*1( 1J +9C7 OP&2'&7*1( 1J & :&2:&;2, <&CC ?*78 & (,6&7*P, <&<<163&<
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S(( .'36 @(+12 \d!do\nE.'::2_ "FU."d"L!! A8, .'36,1( !d E\d!\F "\`L"\# k&C8*(671( N&('&2 `78 ,)*7*1( E:6_ `"eF W&)*&7*1( @(+12169 \d!"K ^U\`n f3,P*,? 1J " 73*&2C – Q3,(+8K NS_\d T O@WA0 3&()1<*b,) +1(73122,) 73*&2Cg !`\
-6=8>742165Q_ !_ S)5'P&(7 - OY7,3(&2 ;,&< ?812, ;3,&C7 3&)*178,3&:9 EkIWAF 71 ;, )1(, J13 <1C7 :&7*,(7C 73,&7,) ?*78 ;3,&C7 +1(C,3P*(6 78,3&:9 EI0AF - kIWA J13 :&7*,(7C ?81 '(),361 & <&C7,+71<9 J13 21+&229 &)P&(+,) ;3,&C7 +&(+,3 E*_,_ A] tumour, T3 with positive margins and/or ≥4 path 1216*+&229 *(P12P,) (1),CF - Patients with ≥4 pathologically involved nodes should undergo WA 71 78, 3,6*1(&2 =G - W,6*<,( +1(C*C7C 1J \e 71 "d +9+2,C *( 717&2K ! +9+2, :,3 )&9 J31< N1()&9 71 Q3*)&9 1P,3 eL `-e\ '(7*2 <&Y*<'< )1C, E(1 3,:,&7 WA J13 3,+'33,(+,CF – E71 +8,+/F \_ H&22*&7*P, R G1 312, 1J (,1L&)5'P&(7 3&)*178,3&:9 J13 +'3&7*P, ;3,&C7 +&(+,3
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@%A#$# '( /"!,"C$ /%## %551>694[ - N1P, ?*78 C?&221?*(6j – )*P*),C 78931621CC&2 +9C7 &() 78931*) (1)'2, J31< 178,3 +&'C,C - MJ *7 <1P,C ?*78 C?&221?*(6K )1,C *7 <1P, ?*78 71(6', :3173'C*1( – 78931621CC&2 +9C7 <1P,C ?*78 :3173'C*1( ;'7 & 78931*) (1)'2, )1,C (17 )4Q1>OI>??6I 9Q?7 $58=2H8>I>OQ[ - Oa'&2 *( <&2,C &() J,<&2,C_ - @++'3C <1C729 *( +8*2)3,( &() &)12,C+,(7C ;'7 ': 71 1(,L78*3) 1++'3 *( :&7*,(7C X \d 9,&3C_ 0674>I>OQ[ - S +9C7*+ ,Y:&(C*1( 1J 78, 3,<(&(7 78931621CC&2 73&+7 – J&*2'3, 1J 78, 78931621CC&2 )'+7 71 1;2*7,3&7, &J7,3 ,<;391216*+ ),C+,(7 1J 78, 78931*) J31< 78, J13&<,( +,+'< &7 78, ;&C, 1J 78, 71(6', 71 21? &(7,3*13 (,+/ (267;12?[ - .<1178K 31'(),)K +9C7*+ 2'<:_ nem &3, *( 78, <*)2*(, ?8*2, \em &3, C2*68729 71 78, 2,J7 13 3*687_ 4C'&229 &C9<:71<&7*+ ;'7 <&9 ;,+1<, *(J,+7,) ?*78 C*('C J13<&7*1( &() C,31:'3'2,(7 )*C+8&36, E1++'3C ?*78 *(+*C*1( 13 3':7'3, 1J +9C7F *8?7>I>OQ[ - 09C7 ?*78 +12'<(&3 13 Ca'&<1'C ,:*78,2*&2 2*(*(6 ?8*+8 <&9 ;, +*2*&7,)_ A8, +9C7 <&9 &2C1 -
!21H>8= 9Q?7 0674>I>OQ[ - 0&( ;, +1(6,(*7&2 13 &+a'*3,)_ E*F 01(6,(*7&2 – ),P,21:<,(7&2 *(+2'C*1( 1J ,:*),3<*C &21(6 2*(,C 1J J'C*1( 1J C/*( ),3<&71<,C EC,,( *( 91'(6,3 :&7*,(7CK :3,C,(7 C*(+, ;*378F_ =1+&7*1(C *(+2'),U ! <,)*&2 T 2&7,3&2 ,()C 1J 78, ,9,;31?C E*(7,3(&2 T ,Y7,3(&2 &(6'2&3 ),3<1*) +9C7CF ! <*)2*(, 1J 78, (1C, E(&C&2 ),3<1*) +9C7CF ! <*)2*(, 1J 78, (,+/ &() 73'(/ E**F S+a'*3,) – )', 71 J13+,) *(+2'C*1( 1J C/*( *(71 C';+'7&(,1'C 7*CC', J1221?*(6 &( *(5'39K 'C'&229 1( J*(6,3C_ .,,( *( 12),3 :&7*,(7CK (1 :3,P*1'C 8*C7139 1J <&CCK 8*C7139 1J 73&'<& 71 &3,& E<&9 8&P, &CC1+*&7,) C+&3F_ *8?7>I>OQ[ - 09C7 2*(,) ;9 ,:*),3<*CK ?*78 ,P*),(+, 1J &)(,Y&2 C73'+7'3,C C'+8 &C 8&*3 J122*+2,CK C,;&+,1'C 62&()C &() C?,&7 62&()C – +9C7*+ 7,3&71<& (267;12?[ - .<&22 (1(L7,(),3 <1;*2, C';+'7&(,1'C 2'<:K <&9 ;, J2'+7'&(7K C/*(L+121'3,) 13 ;2'*C8_ /6<6O2H2<7[ - M<&6*(6 *(P,C7*6&7*1(C E,_6_ cWK 4-.K 0AF &3, *<:137&(7 ,C:,+*&229 J13 +9C7C 1( 78, C/'22 &C 78,9 +&( +1<<'(*+&7, ?*78 +,3,;31C:*(&2 J2'*)_ - 01<:2,7, C'36*+&2 ,Y+*C*1( 1J 78, +9C7K :3,J,3&;29 *( 1(, :*,+, ?-1 C:*22&6, 1J +9C7 +1(7,(7C
+1(7&*( 78931*) &() 29<:81*) 7*CC',_ MJ <&2*6(&(+9 1++'3C E0S 1J 78, 78931621CC&2 )'+7FK *7 *C 'C'&229 & :&:*22&39 +&3+*(1<& Eq#dmF_
)1267H2<7[ - .*C73'(/ :31+,)'3, – 3,C,+7*1( 1J 78, +9C7K *7C 73&+7 &() +,(73&2 :137*1( 1J 78, 891*) ;1(,
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0I;I>OQ[ - S :C,')1+9C7 &CC1+*&7,) ?*78 78, C';2*(6'&2 62&()C &() C';<&()*;'2&3 )'+7C_ - W&('2&C +&( ;, +1(6,(*7&2 13 &+a'*3,) &J7,3 13&2 73&'<& ! 01(6,(*7&2 C,+1()&39 71 &( *<:,3J13&7, C&2*P&39 )'+7 13 1C7*&2 &)8,C*1(C ! S+a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'(%C) $-"'-)-"%CE,$/ %##
+16<9486I 9Q?7 6<=d>1 L8?7;I6 $58=2H8>I>OQ[ - SJJ,+7C ;178 C,Y,C ,a'&229K 'C'&229 *( 91'(6 &)'27C *( 78,*3 \dC 0674>I>OQ[ - D,P,21: ;,+&'C, 1J J&*2'3, 1J J'C*1( 1J 78, ,<;391(*+ C,+1() &()-13 78*3) ;3&(+8*&2 &3+8,C EJ&*2'3, 1J 1;2*7,3&7*1( 1J 78, C,+1() ;3&(+8*&2 +2,J7F - M7 *C 2*(,) ;9 Ca'&<1'C ,:*78,2*'< (267;12?[ - @++'3C &(7,3*13 71 78, '::,3 13 <*))2, 78*3) 1J 78, C7,3(1+2,*)1<&C71*) <'C+2, - .<1178 J*3< C?,22*(6K 1P1*) *( C8&:,K ?*78 *7C 21(6 &Y*C 3'((*(6 )1?(?&3)C &() J13?&3)C - N&9 ;, J2'+7'&(7K 'C'&229 (17 73&(C*22'<*(&;2, E)', 71 ),Ca'&<&7,) ,:*78,2*&2 +,22 +1(7,(7CF - =11/ J13 J*C7'2& *( 78*C &3,& – & ;3&(+8*&2 J*C7'2& ?*22 3'( ;,7?,,( 71(C*22&3 J1CC& &() 78, &(7,3*13 (,+/K :&CC*(6 ;,7?,,( 78, ,Y7,3(&2 &() *(7,3(&2 + &317*) &37,3*,C - QGS 1J 78, +9C7 ?*22 9*,2) 1:&2,C+,(7 J2'*) ?*78 +812,C7,312 +39C7&2C '(),3 <*+31C+1:9 - N&9 ;, +1<:2*+&7,) ;9 3,+'33,(7 *(J,+7*1(C – :'3'2,(7 )*C+8&36,K J*Y&7*1( 71 C'331'()*(6 C73'+7'3,C /6<6O2H2<7[ - MJ J*C7'2& :3,C,(7K :,3J13< J*C7'2163&< 71 ),2*(,&7, +1'3C,_ - .'36*+&2 ,Y+*C*1( 1J 78, +9C7 ?8,3, :1CC*;2,_ -
If fistula/sinus present, inject Bonney’s blue dye into tract prior to surgery to allow accurate C'36*+&2 ,Y+*C*1(_ A3,&7<,(7 1J *(J,+7*1( ?*78 &(7*;*17*+C_ 01<:2*+&7*1(CU +9C7 3,+'33,(+,o +831(*+ )*C+8&36*(6 C*('C_
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@42H>=297>H6 0674>I>OQ[ - D,J*(,) &C & 7'<1'3 1J 78, :&3&6&(62*1( +,22C E:&3&6&(62*1(1<&F 1J 78, +&317*) ;1)9 - =1+&7,) &7 78, ;*J'3+&7*1( 1J 78, +1<<1( +&317*) &37,39 E*(71 78, *(7,3(&2 &() ,Y7,3(&2 +&317*)CF - A8,9 &3, 'C'&229 ;,(*6(K ;'7 21+&229 *(P&C*P, - W*C/ 1J <&2*6(&(+9 *C !dmK ?*78 <,7&C7&C*C 71 21+&2 29<:8 (1),CK (1 8*C71:&781216*+&2 J,&7'3,C J13 <&2*6(&(+9K 78'C <&2*6(&(7 (&7'3, +&( 1(29 ;, )*&6(1C,) ;9 :3,C,(+, 1J <,7&C7&C*C
Pharyngeal pouch (also called Zenker’s =8K21789;I;HG
0674>I>OQ[ - S 8,3(*&7*1( 1J 78, :8&39(6,&2 <'+1C& E:'2C*1( )*P,37*+'2'
(267;12?[ - .12*)K J*3< <&CC &7 78, 2,P,2 1J 78, 891*) ;1(, E?8,3, 78, ;*J'3+&7*1( *C – 2,P,2 MM 1J 78, (,+/F – ;, 6,(72, )'3*(6 :&2:&7*1( &C :3,CC'3, 1( 78, +&317*) ;1)9 +&( +&'C, P&C1P&6&2 C9(+1:,_ - N&CC *C :'2C&7*2, ;'7 (17 ,Y:&(C*2,K )', 71 73&(C<*77,) :'2C&7*1( J31< +&317*)C_ - D', 71 +21C, &-? +&317*) &37,3*,CK 2'<: +&( ;, <1P,) C*), 71 C*), ;'7 (17 ': &() )1?(_ - N&9 ;, ;*2&7,3&2_ - If suspecting aneurysm, listen for bruit, look for signs of Horner’s syndrome, &() ,Y&<*(, 78, 3,C7 1J 78, :,3*:8,3&2 P&C+'2&3 C9C7,<_ !8LL212<786I? 6<= 8<[ - N&*( )*JJ,3,(7*&2 *C +&317*) &37,39 &(,'39C
S(6*163&:89 *C 78, 612) C7&()&3) *(P,C7*6&7*1( – C81?C & 89:,3P&C+'2&3 <&CC )*C:2&+*(6 78, ;*J'3+&7*1(_ N&9 &2C1 C81? P,CC,2 +1<:31<*C, ;9 7'<1'3 *(P&C*1(K &() '(),7,+7,) C9(+831(1'C 7'<1'3C_
)1267H2<7[ - W'2, 1'7 &CC1+*&7,) C9()31<,C E*_,_ :8,1+831<1+971<&F *( 78, :3,L1: :3,:&3&7*1(p - .'36*+&2 ,Y+*C*1( ?*78 :3,L1:,3&7*P, ,<;12*C&7*1( E3,)'+,C ;2,,)*(6 &() +1<:2*+&7*1(CK &() J&+*2*7&7,C 3,C,+7*1(Fo &(9 ,(2&36,) *:C*2&7,3&2 29<:8 (1),C &3, &2C1 3,<1P,) )', 71 78, C<&22 :1CC*;*2*79 1J <&2*6(&(+9 - W&)*178,3&:9 *C &( ,JJ,+7*P, &27,3(&7*P, J13 :&7*,(7C ?81 &3, '(J*7 J13 C'36,39 13 ?81C, 7'<1'3C &3, 711 2&36,_
(267;12? - @++'3C *( 12),3 :&7*,(7C - S +9C7*+ C?,22*(6 21? )1?( *( 78, &(7,3*13 73*&(62,K 'C'&229 1( 78, 2,J7 - .a',2+8*(6 C1'() 1( ),,: :&2:&7*1( - H&7*,(7 +1<:2&*(C 1J 8&2*71C*CK 3,6'36*7&7*1( 1J '()*6,C7,) J11) ?*78 +1'68*(6 &() )9C:8&6*& *( 78, (,+/K 81&3C,(,CCK ?,*687 21CC - 01<:2*+&7*1(CU +8,C7 *(J,+7*1( E)', 71 &C:*3&7*1(Fo )*P,37*+'2&3 (,1:2&C< Eh!mF !86O<>?8?[;&3*'< C?&221? )1267H2<7 - =,&P, *7 &21(, *J C<&22 &() &C9<:71<&7*+ - N*(*<&229 *(P&C*P, 73,&7<,(7U ,()1C+1:*+ +3*+178931*) <9171<9 - .'36*+&2 &::31&+8,C EC,P,3&2 &P&*2&;2,F ! D*P,37*+'2,+71<9 l +3*+178931*)171<9 E)*P,37*+'2,+71<9 &CC1+*&7,) ?*78 3*C/ 1J <,)*&C7*(*7*CK )&(6,31'CF ! D*P,37*+'21:,Y9 E)1(, *( 8*68 3*C/ :&7*,(7CK *(P12P,C C'C:,()*(6 78, 2'<,( 1J 78, :1'+8 *( 78, +&')&2 )*3,+7*1( C1 78&7 J11) &() C,+3,7*1(C +&((17 ,(7,3 78, :1'+8o &C 78, )*P,37*+'2'< *C C7*22 :3,C,(7K 78, 3*C/ J13 <&2*6(&(+9 C7*22 3,<&*(CF
!nd
@%A#$# '( 0'#)$-"'- )-"%CE,$ /%## @Q?789 4QO1>H6 0674>I>OQ[ S +9C7*+ 89631<& *C & +1(6,(*7&2 +9C7*+ 29<:8&7*+ <&2J13<&7*1( J1'() *( 78, :1C7,3*13 73*&(62, 1J 78, (,+/K :31;&;29 J13<,) )'3*(6 +1&2,C+,(+, 1J :3*<*7*P, 29<:8 ,2,<,(7C_ M7 +1(C*C7C 1J 78*(L ?&22,)K C*(62, 13 <'27*:2, *(7,3+1((,+7*(6 13 C,:&3&7, +9C7C ?8*+8 *(C*('&7, 78,H5I89678>
@21K896I 18M (267;12?[ - 4C'&229 <13, C9<:71H6d#94J6<<>H6 (267;12?[ - .21? 631?*(6 7'<1'3 &3*C*(6 J31< :,3*:8,3&2 (,'3&2 C73'+7'3,C 1J 78, (,+/ ,_6_ ;3&+8*&2 :2,Y'CK +,3P*+&2 :2,Y'CK P&6'C (,3P,K :83,(*+ (,3P,K ,7+_ - Q'C*J13
/6<6O2H2<7[ - W&)*1216*+&2 *(P,C7*6&7*1(C ,_6_ 0cWK 0A 71 ),2*(,&7, ,Y7,(7 1J +9C7 - G1(LC'36*+&2 73,&7<,(7 – &C:*3&7*1( &() *(5,+7*1( 1J C+2,31C&(7 E'C'&229 '(C'++,CCJ'2F - .'36*+&2 ,Y+*C*1( – :&37*&2 E71 &22,P*&7, C9<:71
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@%A#$# 0&( ;, )*P*),) *(71 783,, <&*( 631':CU *(J,+7*P,K *(J2&<<&7139K &() (,1:2&C7*+
%C%)'/.
,2K2I?[ A8,3, &3, C*Y 2,P,2C 1J =G *( 78, (,+/K &() )*JJ,3,(7 C73'+7'3,C )3&*( 71 )*JJ,3,(7 631':C 1J (1),CU =9<:8 G1), =,P,2 MS EC';<,(7&2F MI EC';<&()*;'2&3F MM E'::,3 5'6'2&3F
-
MMM E<*) 5'6'2&3F M[ E21?,3 5'6'2&3F [& E:1C7_ 73*&(62,F [; EC':3&+2&P*+'2&3F [M E&(7_ +1<:7_ 63:F [MM
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S(&71<*+&2 I1'()&3*,C"" I13),3,) ;9 &(7,3*13 ;,229 1J )*6&C73*+ <'C+2, &() 891*) ;1(, I13),3,) ;9 &(7,3*13 ;,229 1J )*6&C73*+ <'C+2,K C7921891*) < 'C+2, &() ;1)9 1J <&()*;2, #g;II M6?2 ?;5218>1IQN 4Q>8= M><2 81IQ K C7921891*) <'C+2, <,)*&229K :1C7,3*13 &C:,+7 1J .0N 2&7,3&229 *Q>8= M><2 ?;5218>1IQN 9189>8= 96178I6O2 8 1IQN 2&7,3&2 &C:,+7 1J C7,3(1891*) <'C+2, <,)*&229 &() :1C7,3*13 &C:,+7 1J .0N 2&7,3&229 K 2&7,3&2 &C:,+7 1J C7,3(1891*) <'C+2, @189>8= 96178I6O2 ?;5218>1IQN 9I6K89I2 81IQ <,)*&229 &() :1C7,3*13 &C:,+7 1J .0N 2&7,3&229 01(P,36,(+, 1J .0N &() 73&:,b*'C <'C+2, C':,3*1329K +2&P*+2, *(J,3*1329K :1C7,3*13 ;13),3 1J .0N <,)*&229K &(7,3*13 ;13),3 71 73&:,b*'C <'C+2, 2&7,3&229 0,(73&2 +1<:&37<,(7 E73&+8,&L,C1:8&6,&2 6311P, (1(L:&2:&;2,F – 891*) ;1(, C':,3*1329K C':3&C7,3(&2 (17+8 *(J,3*1329K +1<<1( +&317*) &37,3*,C 2&7,3&229 .':,3*13 <,)*&C7*('<
!168<6O2[ - '16I 96K87Q 6<= >1>5461Q8= S I61Q8= H6I8O<6<9Q L81?7 ?5126= 7> I2K2I B" <=>2?G - C6?>5461Q;1?2 >L 742 )4>16989 !;97 - 01<<,(+, &7 78, 98?721<6 94QI8;,7?,,( SS &() 3*687 +3'C 1J )*&:83&6< - H&CC,C ':?&3)C 7831'68 &137*+ 1:,(*(6 - SC+,()C ;,8*() 1,C1:8&6'C *(+2*(*(6 71 78, 2,J7 &7 78, 2,P,2 1J Ae - S7 78, 3117 1J 78, (,+/K *7 &3+8,C 2&7,3&229 29*(6 ;,7?,,( +&317*) C8,&78 &() P,37,;3&2 &37,39 71 ,(7,3 5'(+7*1( ;,7?,,( 2,J7 *(7,3(&2 5'6'2&3 P,*(C &() 2,J7 C';+2&P*&( P,*(C
R +6972186 .73,:71+1++'CK .7&:8921+1++'CK i2,;C*,22& EJ31< *(73&13&2 :&7812169 ,_6_ ),(7&2 &;C+,CCK 71(C*22*7*CF RR "1Q Kikuchi’s (necrotising lymphadenitis occurring in young females, presenting as painful cervical 29<:8&),(1:&789F
- Virchow’s node therefore lies between the 2 heads of the SCM
""
V,&) &() G,+/ 0&(+,3U S N'27*)*C+*:2*(&39 S::31&+8– :6 !^" A&;2, !d_! !n\
*"#)'-. S6, WQ J13 0SU C<1/*(6K &2+1812_ I,7,2 ('7 A8, 2'<: *7C,2J ! 1(C,7K )'3&7*1(K &CC1+*&7,) C9<:71< #")$ .*b,K C8&:,K C'3J&+,U ,3978,<&K )*C+8&36*(6 C*('C E<'27*:2, 29<:8 (1), ,(2&36,<,(7 ?*78 )*C+8&36*(6 C*('C,C +&( ;, AI 13 &+7*(1<9+1C*Co C'2:8'3 63&('2,C C,,( *( &+7*(1<9+1C*CF
"CB$#)"E%)"'C# (8<2 <22=I2 6?581678>< ! S;2, 71 &++'3&7,29 )*&6(1C, 0S &() AI ! @(29 29<:81<& 3,a'*3,C ,Y+*C*1( IY 71 )*&6(1C, E71 ;, )1(, &J7,3 QGS0F ! D1 (17 )1 ,Y+*C*1( IY J*3C7 &C *7 +&( +1<:31<*C, 3,C,+7*1( 2&7,3 *J =G <,7C *C J31< VTG 0SK ;,+&'C, =G <,7C +1'(7,) &C 21+&229 &)P&(+,) )b EC7*22 3,C,+7&;2,F_ -
M<&6*(6U @)K '273&C1'() E,C:_ 78931*)FK NWM E<&*(29 0S &C :3,L1: ?-'F A1 &CC,CC (&7'3, 1J 2'<:K ,Y7,(7K 178,3 ,(2&36,) (1),C 78&7 &3, (17 +2*(*+&229 :&2:&;2,K &() +&( ;, 'C,) 71 P*C'&2*C, :3*<&39 7'<1'3 *J :3,C,(7
-
H&(,()1C+1:9U 71 211/ J13 C9(+831(1'C 7'<1'3C &CC<1/*(6 - &2+1812 &JJ,+7 Ca'&<1'C +,22C ! G1C, – &*3?&9U (&C12&39(61C+1:9K ;31(+81C+1:9 ! N1'78 – 0O 5'(+7*1(U @BD
/%C%E$/$C) S++13)*(6 71 QGS0 3,C'27C N&2*6(&(7 – ?13/ ': J13 :3*<&39 *J :3,C,(7 E,_6_ Ca'&<1'C +,22 +&3+*(1<& – 211/ J13 13&2 +&P*79K C/*(K OGAK 2'(6 <&2*6(&(+9o &),(1+&3+*(1<& – 211/ J13 ;3,&C7K BM 73&+7 <&2*6(&(+9F &() 73,&7 &C &::31:3*&7, M(J,+7*P,-M(J2&<<&7139– 73,&7 '(),329*(6 +1()*7*1(
“Is there any pain? I am going to feel the lump, if any pain, let me know” K 1(, C*), &7 & 7*<, – C7&37 &7 C';<,(7&2K 78,( C';<&()*;'2&3K :3,&'3*+'2&3K 06I5672 L1>H M248<= :1C7&'3*+'2&3K &21(6 &(7,3*13 ;13),3 1J C7,3(1+2,*)1<&C71*)K C':3&+2&P*+'2&3K :1C7,3*13 73*&(62,K 2&C729 1++*:*7&2_ 4C, :'2:C 1J 78, J*(6,3C *( & 6,(72, 3122*(6 <1P,<,(7_ A,(),3(,CC 71 :&2:&7*1( 01(C*C7,(+9 – 8&3)K <&77,) (1),C &3, <13, C'C:*+*1'C J13 <&2*6(&(+9 Q*Y&7*1( 71 1P,329*(6 C/*( 13 '(),329*(6 C73'+7'3,C
0>72<786I =168<6O2 ?872?[ 4::,3 =G EeF U N@4AVppK J&+,K C+&2:K 78931*)K C&2*P&39 62&()C =&7,3&2 =GU 78931*) =1?,3 =GU 4=K I3,&C7K ='(6CK S;)1<,( E*J [*3+81?CFK @,C1:8&6'C .'C:,+7 29<:81<& E"FU &Y*22&K :&317*)K *(6'*(&2 l 2*P,3-C:2,,( )> 9>H5I272 742 2R6H8<678><[ OY&<*(, C/*(K J&+,K (,+/K C+&2: &() ,Y7,3(&2 &')*7139 +&(&2 Q13<&2 OGA +2,&3&(+, 1J '::,3 &,31L)*6,C7*P, 73&+7 E4SDAF ,C:,+*&229 211/*(6 &7 78, :1C7L(&C&2 C:&+, J13 (&C1:8&39(6,&2 +&3+*(1<& EGH0 ;,*(6 78, <1C7 +1<<1( +&(+,3 +&'C*(6 ,(2&36,) +,3P*+&2 29<:8 (1),CF OY&<*(&7*1( 1J 78, 78931*) 62&() T <&513 C&2*P&39 62&()C OY&<*(&7*1( 1J 29<:813,7*+'2&3 C9C7,< – 178,3 29<:8 (1), 631':CK 2*P,3K C:2,,( Q'22 3,C:*3&7139 &() &;)1<*(&2 ,Y&<*(&7*1( ,C:,+*&229 *J C':3&+2&P*+'2&3 29<:8 (1), J1'() I3,&C7 ,Y&<*(&7*1( *( J,<&2, :&7*,(7
!n"
#%,"B%-. E,%C! #p$,,"CE#
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%C%)'/.
- .'331'(),) ;9 71'68 J*;31'C +&:C'2,– 78, :&317*) C8,&78 E78'C <'<:C *C :&*(J'2 &C 78, 62&() C?,22C ?*78*( & 7*687 ,(P,21:,F - =1+&7,) ;,7?,,( 78, :1C7,3*13 ;13),3 1J 78, 3&<'C 1J 78, <&()*;2, &() 78, <&C71*) :31+,CC
#A+/%C!"+A,%- E,%C! - "H5>176<7 ?71;97;12? 78&7 :&CC 7831'68 78, 62&() *( 13),3 J31< 2&7,3&2 71 <,)*&2U E*F Q&+*&2 (,3P, &() *7C ;3&(+8,C E**F W,731<&()*;'2&3 P,*( E<&Y*22&39 P,*(C )3&*( *(71 78, C':,3J*+*&2 7,<:13&2 P,*(F E***F OY7,3(&2 +&317*) &37,39 E\ 7,3<*(&2 ;3&(+8,CU C':,3J*+*&2 7,<:13&2 T <&Y*22&39 &37,39F - C21K2 ?;55IQ[ E*F H&3&C9<:&78,7*+ C,+3,71<1713 C'::29 J31< &'3*+'217,<:13&2 (,3P, +&339*(6 :1C76&(62*1(*+ J*;3,C E621CC1:8&39(6,&2 (,3P, – 0G McF J31< 78, 17*+ 6&(62*1( E:3,6&(62*1(*+ J*;3,C J31< *(J,3*13 C&2*P&39 ('+2,'CFo E**F .1<&7*+ C,(C139 C'::29 1J 78, 62&() J31< &'3*+'217,<:13&2 (,3P,o C,(C139 C'::29 1J 78, +&:C'2, J31< 78, 63,&7 &'3*+'2&3 (,3P,_ - 061>78= =;97E1J .7,(C,(F 3'(C e+< &+31CC 78, <&CC,7,3 EC'3J&+, <&3/*(6U 2*(, J31< *(7,373&6*+ (17+8 71 <*):1*(7 1J :8*273'I>OQ[:3,)1<*(&(729 C,31'C &+*(*K <&(9 )'+7C E178,3 62&()C 8&P, J,? )'+7CF - 01(C*C7C 1J & 2&36, C':,3J*+*&2 :&37 &() & C<&22 ),,: :&37 78&7 &3, +1(7*('1'C ?*78 1(, &(178,3 &31'() 78, J3,, :1C7,3*13 ;13),3 1J 78, <921891*) - A8, ),,: :&37 1J 78, 62&() *C +21C,29 &CC1+*&7,) ?*78 78, 2*(6'&2 (,3P, E?*78 78, &77&+8,) C';<&()*;'2&3 6&(62*1(F &;1P, *7K &() 78, 89:1621CC&2 (,3P, &() C';<&()*;'2&3 )'+7 ;,21? *7 – C'36,39 <&9 *(5'3, 78,C, (,3P,C
#A+,"CEA%, E,%C! - S C<&22 &2<1()LC8&:,) 62&() 21+&7,) '(),3 78, <'+1C& 1J 78, J2113 1J 78, 13&2 +&P*79 - O&+8 62&() 8&C !e 13 C1 )'+7CK 8&2J 1J ?8*+8 )3&*( *(71 78, C';<&()*;'2&3 )'+7K 78, 3,C7 )3&*(*(6 )*3,+729 *(71 78, 13&2 +&P*79 - C21K2 ?;55IQ[C*<*2&3 71 78, C';<&()*;'2&3 62&() - *8?7>I>OQ[&2<1C7 C12,29 <'+1'C &+*(*K J,? )'+7C
- C21K2 ?;55IQ[:&3&C9<:&78,7*+ C,+3,71<1713 C'::29 J31< 2*(6'&2 (,3P, +&339*(6 :1C76&(62*1(*+ J*;3,C EJ&+*&2 (,3P, E+813)& 79<:&(*F – 0G[MMF J31< 78, C';<&()*;'2&3 6&(62*1( E:3,6&(62*1(*+ J*;3,C *( C':,3*13 C&2*P&39 ('+2,'CF - #;MH6<=8M;I61 =;97 E1J k8&371(F &3*C,C J31< C':J_ :&37 1J 78, 62&()K 3'(C J13?&3)C ),,: 71 <921891*) &() )3&*(C *(71 78, 13&2 +&P*79 &7 78, C';2*(6'&2 :&:*22& 5'C7 &)5&+,(7 71 78, J3,('2'< - *8?7>I>OQ[<*Y,) C,31'C &() <'+1'C &+*(*K J,? )'+7C !n]
*"#)'-. S 0*.#"@%, $P%/"C%)"'C - S;1'7 78, 2'<:U 1(C,7K )'3&7*1(K :3163,CCK &CC1+*&7,) C9<:71
06I5672 L1>H M248<= - SC/ :&7*,(7 &;1'7 &(9 :&*( ;,J13, C7&37*(6 71 :&2:&7, - H&2:&7, 78, 1;P*1'C29 ,(2&36,) 62&()K &() &2?&9C 3,<,<;,3 71 &2C1 :&2:&7, 78, +1(73&2&7,3&2 62&() J13 &(9 C?,22*(6 - 08,+/ J13 ?&3<78 1J 1P,329*(6 C/*(K 7,(),3(,CCK +1(C*C7,(+9K C'3J&+,K <&36*(C - Q*Y&7*1( 71 '(),329*(6 C73'+7'3,C – J13 :&317*)K &C/ :&7*,(7 71 +2,(+8 78, 7,,78 71 +1(73&+7 78, <&CC,7,3K 78,( 739 71 <1P, 78, 62&() - Q*Y&7*1( 71 1P,329*(6 C/*( - H&2:&7, J13 +,3P*+&2 29<:8&),(1:&789
@%A#$# '( #p$,,"CE '( )*$ 0%-')"! -
I,(*6( E*_,_ Hleomorphic adenoma, Warthin’sK N1(1<13:8*+ &),(1<&K @(+1+971<&F N&2*6(&(7 E*_,_ <'+1,:*),3<1*)K &),(1*) +9C7*+ +&3+*(1<&K +&3+*(1<& ,YL:2,1<13:8*+K &+*(*+ +,22 &),(1+&3+*(1<&F - =9<:81<& &() 2,'/&,<*&R #7><2? - .*&212*78&C*C - N'<:CR "< - 0831(*+ 3,+'33,(7 C*&2&),(*7*C ?J2II88HH;<2 - Sjogren’s syndrome* "< - .&3+1*)1C*CR - S2+1812*+ 2*P,3 )*C,&C, - D*&;,7,C <,22*7'C #Q?72H89 - H&(+3,&7*7*C =8?26?2_ - S+31<,6&29 - N&2('73*7*1( C>=2? - N,7&C7&7*+ E*_,_ GH0K :,3*L&'3*+'2&3 2,C*1(CF +I>>= B2??2I? - S[NK 8&,<&(6*1<& C><35612<94QH6I ,QH546789? - =9<:8&(6*1<&C ?J2II8
C2>5I6?86
-
"CB$#)"E%)"'C - QGS0U <&2*6( PC_ ;,(*6( - 0AU +1(J*3< C&2*P&39 62&() EPC =GF ! ,C:_ :&317*) – <'27*:2, C?,22*(6 2*/,29 =G EDDY k&378*(F
'7421 72?7? - Q&+*&2 (,3P, ,Y&<*(&7*1( - OY&<*(&7*1( 1J 78, )'+7 1:,(*(6CU !
! !
4C*(6 & 713+8 &() & 71(6', ),:3,CC13K ,Y&<*(, 1::1C*7, 78, C,+1() '::,3 <12&3 71178 J13 78, 1:,(*(6 1J 78, :&317*) )'+7K &() '(),3 78, 71(6', J13 78, 1:,(*(6 1J 78, C';<&()*;'2&3 )'+7_ =11/ J13 3,) *(J2&<,) )'+7 1:,(*(6K )*C+8&36, E:'3'2,(7FK 13 &(9 P*C*;2, C71(,_ Q13 78, :&317*) )'+7K +&( :&2:&7, 78, )'+7 &21(6 78, <&CC,7,3 J13 C71(,K &() 211/ J13 )*C+8&36, *(C*), 78, <1'78 ?8*2, :&2:&7*(6_
- H&2:&7, 78, 62&() 1:,(*(6C J13 C71(,C_ - I*<&('&2 :&2:&7*1( 1J 78, C';<&()*;'2&3 62&()
#;?5898>;? L267;12? >L H6I8O<6<9Q[ - V9:,3&,<*+ 817 C/*( 1P,3 2'<: - H&*( - Q*Y&7*1( 71 '(),329*(6 C73'+7'3,C 13 C/*( - V&3) +1(C*C7,(+9 - M33,6'2&3 C'3J&+, 13 *22L),J*(,) ;13),3 - Q&+*&2 (,3P, *(P12P,<,(7 !ne
#%,"B%-.
Warthin’s tumour
E,%C! ) A/'A-#
$58=2H8>I>OQ[ - ^dm 1++'3 *( 78, :&317*)K 1J ?8*+8 ^dm &3, ;,(*6( E^dm 1J 78, ;,(*6( 7'<1'3C &3, :2,1<13:8*+ &),(1<&CF - !dm 1++'3 *( 78, C';<&()*;'2&3K 1J ?8*+8 `dm &3, ;,(*6( E#em :2,1<13:8*+ &),(1<&F - !em 1++'3 *( <*(13 C&2*P&39 62&()CK 1J ?8*+8 edm &3, ;,(*6( E&22 ;,(*6( 7'<1'3C &3, :2,1<13:8*+ &),(1<&CF - d_"m 1++'3 *( C';2*(6'&2 62&()CK 1J ?8*+8 &22 &3, <&2*6(&(7 0674>I>OQ $58742I86I %=2<>H6? FM2<8O
@6198<>H6? FH6I8O<6<7G N'+1,:*),3<1*) 0&3+*(1<& S),(1*) +9C7*+ +&3+*(1<& 0&3+*(1<& ,YLH2,1<13:8*+ S+*(*+ +,22 S),(1+&3+*(1<& .a'&<1'C +,22 +& 4()*JJ,3,(7*&7,)
C><3258742I86I V&,<&(6*1<& =9<:8&(6*1<& G,'31J*;31<& G,'3*2,<<1<& EC+8?&((1<&F =*:1<& .&3+1<& N&2*6(&(7 29<:81<&
0I2>H>15489 6=2<>H6 $58=2H8>I>OQ[ - N1C7 +1<<1( ;,(*6( 7'<1'3 - ^em 1++'3 *( 78, :&317*) 62&() - Oa'&2 C,Y 3&7*1K 1++'3C *( 91'(6,3 :&7*,(7C 2,CC 78&( ed 9,&3C 12) *8?7>I>OQ[ [,39 8,7,316,(,1'C &::,&3&(+,K +1(7&*(*(6 ,:*78,2*&2 +,22C C'331'(),) ;9 211C, C731<& ?*78 *C2&()C 1J +81()31<9Y1*) E<,C,(+89<&2 +1<:1(,(7CFK &() *(7,3C:,3C,) *C2&()C 1J <91,:*78,2*&2 +,22C_ A8, 7'<1'3 &::,&3C 71 ;, ,(+&:C'2&7,)K ;'7 8*C712169 C81?C <'27*:2, C*7,C 1J +&:C'2&3 :,(,73&7*1( ;9 7'<1'3 +,22C_
$58=2H8>I>OQ[ - \() <1C7 +1<<1( 7'<1'3 1J 78, C&2*P&39 62&() - @(29 1++'3C *( 78, :&317*) 62&() E!dm 1J :&317*) 7'<1'3CF – &2<1C7 ,Y+2'C*P,29 *( 78, C':,3J*+*&2 21;, 1J 78, :&317*) 62&() - N13, +1<<1( *( <&2,C 78&( J,<&2,C E]U!F - @++'3C *( 12),3 :&7*,(7C Eed – nd 9,&3CF - W,2&7,) 71 +*6&3,77, C<1/*(6 *8?7>I>OQ[ - I,(*6( (,1:2&C< E&/& :&:*22&39 +9C7&),(1<& 29<:81<&71C'< 13 5'C7 &),(129<:81<&F - B31CC29 ;*2&7,3&2 E!dmFK <'27*J1+&2 E!dmFK 1P&2-31'() ,(+&:C'2&7,) <&CC +1(7&*(*(6 +9C7*+ C:&+,C J*22,) ?*78 <*2/9 C,+3,7*1( E<'+*(F - 01(C*C7C +9C7*+ C:&+,C 2*(,) ;9 7?1L7*,3,) ,:*78,2*'?8?;9 +2*(*+&2K QGS0 l NWM )1267H2<7 - 0&( ;, 2,J7 &21(, *J &;C12'7,29 +,37&*( 78&7 78, entire mass is composed of only Warthin’s 7'<1'3 +,22CK C*(+, 78,3, *C (1 <&2*6(&(7 :17,(7*&2 - .':,3J*+*&2 :&317*),+71<9 *J +&'C*(6 731';2, 71 :&7*,(7
(267;12?[ - .21?L631?*(6K :&*(2,CC C?,22*(6 1++'33*(6 *( 78, 21?,3 :12, 1J 78, :&317*) - M33,6'2&3 &() 21;'2&7,) C'3J&+,K 7 exture of cartilage (slightly harder than Warthin’s) - D1,C (17 *(P&), 13 <,7&C7&C*C, - 08&(+, 1J <&2*6(&(7 73&(CJ13<&7*1( *J 2,J7 J13 !dL!e 9,&3C E!L`m 3*C/F - MJ (17 +1<:2,7,29 ,Y+*C,)K +&( 3,+'3 E3,+'33,(+, 3&7, 1J \mF !86O<>?8?;9 +2*(*+&2K QGS0K l NWM )1267H2<7– ?;1O896I 2R98?8>< - H&317*)U .':,3J*+*&2 :&317*),+71<9 J13 C':,3J*+*&2 7'<1'3o *J 7'<1'3 *C ),,: 13 2&36,K 717&2 :&317*),+71<9 ?*78 :3,C,3P&7*1( 1J 78, J&+*&2 (,3P, - .';<&()*;'2&3U A17&2 62&() ,Y+*C*1( 716,78,3 ?*78 &)5&+,(7 +1((,+7*P, 7*CC',K C:&3*(6 2*(6'&2 &() 89:1621CC&2 (,3P,C !n`
/6I8O<6<7 7;H>;1? N1C7 +1<<1( <&2*6(&(+*,C &3, <'+1,:*),3<1*) E"]mF &() &),(1*) +9C7*+ +&3+*(1<&C E\\mF – ,a'&2 C,Y 3&7*1K +&( 1++'3 *( &(9 C&2*P&39 62&()K *( 12),3 :&7*,(7C E'C'&229 X`d 93CF N'+1,:*),3<1*) +& *C 78, <1C7 +1<<1( <&2*6(&(7 7'<1'3 *( 78, :&317*)K ?8*2, &),(1*) +9C7*+ +& *C 78, <1C7 + 1<<1( *( 78, C';<&()*;'2&3K C';2*(6'&2 &() <*(13 C&2*P&39 62&()C
T` @'/0,"@%) "'C# '( 0%-') "!$@) '/.
"HH2=8672 F8<7163>521678K2G !_ M(73&1:,3&7*P, J&+*&2 (,3P, 73&(C,+7*1(– =NG :&2C9 - Q&+*&2 G,3P, I3&(+8,C E<1713 ;3&(+8,CF s A,<:13&2K x961<&7*+K I'++&2K N&()*;'2&3K 0,3P*+&2 - x961<&7*+U 2,&) 71 *(+1<:2,7, +21C'3, 1J ,9, 'C, 1:878&2<*+ )31:C &() ,9, :317,+7*1( &7 (*687 - R*( +1(73&C7K ?;MH6<=8M;I61 OI6<= ?;1O21Q +&( )&<&6, 78, 89:1621CC&2 &()-13 2*(6'&2 (,3P,C W':7'3, 1J +&:C'2, 1J :&317*) 7'<1'3 M(+1<:2,7, C'36*+&2 3,C,+7*1( 1J :&317*) 7'<1'3
N&2*6(&(7 :2,1<13:8*+ &),(1<& - 4C'&229 1++'3C *( :3,L,Y*C7*(6 :2,1<13:8*+ &),(1<&K 3&3,29 ), (1P1 - k13C7 :316(1C*C 1J &(9 C&2*P&39 62&() 7'<1'3 - "dLndm 3,+'33,(+, &() <,7&C7&C*C 3&7,
\_ "_
)1267H2<7 >L ?6I8K61Q OI6<= 96<921? H&317*)U - A17&2 :&317*),+71<9 ?*78 C&+3*J*+, 1J J&+*&2 (,3P, *J 7'<1'3 8&C *(J*273&7,) *7 E<&9 ;, 63&J7,) ?*78 63,&7 &'3*+'2&3 (,3P,F - W&)*+&2 (,+/ )*CC,+7*1( *J (,+/ (1),C :1C*7*P, - H1C71:,3&7*P, 3&)*178,3&:9
$61IQ FD 7> Tc =6Q?G !_ A,<:13&39 J&+*&2 ?,&/(,CC E(,'31:3&Y*& 1J J&+*&2 (,3P, – #dm 3,C12P,C *( ! <1(78F \_ D*P*C*1( 1J 63,&7 &'3*+'2&3 (,3P, 21CC 1J C,(C&7*1( 1P,3 :*((& "_ H&317*) J*C7'2& 73,&7 +1(C,3P&7*P,29K Z &(7*+812*(,36*+ Z ;17'2*('< 71Y*( ]_ A3*C<'C E*(J2&<<&7*1( &() J*;31C*C 1J <&CC,7,3 <'C+2, – 'C'&229 <*2) &() 73&(C*,(7F e_ k1'() *(J,+7*1( - k1'() C,31<& `_ V&,<1338&6, - V,<&71<& n_ ./*( J2&: (,+31C*C E3&3,F
.';<&()*;'2&3U - W&)*+&2 ,Y+*C*1( 1J 62&() ?*78 29<:8&7*+ +2,&3&(+, 1J C';<&()*;'2&3 73*&(62, - W&)*+&2 (,+/ )*CC,+7*1( *J (,+/ (1),C :1C*7*P, - H1C71:,3&7*P, 3&)*178,3&:9
,672 FH>12 746< Tc =6Q?G !_ Q&+*&2 C9(/*(,C*C &J7,3 J&+*&2 :&2C9 \_ V9:1,C78,C*& 1J 63,&7,3 &'3*+'2&3 (,3P, "_ W,+'33,(7 A'<1'3 ]_ 01C<,7*+ :31;2,
"]
Frey’s syndrome – O;?767>1Q ?J2678
S+7& @7138*(12&39(612 M7&2_ %'( \ddeo \eE"FU !n]–!n^_ !nn
#"%,',") *"%#"# $58=2H8>I>OQ - .71(,C 1J 78, C&2*P&39 62&() 78&7 <&9 ;, *<:&+7,) ?*78*( 78, 62&() *7C,2J 13 *( 78, )'+7_ - 4C'&229 1++'3C *( <&2,C <13, 78&( J,<&2,CK &() ;,7?,,( 78, &6,C 1J "d &() `d_ - ^dm 1J C&2*P&39 C71(,C 1++'3 *( 78, C';<&()*;'2&3 62&() E)', 71 *7C 8*68,3 <'+'C &() +&2+*'< +1(7,(7 ?*78 & 21(6 )'+7K &() C21? J21? 1J 78, C&2*P& &6&*(C7 63&P*79Fo !dm 1++'3 *( 78, :&317*)K nm C';2*(6'&2_ - N1C7 C';<&()*;'2&3 62&() C71(,C 1++'3 *( 78, )'+7K ?8*2, edm 1J :&317*) C71(,C 1++'3 *( 78, 62&() *7C,2J_ - ^dL#em 1J C';<&()*;'2&3 C71(,C &3, 3&)*1L1:&a', &() +&( ;, C,,( 1( &( cL3&9 1J 78, J2113 1J 78, <1'78K &() `dm 1J :&317*) C71(,C &3, 3&)*1L1:&a',_ 012?2<7678>< - @>H5I272 >M?71;978>< S+'7, :&*( &() C?,22*(6 1J 78, 62&() *(P12P,) &7 <,&2 7*<,CK 3&:*) 1(C,7 ?*78*( <*('7,C 1J C7&37*(6 71 ,&7K 3,C12P,C &;1'7 &( 81'3 &J7,3 78, <,&2_ - 061786I >M?71;978>< @++&C*1(&2 C9<:71<&7*+ ,:*C1),C *(7,3C:,3C,) ;9 &C9<:71<&7*+ :,3*1)C 1J )&9C 71 ?,,/CK +831(*+&229 ,(2&36,) <&CC *( 78, C';<&()*;'2&3 3,6*1( - 0&( 3,C'27 *( ?86I6=2<878? K &() ,P,( &;C+,CC J13<&7*1( ?13C,(*(6 1J C9<:71K6I ! A3&(C 13&2 3,<1P&2 1J C71(,C J13 C';<&()*;'2&3 )'+7 C71(,C Eedm +&( ;, 3,<1P,) 78'CFK 2,CC J13 :&317*) )'+7 C71(,C ! MJ C71(,C +&((17 ;, 3,<1P,) P*& 73&(C 13&2 C'36,39 13 *C *(73&62&()'2&3K :&37*&2 62&() 3,C,+7*1( +&( ;, :,3J13<,) - @78,3 1:7*1(CU =*78173*:C9K ?*3, ;&C/,7 3,<1P&2K C*&21,()1C+1:9 !n^
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01>MI2H J874 9>HQ E*F .12*7&39 78931*) (1)'2, E<1C7 +1<<1( *( ,Y&
D1<*(&(7 G1)'2, 1J & NGB - Q122*+'2&3 S),(1<& - 09C7C - 0&3+*(1<&
E**F N'27*(1)'2&3 61*73,
A1Y*+ NGB - Hashimoto’s thyroiditis
E***F D*JJ'C, ,(2&36,<,(7
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Graves’ Disease .*<:2,K (1(L71Y*+ 61*73, - Hashimoto’s thyroiditis - .';L&+'7, 78931*)*7*C - =9<:81<&
%M>;7 #./0)'/%)','E. N1C7 :&7*,(7C ?*78 78931*) (1)'2,C 8&P, J,? 13 (1 C9<:71
01>MI2H J874 L;<978>< F?22 M2I>JG
B,(,3&2 N11)
@78,3 .9<:71
V9:,378931*) V9:,3&+7*P, O&C*29 M33*7&;2, M(C1<(*& 13 S(Y*,79 D,:3,CC*1( E,2),329F k,*687 21CC ),C:*7, *(+3,&C,) &::,7*7, V,&7 *(712,3&(+, E:3,J,3,(+, J13 +12)F M(+3,&C,) C?,&7*(6 D*&3381,& H&2:*7&7*1(CK A3,<13C @2*61<,(13381,& &() 21CC 1J 2*;*)1
V9:178931*) A*3,)(,CC - =,78&369 N11) +8&(6, *(+2')*(6 ),:3,CC*1(
k,*687 6&*( ),C:*7, ),+3,&C,) &::,7*7, 012) *(712,3&(+, E:3,J,3,(+, J13 ?&3<78F 01(C7*:&7*1( I3&)9+&3)*& N,(1338&6*&
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068< – ;2,,)*(6 *(71 +9C7 +&( 3,C'27 *( C')),( *(+3,&C, *( C*b, &() :& *(o 3&3,29 :&*( +&(
-
– )*JJ*+'279 C?&221?*(6K )*JJ*+'279 ;3,&78*(6K 81&3C,(,CC 1J P1*+, @>H512??8K2 #QH57>H? E;,(*6( :&781216*,C &2<1C7 (,P,3 +1<:3,CC 78, 3,+'33,(7 2&39(6,&2 (,3P,F (8R2= E6l2– 3*C/ 1J 1:7*+ (,3P, +1<:3,CC*1( EC'36*+&2 ,<,36,(+9F *8O4 ';75;7 @61=869 (68I;12 – &C/ &;1'7 )9C:(1,&K ,JJ137 712,3&(+, )4Q1>8= #7>1H13 )4Q1>7>R89>?8? @18?8? E<,7&;12*+ &() 8,<1)9(&<*+ *(C7&;*2*79F
1++'3 *( &(&:2&C7*+ +&3+*(1<& &() 78931*)*7*C =1+&2
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-
%M>;7 -"#h (%@)'-# V*C7139 1J 6;7>8HH;<2 =8?26?2 ,_6_ 79:, M DNK .=OK WSK :,3(*+*1'C &(,<*& E&CC1+*&7*1(C ?*78 -
Graves and Hashimoto’s) V*C7139 1J 96<921 ,2C,?8,3, – <,7&C7&7*+ )*C,&C, 71 78931*)o 29<:81<&o :&:*22&39 +&(+,3 *C &CC1+*&7,) ?*78 J&<*2*&2 :129:1C*C C9()31<,C &C/ &;1'7 BM :129:C-+&(+,3C V*C7139 1J74Q1>8= =8?26?2– 21(6LC7&()*(6 NGB +&( :3163,CC 71 29<:81<& @++':&7*1(&2 8*C7139 – &(9 ,Y:1C'3, 718><8l8< E:&:*22&39 +&(+,3 3*C/ ↑3xF (6H8IQ 48?7>1Q1J 78931*) +&(+,3 – q\dm 1J <,)'22&39 +&(+,3C &3, J&<*2*&2 ENOG\K SD *(8,3*7&(+,FK q em 1J :&:*22&39 +&(+,3C #H>g8
%M>;7 512K8>;? )-$%)/$C) L>1 68= =8?26?2 /2=89678>6978K2 8>=8<2 73,&7<,(7 – ?8&7 ?&C 78, 3,C'27j MC 78, :&7*,(7 3,+,*P*(6 3,:2&+,<,(7j #;1O21Q– ?8&7 /*() 1J C'36,39K &(9 +1<:2*+&7*1(Cj (>II>J3;5– ?8&7 *(P,C7*6&7*1(C )1(,j
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0*.#"@%,$P%/"C%) "'C +W )*.-'"! #)%)A# %"/[ 74Q1>8= r IQH546=2<>5674Q r L267;12? >L H6I8O<6<9Q r 9>H512??8K2 ?QH57>H? r 9;112<7 QS0O 74Q1>8= ?767;? F4Q521 d 4Q5> d 2;74Q1>8=G !_ OY:3,CC*1( – C7&3*(6K '(;2*(/*(6 E89:,378931*)Fo 2,78&36*+K &:&78,7*+ E89:178931*)F \_ 01<:2,Y*1( – dry, ‘peaches L&()Lcream’ complexion, loss of outer third of eyeb 31?C %W )*.-'"! E,%C! E89:178931*)F HWO=MNMGSWMO. "_ O9,CR !_ B3,,7 H&7*,(7 &() &C/ J13 :,3<*CC*1( 71 ,Y&<*(, E&(9 P1*+, 81&3C,(,CC– W=G *(P&),)F &_ =*) 2&6 E,9,2*) 2&6C ;,8*() ,9, ?8,( :&7*,(7 J1221?C 91'3 J*(6,3 )1?(?&3)CF \_ H1C*7*1( :&7*,(7 &() ,Y:1C, &),a'&7,29 – ,(7*3, (,+/K C7,3('< &() +2&P*+2,C ;_ =*) 3,73&+7*1( EC+2,3& P*C*;2, ;,7?,,( '::,3 2*<;'C 1J *3*C &() '::,3 ,9,2*)F "_ M(C:,+7*1( J31< 78, J31(7 +_ $R>54746IH>?EC+2,3& P*C*;2, ;,7?,,( 21?,3 2*<;'C &() 21?,3 ,9,2*)F &_ S(9 C?,22*(6j )_ @42H>?8?E1,),<& &() ,3978,<& 1J +1(5'(+7*P&F – *J :3,C,(7 +1(C*),3 'C*(6 J2'13,C+,*( 71 ;_ S(9 C+&3Cj E&(9 73&(CP,3C, *(+*C*1( *( & C/*( +3,&C,K \QI &;1P, C':3&C7,3(&2 (17+8F 211/ J13 +13(,&2 '2+,3&7*1( +_ S(9 C/*( +8&(6,C 1P,3 78, <&CCj ,_ '54746IH>5I2O86 E3,C73*+7*1( 1J ,9, <1P,<,(7Co &C/ &;1'7 )*:21:*&pF )_ S(9 C7*6<&7& 1J 89:,378931*)*C< E*_,_ &6*7&7*1(F 13 89:178931*)*C< E*_,_ ;3&)9/*(,C*&F J_ 01>57>?8?(look from above patient’s head – ,9, P*C*;2, 1P,3 C':3&13;*7&2 3*)6,F ,_ 08,+/ J13 :2,7813& 1J J&+,K )*C7,(),) (,+/ P,*(C – <&9 ;, )', 71 +1<:3,CC*P, (&7'3, 1J R Lid lag and lid retraction are result of excess sympathetic activity and not specific to Graces’ disease. The rest (cLJF &3, C:,+*J*+ J13 Graves’ disease – &JJ,+7C ': 71 `dm +2*(*+&229 EC<1/*(6K &6,K <&2, &() WSM *(+3,&C, 3*C/ 1J 1:878&2<1:&789 *( BDF <&CC E;'7 3&3,29 C,,(F_ [email protected] DMQQOWOGAMS= [email protected]. Q@WAV>W@MD =4NH !_ 08,+/ *J <&CC <1P,C 1( C?&221?*(6 ;9 &C/*(6 :&7*,(7 71 7&/, & C*: 1J ?&7,3 – “Please take a sip of water and hold it in your mouth, do not swallow until I tell you to.” \_ 08,+/ *J <&CC <1P,C 1( :3173')*(6 78, 71(6', – “Please open your jaw C2*68729_ G1?K ?*781'7 moving your jaw, please stick your tongue out and back in again.” "_ 08,+/ *J <&CC <1P,C 1( C?&221?*(6 13 71(6', :3173'C*1( &6&*( ?*78 8&()C :&2:&7*(6 78931*) _ S 78931*) C?,22*(6 <1P,C 1(29 1( C?&221?*(6o & 78931621CC&2 +9C7 ?*22 <1P, 1(
$%&'
C?&221?*(6 &() :3173'C*1(
1J 78, 71(6',
HS=HSAO AV>W@MD QW@N IOVMGD – 1(, C*), &7 & 7*<, ?*78 78, 1::1C*7, 8&() C7&;*2*b*(6 78, 62&()_ B,(729 7*27 8,&) J13?&3) 71 3,2&Y &(7,3*13 (,+/ <'C+2,CK 3,C7 J*(6,3C 1( 2&7,3&2 21;, 1J 78931*) ESC/ J13 :&*( ;,J13, :&2:&7*(6pF DW @461697218?789? >L I;H5 6<= ?;11>;<=8W@MD !_ H&2:&7, J13 73&+8,&2 ),P*&7*1( \_ H,3+'CC <&(';3*'< J13 C*6(C 1J &(9 3,731C7,3(&2 ,Y7,(C*1( "_ S'C+'27&7, 1J &(9 (,+/ ;3'*7 E'C*(6 78, ;,22F – specific for Graves’
4HHOW =MNI !_ OY&<*(, J13 H31Y*<&2 <91:&789 \_ Q*(, :1C7'3&2 73,<13 – &++,(7'&7, ;9 :2&+*(6 & C8,,7 1J :&:,3 1( 78, 8&()C "_ W,J2,Y,C E,2;1? 3,J2,YF R Offer Pemberton’s Sign flushing of face with both hand raised – E!<*(F
HS=N !_ H&2
Q,,2 :'2C, – 7&+89+&3)*&K SQ Emore in toxic MNG than Graves’) K ;3&)9+&3)*& E89:178931*)*C
@AVOW. !_ =,6C J13 :3,7*;*&2 <9Y1,),<&R EC:,+*J*+ J13 Graves’ E"mF 13 89:178931*)F \_ W,J2,Y,C E&(/2, 5,3/F – C21? 71 3,2&Y *( 89:178931*)*C< "_ @JJ,3 71 +8,+/ 74Q1>8= ?767;?&() &C/ :&7*,(7 &;1'7 9>H512??8K2 ?QH57>H? _ R O2,P&7,) C8*( 2,C*1(C ?*78 ?,22L),J*(,) ,)6,C E*(J*273&7*P, ),3<1:&789F – 2,C*1(C <&9 ;, (1)'2&3 13 :2&a', 2*/,K :'3:2*C8 3,) 13 ;31?( &() 78, C/*( *C C8*(9 ?*78 & 78*+/,(,) 13&(6, :,,2 &::,&3&(+, OY&<*(&7*1( B,(,3&2 M(C:,+7*1( O9,C
4::,3 =*<; l V&()C =1?,3 =*<;
V9:,378931*) k,*687 =1CC S21:,+*& Q&+, &::,&3C J2'C8,) 2*) 3,73&+7*1(K 2*) 3,73&+7*1(K ,Y1:878&2<1CK 1+'21<1713 :&2C*,C H31Y*<&2 N91:&789 k&3< T .?,&79 :&2
V9:178931*) @;,C*79 D39 A8*( V&*3 ‘Peaches & cream’ complexion =1CC 1J 1'7,3 !-" 1J ,9,L;31?C N'C+2, k,&/(,CC 012) :,3*:8,3*,C 0&3:&2 A'((,2 .9()31<, V9:13,J2,Y*& I3&)9+&3)*& @,),<&
!^d
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$/+-.'C"@ '-"E"C# A8931*) 62&()U ),P,21: J31< 78, ,()1),3< 1J 78, :3*<*7*P, J13,6'7 C*7, 1J 78, *(*7*&2 ),P,21:<,(7 &7 78, J13&<,( +&,+'< E<*)2*(,K 5'(+7*1( ;,7?,,( &(7,3*13 7?1L78*3)C &() :1C7,3*13 1(,L78*3) 1J 78, 71(6', ),C+,(7C )1?( 78931621CC&2 73&+7 *(71 78, (,+/ &(7,3*13 71 78, 891*) ;1(, &() 2&39(6,&2 +&37*2&6, E78931*) +1<:2,7,C *7C ),C+,(7 *( 78, n78 6,C7&7*1(&2 ?/F
H&3&78931*) 62&()C[ \ C':,3*13 &() \ *(J,3*13 62&()C_ A8, *(J,3*13 :&3&78931*) 62&()C &3*C, J31< 78, "3) :8&39(6,&2 :1'+8 E)13C&2 ?*(6F – P,(73&2 ?*(6 ;,+1<,C 78, 789<'C ?8*+8 <*63&7,C +&')&229 &() <,)*&229 :'22*(6 78, :&3&78931*) ?*78 *7_ A8, C':,3*13 :&3&78931*) 62&()C &3*C, J31< 78, ]78 :8&39(6,&2 :1'+8 E)13C&2 ?*(6F
%C%)'/. .73'+7'3,[ \ 2&7,3&2 21;,C 51*(,) ;9 &( *C78<'C 78&7 2*,C *( J31(7 1J 78, \()K " 3) &() ]78 73&+8,&2 3*(6CK &(7,3*13 71 2&39(Y &() 73&+8,&_ .73&: <'C+2,C 1J 78, (,+/ 2*, C':,3J*+*&2 71 78, 78931*) 62&()_
G,3P,C &() P,CC,2CU .':,3*13 A8931*) S37,39 EJ31< ,Y7,3(&2 +&317*)RF
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.9(78,C*C 1J 78931*) 813<1(, "'!"!$ )-%00"CE A.V 3,+,:713 EA.VWF ;1'() 71 A.V -
-
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C7*<'2&7,C *1)*), 73&(C:137 *(71 78, 78931*) 62&() ;9 78, C1)*'< *1)*), C9<:137,3 EGM.F "'!"!$ 'P"!%)"'C s '-E%C"("@%)"'C M1)*), *C
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!
S+7*1(C M(8*;*7C AH@ – 78931*) :,31Y*)&C, HA4 &2C1 *(8*;*7C :,3*:8,3&2 ),*1)*(&7*1( 1J A] M(7,3J,3,C ?*78 136&(*J*+&7*1( &() *(8*;*7 813<1(, 3,2,&C,
W,<&3/C HA4 – (17 78, !C7 2*(, )3'6K 1(29 'C,) *( :3,6(&(+9 E! C7 73*<,C7,3F – (17 'C,) J13 \ () T " 3) 73*<,C7,3 )', 71 3*C/ 1J 8,:&7171Y*+*79 – C?*7+8 71 NNM &7 C7&37 1J \ () 73*<,C7,3"e 0Nx – C-,U &63&('21+971C*CK 3&C8 E89:,3C,(C*7*P*79 3,&+7*1(FK +812,C7&7*+ 8,:&7*7*CK &3783&26*&
MJ *(5'3,) s *(&;*2*79 71 :31)'+, 8*68 :*7+8 C1'()C &21(6 ?*78 ,&C9 P1*+, J&7*6&;*2*79 E'C'&229 <1(1L 71(,) P1*+, – 3&(6, &() :1?,3 1J P1*+, &JJ,+7,)F – :,3<&(,(7 :&3&29C*C *C 3&3, *J (,3P, 8&C ;,,( *),(7*J*,) )'3*(6 1:_ Q13 <1C7 :&7*,(7CK 78, +8&(6,C &3, C';72,
W,+'33,(729 2&39(6,&2 (,3P, – C'::2*,C &22 8<718L 742 I61Q
S(7*L78931*) )3'6C
D*P*), 78, *(J,3*13 78931*) &37,39 J&3 &?&9 J31< 78, 62&() 71 &P1*) )&<&6, 71 78, 3,+'33,(7 2&39(6,&2 (,3P,
OY7,3(&2 I3&(+8 1J .':,3*13 =&39(6,&2 G,3P, – C'::2*,C 78, 9189>74Q1>8=E7,(C, P1+&2 +13)F &() 3'(C *<<,)*&7,29 ),,: 71 78, C':,3*13 78931*) &37,39 !
1Y*)*C,) &() ;1'() 71 7931C*(, 3,C*)',C *( 78931621;'2*( EABF 71 J13< *1)17931C*(, ENMA - DMAF @'A0,"CE NMA &() DMA +1':2, 71 J13< 78, 813<1(&229 &+7*P, *1)178931(*(,CK A] &() A"_
D*P*), 78, C':,3*13 78931*) &37,39 +21C, 71 78, 62&()K 71 &P1*) )&<&6, 71 78, ,Y7,3(&2 ;3&(+8 1J 78, C':,3*13 2&39(6,&2 (,3P,
M(J,3*13 A8931*) S37,39 EJ31< 78931+,3P*+&2 73'(/K ;3&(+8 1J !C7 :&37 1J C';+2&P*&( &37,39F
MJ '(*2&7,3&2 )&<&6, s &JJ,+7,) +13) 2*,C *( 78, :&3&<,)*+&2 :1C*7*1( E*(&),a'&7, 62177*C +21C'3,F :3,C,(7C ?*78 ?,&/ ;3,&789 P1*+,K 81&3C,(,CC MJ ;*2&7,3&2 )&<&6, s &+'7, )9C:(1,& &C & 3,C'27 1J 78, :&3&<,)*+&2 :1C*7*1( 1J ;178 P1+&2 J12)C ?8*+8 3,)'+, &*3?&9 71 \L"<< &() ?8*+8 7,() 71 6,7 C'+/,) 716,78,3 1( *(C:*3&7*1( A8, 3*687 3,+'33,(7 2&39(6,&2 (,3P, *C <13, C'C+,:7*;2, 71 )&<&6, )'3*(6 78931*),+71<9 E3,2&7*P, <,)*&2 21+&7*1(F 781'68 & 2,J7 P1+&2 +13) :&2C9 *C 78, <1C7 +1<<1( E21(6 *(73&L7813&+*+ +1'3C,K +1<<1(29 *(P12P,) *( *(J2&<<&7139 &() (,1:2&C7*+ +1()*7*1(C *(P12P*(6 78, 2,J7 8*2'
061674Q1>8=[.':,3*13 :&3&78931*) 62&()C 'C'&229 21+&7,) 1( 78, :1C7,3*13 :&37 1J 78, '::,3 21;, 1J 78, 78931*)_ M(J,3*13 :&3&78931*) 62&()C &3, C';5,+7 71 P&3*&7*1(C E*_,_ :1C7,3*13 :&37 1J 78, 21?,3 :12, 1J 78, 78931*)K +&317*) C8,&78K C':,3*13 <,)*&C7*('< *( &-? E13 ,P,( ?*78*(F 78, 789<'CK 3&3,29 ;,8*() 78, 1,C1:8&6'CF
S)P&(7&6, – 8,2:C 71 ),+3,&C, C*b, &() P&C+'2&3*79 1J 62&() R I3&(+8,C 1J 78, ,Y7,3(&2 +&317*) &37,39 “Some Attending’s Like Freaking Out Potential Medical Students “ L C':,3*13 78931*) &37,39 – &C+,()*(6 :8&39(6,&2 &37,39 – 2*(6'&2 &37,39 – J&+*&2 &37,39 – 1++*:*7&2 &37,39 – :1C7,3*13 &'3*+'2&3 &37,39 – <&Y*22&39 &37,39 – C':,3J*+*&2 7,<:13&2 &37,39
"e
':71)&7,U V9:,378931*)*C< )'3*(6 :3,6(&(+9U A3,&7<,(7 !^!
@,"C"@%, 0*.#"','E. 0&'C,C 1J 7893171Y*+1C*C D*C,&C, H3*<&39 V9:,378931*)*C<
.,+1()&39 V9:,378931*)*C<
Graves’ Disease
)>R89 %=2<>H6n )>R89 /CE A.VLC,+3,7*(6 :*7'*7&39 &),(1<& B,C7&7*1(&2 7893171Y*+1C*C G,1:2&C
A893171Y*+1C*C ?*781'7 V9:,378931*)*C<
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)#* ?;5512??8>< - =*J,21(6 21(6L7,3< C'::3,CC*1( 1J A.V E2,P,2C 71 hd_dde4-=F ? *78 =L78931Y*(, 71 ),+3,&C, 3,+'33,(+, &() *<:31P, C'3P*P&2
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-
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,QH54 <>=2 9I2616<92 - A3&+8,1L1,C1:8&6,&2 6311P, E2,P,2 [MF (1), +2,&3&(+, 'C'&229 )1(, - W&)*+&2 (,+/ )*CC,+7*1( 13 <1)*J*,) 3&)*+&2 (,+/ *JU E*F A3&+8,1L1,C1:8&6,&2 6311P, (1),C 8*C71216*+&229 :1C*7*P, J13 +&(+,3 E**F 02*(*+&229 :1C*7*P, (1),C *( 78, (,+/ – :&2:&;2, 13 ,(2&36,) 1( '273&C1'() -6=896I C29g !8??2978>< F-C!G - A8, 3,<1P&2K ,(L;21+K 1J 78, ,(7*3, *:C*2&7,3&2 29<:8&7*+ C73'+7'3,C 1J 78, (,+/K J31< 78, <&()*;2, C':,3*1329 71 78, +2&P*+2, *(J,3*1329K J31< 78, *(J3&891*) <'C+2,C <,)*&229 71 78, &(7,3*13 ;13),3 1J 78, 73&:,b*'C 2&7,3&229 - Classic radical neck dissection (Crile’s) – E!F *(7,3(&2 5'6'2&3 P,*(K E\F C7,3(1+2,*)1<&C71*) <'C+2,K &() E"F C:*(&2 &++,CC139 (,3P, &3, 3,C,+7,)_ .73'+7'3,C (17 3,C,+7,)U +&317*) &37,3*,CK P&6'C (,3P,K 89:1621CC&2 (,3P,K ;3&+8*&2 :2,Y'CK :83,(*+ (,3P,
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-
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-
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W*C/ 6'*),C 73,&7<,(7 – I>J 18?g 56782<7? 96< ;<=21O> 42H8374Q1>8=297>HQ ?*781'7 &;2&7*P, 3&)*1*1)*(, 78,3&:9 :1C7L1:K ?8*2,48O4 18?g 56782<7? ;<=21O> 7>76I 74Q1>8=297>?*78 HQ :1C7L1: &;2&7*P, WSM 73,&7<,(7o 73,&7<,(7 *( *(7,3<,)*&7, 3*C/ :&7*,(7C *C 7&*213,) 71 78, )*C,&C,K ;'7 'C'&229 *7 *C C*<*2&3 71 78&7 *( 8*68 3*C/ :&7*,(7C e 9,&3 C'3P*P&2 *C &2C1 :316(1C7*+&7,) ;9 78, 3*C/U 21? 3*C/ :&7*,(7C 8&P, & C'3P*P&2 1J #eL#^mK *(7,3<,)*&7, 3*C/ :&7*,(7C ^^mK &() 8*68 3*C/ :&7*,(7C edm A8'CK 3*C/ C73&7*J*+&7*1( 8,2:C 71 6'*), 78, ,Y7,(7 1J C'36*+&2 3,C,+7*1( *( )*JJ,3,(7*&7,) 78931*) cancer according to the patient’s disease.
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/>=8L82= -6=896I <29g !8??2978>< F/-C!G M_ A9:, MU 1(, 1J 78, 783,, C73'+7'3,C (17 3,<1P,)K 'C'&229 .SG MM_ A9:, MMU 7?1 1J 78, C73'+7'3,C (17 3,<1P,) – .SG &() M%[ MMM_ A9:, MMMU &22 1J 78, 783,, C73'+7'3,C (17 3,<1P,)– .0NK .SGK M%[ &_ i(1?( &C Q'(+7*1(&2 G,+/ D*CC,+7*1( $R72<=2= C29g !8??2978>< W,C,+7*1( 1J 29<:8 (1),C &()-13 C73'+7'3,C (17 *(+2'),) *( 78, +2&CC*+ (,+/ )*CC,+7*1( @>H5I89678>L 16=896I <29g =8??2978>< F@*""0#G E*F E**F E***F E*PF EPF EP*F
0&317*) ;21?1'7 – 3*C/ J&+713CU *(J,+7*1(K *33&)*&7*1( 3,C'C+*7&7,K &::29 +1(C7&(7 :3,CC'3, &22 78, ?&9 71 78, @Ap V&,<&71<& ;3*(6 ;&+/ 71 @A 71 J*() C1'3+, 1J ;2,,)*(6 &() C71: *7 M(5'39 71 (,3P,C – vagus (vocal cord paralysis), cervical sympathetic chain (Horner’s), <&()*;'2&3 ;3&(+8 1J J&+*&2 E21?,3 2*: ?,&/(,CCF M(J,+7*1( E?1'()F – 3*C/ J&+713CU :3,P*1'C *33&)*&7*1(K *J '::,3 &,31 )*6,C7*P, 73&+7 *C 1:,(,) )'3*(6 C'36,39 ?*78 C&2*P&39 +1(7&<*(&7*1(K C&2*P&39 J*C7'2& H113 8,&2*(6 – 'C'&229 *( *33&)*&7,) C/*(o ?,&/,C7 :1*(7 *C 78, 5'(+7*1( 1J 78, 73*J'3+&7, *(+*C*1( .&2*P&39 J*C7'2& E'C'&229 ?8,( :&7*,(7 8&C 3,+,*P,) WA 71 78, (,+/K &() *J 78, '::,3 BM 73&+7 ?&C 1:,(,) )'3*(6 78, C'36,39F – *(J,+7*1( +&( 3,C'27
!8?6=K6<76O2? >L ))[ - W*C/ 1J ;*2&7,3&2 3,+'33,(7 2&39(6,&2 (,3P, *(5'39 &() :,3<&(,(7 89:1:&3&78931*)*C< - [,39 21? *(+*),(+, 1J +&(+,3 3,+'33,(+, *( 3,C*)'&2 78931*) – <*+31LJ1+* :31;&;29 (17 +2*(*+&229 C*6(*J*+&(7 - =*<*7,) 78931*),+71<9 <&9 C:&3, :&7*,(7 J31< 8&P*(6 71 ;, 1( 2*J,21(6 78931*) 813<1(, 3,:2&+,<,(7
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0%-) `[ #A-E$-. "C+$C"EC)*.-'"!!"#$%#$ "<=89678>1 ?;1O21Q[ FV@?G !_ 0&((17 ;, 73,&7,) <,)*+&229 L J&*2,) <,)*+&2 78,3&:9 13 '(C'*7&;2, J13 <,)*+&2 7Y \_ 0&(+,3 "_ 01<:3,CC*1( 1( (,*68;1'3*(6 C73'+7'3,C ]_ 01C<,C*C e_ 01<:2*&(+,-+1C7 :31;2,L ?;1O21Q 6K68I6MI2[ !_ V,<*78931*),+71<9 – 3,<1P&2 1J 1(, 21;, 1J 78, 62&()K *(+2')*(6 78, *C78<'C &() 78, :93&<*)&2 21;,o 'C'&229 J13 C'C:*+*1'C 78931*) (1)'2,C \_ A17&2 78931*),+71<9 – ,(7*3, 62&() 3,<1P,) +1<:2,7,29o 'C'&229 )1(, *( NGB "_ .';717&2 78931*),+71<9 E3&3,29 )1(,F -
01(P,(7*1(&2 C';717&2 78931*),+71<9 – 2,&P, & 78'<;LC*b,) &<1'(7 E&;1'7 ]L`6F 1J 3,<&*(*(6 78931*) 7*CC', 1( ;178 C*),C V&32,9LD'(8*22 C';717&2 78931*),+71<9 – 2,&P, & 78'<;LC*b,) &<1'(7 1(29 1( 1(, C*), ?*78 3,<1P&2 1J 78, 3,C7 1J 78, 62&()
)>76I K21?;? ?;M7>76I 74Q1>8=297>HQ EJ13 89:,3 J'(+7*1(*(6 78931*) )*C,&C,F - W,C'27 1J 717&2 78931*),+71<9 *C &2?&9C 89:178931*)*C
B,(, *(P12P,) *C ;<= #)(&(>(-*(?,-, 5& *')(3(%(3, 8@988AB?8,3, &+7*P&7*(6 <'7&7*1(C 1++'3 W,C'27C 1J C';717&2 78931*),+71<9 E&7 e 9,&3CFU ! `dLndm ,'78931*) E)1 (17 3,a'*3, <,)*+&7*1( ;'7 C7*22 8&P, 71 ;, J1221?,) ': +21C,29F A?1 )*C7*(+7 631':C 1J )*C13),3C ! !`L\dm 89:178931*) E'C'&229 ;,+1<,C ,P*),(7 ?*78*( ! 9,&3 1J C'36,39F ! NOG \& E.*::2, C9()31<,F ! ^L!dm 89:,378931*) Em *(+3,&C,C :31:137*1(&7,29 ?*78 7*<, J&*2'3, 1J C'36*+&2 78,3&:9F /2=;II61Q 74Q1>8= 96198<>H6 E&22 :&7*,(7CF – 1JJ,3 :31:892&+7*+ AA 042>941>H>9Q7>H6 EedmF D*JJ*+'279 *( <&(&6*(6 :1C7L1:,3&7*P,29 &() *( 78, 21(6 7,3< &C :&7*,(7C (,,) +21C, <1(*713*(6 061674Q1>8= 4Q5215I6?86N *Q521561674Q1>8=8?H E"dmF E;,77,3 1JJ 71 5'C7 3,:2&+, ,P,391(, &J7,3 AAFK ;'7 ?,*68 78*C &6&*(C7 78, ;,(,J*7C 1J (17 3,a'*3*(6 @78,3 J,&7'3,CU &;)1<*(&2 :&*(K V*3C+8C:3'(6 )*C,&C, &(9 <,)*+&7*1( EJ13 ?8*+8 78,3, *C & 611) +8&(+,F ! NOG \; Ek*22*&< C9()31<,F N,)'22&39 +&3+*(1<& &() H8,1+831<1+971<& *(P12P,<,(7 2*/, NOG \&K ;'7 <> 4Q521561674Q1>8=8?H C2;1>9;76<2>;? H6<8L2?7678>L 742 H8=3L692N /61L6<>8= 46M87;?N H;I785I2 H;9>?6I <2;1>H6?
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MNNODMSAO Eh\]VW.F DW *62H>1146O2 J874 462H67>H6 L>1H678>< - V&,<&71<& J1361?2<2?? >1 681J6Q 9>H51>H8?2 L1>H 129;112<7 I61Q8=8?H - W,C,+7*1( 1J 62&() +&( 3,2,&C, 2&36, &<1'(7C 1J C713,) 78931*) 813<1(, *(71 ;211)C73,&< - N&9 3,C'27 *( 78931*) C713< EC,, N&(&6,<,(7 1J 78931*) C713H6I6986 - Q21::*(,CC 1J 73&+8,& 3,C'27*(6 J31< +831(*+ +1<:3,CC*1( ,_6_ ;9 2&36, 61*73, - W,a'*3,C *(7';&7*1( 71 C,+'3, &*3?&9
=SAO EN@WO AVSG "d DS>.F DW *Q5>74Q1>8=8?H \W *Q52174Q1>8=8?H FL68I2= 71267H2<7G TW 021H6<2<7 4Q5>561674Q1>8=8?H `W *Q52171>5489 ?961181 g2I>8= L>1H678>< – &C/ :&7*,(7 *J 8,-C8, 8&C /,21*)C
)*.-'"!#) '-/ D*&6(1C7*+ 03*7,3*& – C,, ;,21? H89C*+&2 OY&< <&9 3,P,&2 61*73,K 1:878&2<1:&789K 2*) 2&6K 8&() 73,<13K ?&3< <1*C7 C/*( H3,+*:*7&7*(6 0&'C,C ! A8931*) .'36,39 E,C:_ *J :&7*,(7 ?&C 89:,378931*) :3*13 71 C'36,39F ! W&)*1*1)*(, ! k*78)3&?&2 1J )3'6C ! S+'7, M22(,CC A3,&7<,(7 H3*(+*:2,C – &+'7, <&(&6,<,(7
! ! ! ! !
MGAOWNODMSAOE! DS> A@ ! NAVF DW "< \W *Q5>561674Q1>8=8?H I26=8 4Q5>96I962H86 -
W*C/ 1J :,3<&(,(7 89:1:&3&78931*)*C< *C !L]m E1(29 *( 717&2 13 C';717&2 78931*),+71<*,CFo !dL\dm 1J
-
:&7*,(7C <&9 8&P, 7,<:13&39 89:1+&2+&,<*& M<:137&(7 71 +8,+/ 78, C,3'< +&2+*'< 2,P,2C :1C7L1:,3&7*P,29 S)5'C7,) +&2+*'< C81'2) ;, X !_#d<<12-= ! ! .1<, +,(73,C C'66,C7 +8,+/*(6 C,3'< HAV 2,P,2C &7 C/*( +21C'3, 71 3,2*&;29 :3,)*+7 +2*(*+&229 3,2,P&(7 89:1+&2+&,<*&]d SC/ :&7*,(7 J13 &(9 C9<:71
-
-
-
@>112972= @6I98;H U /26?;12= ?21;H 96I98;H s cWc\ – %IM;H8L DcZ 96I98;H OI;9><672 >K21 DcH8< F?I>J M>I;?G ! Don’t give bolus :&7*,(7 ?*22 6,7 +&3)*&+ &33,C7 E8,&37 C71:C *( C9C712*+ C7&7,F W,:2&+,<,(7U !_\e6 +&2+*'< +&3;1(&7, ID Z +&2+*73*12 d_e<+6 @N EP&39 ;,7?,,( *(C7*7'7*1(F V9:1calcaemia may also occur due to “hungry bone syndrome” after thyroidectomy in =A 7893171Y*+1C*C
M(73&P,(1'C EM[F Q2'*)C B2'+1+137*+1*)C 71 3,)'+, A]LA" +1(P,3C*1( "B 4Q=1>9>178?><2 DccHO iX* I,7&LI21+/,3 71 +1(7312 C9<:71516<>I>I Vc3XcHO >16IIQ i`* A8*1(&<*), 71 ;21+/ (,? 813<1(, C9(78,C*C 01>5QI748>;1698I F0)AG – VccHO 742< \ccHO i`3V* M1)*(, C12'7*1( 71 ;21+/ 3,2,&C, 1J 78931*) 813<1(,C Lugol’s Solution 10 drops (20 =1>5?dH,N XHO 8>=8<2d=1>5G F>16IG – &)<*(*C7,3 &7 2,&C7 1(, 81'3 &J7,3 HA4 &)<*(*C73&7*1( 71 :3,P,(7 *1)*(, J31< ;,*(6 'C,) &C C';C73&7, J13 (,? 813<1(, C9(78,C*C
Q13 ),J*(*7*P, 78,3&:9 3&)*1*1)*(, 78,3&:9 13 C'36,39
+;194 6<= p617>L?gQ #9>18
A,<:,3&7'3,
A&+89+&3)*&
0G. OJJ,+7C B&C731*(7,C7*(&2 T V,:&7*+ D9CJ'(+7*1( 01(6,C7*P, V,&37 Q&*2'3, S73*&2 Q*;3*22&7*1( H3,+*:*7&(7 V*C7139
]d
.+13*(6 H1*(7C "n_\L"n_n e "n_^L"^_\ !d "^_"L"^_^ !e "^_#L"#_] \d "#_]L"#_# \e X]d_d "d ##L!d# e !!dL!!# !d !\dL!\# !e !"dL!"# \d X!]d \e N*2) ES6*7&7*1(F !d N1),3&7, ED,2*3*'< - HC9+81C*CF \d .,P,3, E.,*b'3, - 01<&F "d N1),3&7, ED*&3381,&F !d .,P,3, E%&'()*+,F \d N*2) e N1),3&7, !d .,P,3, !e S;C,(7 d H3,C,(7 !d S;C,(7 d H3,C,(7 !d
k132) % .'36 E\d!\F "`U!"dd –!"d` !^^
0$-"0*$-%, %-)$-"%, !"#$%#$ %-) $-"$#
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A8, L2H>16I 61721Q78,( )*P*), *(71 EeF ;3&(+8,CU ?;521L8986I 258O6?7189 61721QN ?;521L8986I 9819;HLI2R 61721QN ?;521L8986I 2R721<6I 5;=2<=6I 61721QN =225 2R721<6I 5;=2<=6I &() 61721Q 78, 51>L;<=6 L2H>18?E13 ),,: J,<13&2F ! A8, 51>L;<=6 L2H>18?&3*C,C :1C7,31L2&7,3&229 J31< J,<13&2 &37,39K e+< )*C7&2 71 78, *(6'*(&2 2*6&<,(7 – C'::2*,C 78, <'C+2, 1J 78, 78*68 P*& E"F ;3&(+8,CU H2=86I 6<= I67216I 9819;HLI2R L2H>16I 6172182? &() J1'3 521L>1678
-
A8, ?;521L8986I L2H>16I 3'(C )*C7&229K ,(7,3*(6 78, &))'+713 +&(&2 &() :&CC,C 7831'68 78, 8*&7'C *( 78, &))'+713 <&6('C 71 3,&+8 78, :1:2*7,&2 J1CC&K ?8,3, *7 +8&(6,C *7C (&<, 71 ;,+1<, 78, :1:2*7,&2 &37,39
A8, 5>5I8726I 61721Q :&CC,C 71 21?,3 ;13),3 1J :1:2*7,'C &() )*P*),C *(71 E\F ;3&(+8,CU 6<7218>1 78M86I 61721Q&() 78, 5>?7218>1 78M86I 61721Q E&2C1 +&22,) 7*;*1:,31(,&2 73'(/ ;9 C1<,F ! A8, 6<7218>1 78M86I6*P,C 1JJ ?H6II M16<942? J4894 L>1H 9>II67216I? ?*78 78, P,CC,2 &31'() 78, /(,, &() 78,( +31CC,C *(71 78, &(7,3*13 +1<:&37<,(7 1J 78, 2,6 &() C'::2*,C 78, <'C+2,C 78,3,K &() 78,( ,Y7,()C *( J31(7 1J 78, &(/2, 51*(7 ?8,3, *7 +1(7*(',C &C 78, =>1?6I8? 52=8?*( 78, J117 EC'3J&+, 2&()<&3/U 1(, 78*3) 1J 78, ?&9 )1?( & 2*(, 51*(*(6 78, <*):1*(7 1J 78, 7?1 <&22,12* 71 78, +2,J7 ;,7?,,( 78, J*3C7 &() C,+1() 71, 21+&7,) ;,7?,,( 78, ,Y7,(C13 8&22'+,C 21(6'C &() ,Y7,(C13 )*6*713*'< 21(6'CF !
A8, 5>?7218>1 78M86I6*P,C 1JJ 78, 521><26I 61721QEC'::2*,C 2&7,3&2 +1<:&37<,(7F &() *7C,2J C'::2*,C 78, :1C7,3*13 +1<:&37<,(7 1J 78, 2,6 &() :&CC,C :1C7,3*13 71 78, <,)*&2 <&22,12'C EC'3J&+, 2&()<&3/U 1(, 78*3) 1J 78, ?&9 )1?( & 2*(, 51*(*(6 78, <,)*&2 <&22,12'C 71 78, 8,,2F ;,J13, )*P*)*(6 *(71 H2=86I 6<= I67216I 5I6<761 6172182? 71 C'::29 78, C12, 1J 78, J117
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-
W,J,3 71 )*&63&< – *<:137&(7 71 /(1? 78, &33&(6,<,(7 1J 78, &(7,3*13 7*;*&2K :1C7,3*13 7*;*&2 &() :,31(,&2 P,CC,2C &7 78, 73*J'3+&7*1( &C 91' <&9 ;, &C/,) 71 3,&) &( &(6*163&< 1J 78,C, P,CC,2C_ Q31< 2&7,3&2 71 <,)*&2U S(7,3*13 7*;*&2K H,31(,&2K H1C7,3*13 7*;*&2
@I8<896I #8O<8L896<92 Q,<13&2 &37,39 <&9 ;, :&2:&7,) &7 78, <*)L*(6'*(&2 :1*(7 C*7, J13 SIB &() &37,3*163&:89 S P,(1'C C&<:2, <&9 ;, 1;7&*(,) J31< 78, J,<13&2 P,*( ?8*+8 2*,C *<<,)*&7,29 <,)*&2 71 78, J,<13&2 &37,39 A8, J,<13&2 &37,39 *C a'*7, C':,3J*+*&2 *( 78, J,<13&2 73*&(62, ,&C*29 *(5'3,) H1:2*7,&2 &37,39 +&( 1(29 ;, :&2:&7,) *( 78, 21?,3 :&37 1J 78, :1:2*7,&2 J1CC& E+1<:3,CC,) &6&*(C7 78, '::,3 ,() 1J 78, 7*;*&F – *( 78, '::,3 :&37 1J 78, J1CC& *7 ?*22 ;, :'C8,) *(71 78, *(7,3L+1()92&3 (17+8 H1:2*7,&2 &37,39 &(,'39C< +&( *(+3,&C, 3*C/ 1J D[A E:3,CC'3, 1( P,*(FK :&*( &() (,3P, :&2C*,C E:3,CC'3, 1( 7*;*&2 &() +1<<1( :,31(,&2 (,3P,F A8,3, *C & 3*+8 &(&C71<1C*C ;,7?,,( J,<13&2 &37,39 &() *7C ;3&(+8,C ?8*+8 *C *<:137&(7 *( 78, ),P,21:<,(7 1J +122&7,3&2C *( &37,3*1C+2,317*+ )*C,&C, $R721<6I 8I869 61721Q +1(7*(',C &C 78, L2H>16I 61721Q&J7,3 +31CC*(6 78, *(6'*(&2 2*6&<,(7 EC'3J&+, 2&()<&3/U 78, 3$4>$-?C$-50 #($-& *_,_ <*)?&9 ;,7?,,( 78, :';*+ C9<:89C*C &() 78, &(7,3*13 C':,3*13 *2*&+ C:*(,F !^#
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Q13 :&7*,(7C ?*78 M0K 1(29 & a'&37,3 1J :&7*,(7 ?*22 ,P,3 C*6(*J*+&(729 ),7,3*13&7, ! .9<:71<&7*+ C7&;*2*b&7*1( )', 71 !_ D,P,21:<,(7 1J +122&7,3&2C \_ N,7&;12*+ &)&:7&7*1( 1J *C+8,<*+ <'C+2, "_ H&7*,(7 &27,3C 6&*7 71 J&P1'3 (1(L*C+8,<*+ <'C+2, 631':C Q13 :&7*,(7C ?*78 M0 78, ;,C7 :3,)*+713 1J ),7,3*13&7*1( 1J HSD E*_,_ (,,) J13 &37,3*&2 C'36,39 <&513 &<:'7&7*1(F *C &( SIM 1J h d_e H&7*,(7C ?*78 21? &(/2, :3,CC'3, E*_,_ ]dL`d<
% S< 0122 0&3)*12 \dd`o]nU!\"#–!"!\_ !#d
0$-"0*$-%,%-) $-"%,#.#) $/F*"#) '-.d 0*.#"@%,$P%/"C%) "'Cd "CB$#) "E%) "'C#d /%C%E$/$C)G *"#)'-. DW %O2 >L 742 56782<7 S >99;5678>< \W 068< >L "<721H8772<7 @I6;=89678>< - p4894 56171J 78, 21?,3 2*<; )1,C 78, :&*( 1++'3 *( !_ .7,(1C*C 1J 21?,3 &137& &() +1<<1( *2*&+ ;'771+/ +2&')*+&7*1( Z *<:17,(+, \_ .7,(1C*C 1J ,Y7,3(&2 *2*&+ 78*68 +2&')*+&7*1( "_ .7,(1C*C 1J C':,3J*+*&2 J,<13&2 +&2J +2&')*+&7*1( - G&7'3, 1J 78, :&*( - W&)*&7*1( - .,P,3*79 - %OO16K67898672=?QH57>H?– *_,_ impotence in LeRiche’s - !;1678><[k8,( )*) :&*( J*3C7 C7&37 – <13, 78&( \ ?,,/C &61 - 01>O12??C*(+, J*3C7 (17*+,) '(7*2 +'33,(729 E?13C,(*(6 :&*(K *(+3,&C*(6 &3,&C 1J 21?,3 2*<; &JJ,+7,)K :&*( 1( 2,CC ,Y,37*1(K ),P,21:<,(7 1J 3,C7 :&*(F - @;112<7 9I6;=89678>< =8?76<92 – L8R2= >1 K6186MI2 - *>J 46? ?QH57>H? 6LL2972= I8L2?7QI2 ,_6_ *<:&*3,) <1;*2*79 TW
-8?g L697>1? d 06?7 /2=896I *8?7>1Q - 0'33,(7 C<1/,3 - OYLC<1/,3 EC731(6,C7 WQo "L`Y 3*C/ 1J M0K 8*68,3 78&( 78, 3*C/ J13 MVDF - D*&;,7,C <,22*7'C – \Y *(+3,&C, 3*C/K ,P,39 !m *(+3,&C, *( V;S!+ s \`m *(+3,&C, 3*C/ 1J HSD !_ k8,( ?&C 78, 2&C7 SIMj – 3,+1<<,() 71 )1 ,P,39 J*P, 9,&3C - V9:,37,(C*1( - V9:,32*:*)&,<*& - V9:,381<1+9C7,*(,<*&– C731(6,3 WQ J13 HSD 78&( 0SD - 0131(&39 S37,39 D*C,&C, - .731/, - AMS Ej +&317*) )*C,&C,F - Q&<*29 8*C7139 – *_,_ J&<*29 8Y 1J & J*3C7 ),63,, 3,2&7*P, ?*78 & SSS
VW
!1;O 48?7>1Q - SC:*3*( *(7&/, - S(9 &22,36*,C 71 +1(73&C7 EJ13 &(6*163&:89F
^W
#>986I 48?7>1Q -
Impact on patient’s j;6I87Q >L I8L2– 8W2W J>1g 6<= ?I225 012H>1M8= L;<978>< 6<= 9;112<7 L;<978>< .1+*&2 C'::137 &() 81<, +1()*7*1( E(,,) 71 +2*<; C7&*3CjF @++':&7*1(
-2?7 068< - #872 – ;?;6IIQ 8< I26?7 J2II 521L;?2= 6126 F8W2W >K21 7>2? 6<= L>12L>>7G !_ 0&2J :&*( &7 (*687 *( 78, &;C,(+, 1J J117 :&*( *C '(2*/,29 *C+8,<*+ *( 13*6*( -
`W
YW
G&7'3, – *_,_ &+8*(6 #2K2187Q– 8W2W J6g2? 56782<7 L1>H ?I225 %OO16K6781H6I 6<6IO2?89? j @3 3,a'*3, 1:*1*) &(&26,C*&j *>J I>
%1 O6J21 I8HMf J>1182= 6M>;7 9187896I 8?942H86 - SC/ &;1'7 >O12??EC7&;2,K 13 *(+3,&C*(6 *( C*b,K 6,77*(6 ?13C,F - MJ '2+,3K &(9 :3,+,)*(6 73&'<&j M22LJ*77*(6 C81,Cj S27,3,) C,(C&7*1( *( 78, J117j D1,C :&7*,(7 7&/, +&3, 71 :317,+7 J117j H&*(j W,)(,CC-C?,22*(6-?&3<78 *( C'331'()*(6 C/*(j H'3'2,(7-J1'2LC<,22*(6 )*C+8&36, J31< 78, '2+,3j - MJ 6&(63,(,K *C *7 ?,7 13 )39j W,)(,CC-C?,22*(6-?&3<78 *( C'331'()*(6 C/*(j S(9 J,,2*(6 *( 78, 71, *(P12P,)j S(9 C,(C139 +8&(6,C *( 78, 178,3 (13<&2 71,CK J117K 2*<;j - S(9 ?Q?72H89 ?8OL 8< – J,P,3K +8*22CK 3*613CK <&2&*C,
!#!
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Examine the patient’s lower limbs in a warm room, with the patient exposed optimally (from the 631*( 71 78, 71,CK ?,&3*(6 '(),3?,&3F_ H&7*,(7 *C C':*(, ?*78 78, ;,) J2&7_
,>>g F"?7 >L 742 5674>I>OQ J8II M2 61>;<= 742 L227 6<= 7>2?t !_ 0121'3 1J 78, 21?,3 2*<; - W,) – P&C1)*2&7&7*1( 1J 78, <*+31+*3+'2&7*1( )', 71 7*CC', *C+8,<*& - k8*7, – &)P&(+,) *C+8,<*& - H'3:2,-;2', – ,Y+,CC ),1Y96,(&7,) ;211) *( 78, 7*CC', \_
A31:8*+ +8&(6,C - =1CC 1J 8&*3 - A8*+/,(*(6 1J 78, (&*2C - D39K C8*(9 C/*( – &'71(1<*+ (,'31:&789 - .<&22 (1(L8,&2*(6 C13,C-'2+,3C – ,C:_ ;,7?,,( 71,C - C12,C - 8,,2C E211/ &7 :3,CC'3, :1*(7CF
"_
=1CC 1J )*6*7C - J117 – )', 71 :3,P*1'C 6&(63,(, - &<:'7&7*1( – C,, ;,21?
]_
H3,C,(+, 1J '2+,3 EC,, ;,21?F - =11/ +&3,J'229 &7 78, ,(7*3, 21?,3 2*<;K *(+2')*(6 78, 8,,2C &() ;,7?,,( 78, 71,C -
#872 1J 78, '2+,3
-
#8l2N ?4652 $=O2?E:'(+8,) 1'7 T ?,22 +*3+'
-
-
0&:*22&39 W,J*22 A*<, - H3,CC 8&3) 1( & 71, J13 & J,? C,+1()CK 78,( 3,2,&C, - G13<&2 +&:*22&39 3,J*22 *C h \ C,+ - MJ & 71, *C ;2',K +8,+/ J13 ;2&(+8&;*2*79 EJ*Y,) C7&*(*(6 s ),&) 71,F
"_
H&2:&7*(6 78, '2+,3 *J :3,C,(7 – &(9 C?,22*(6 - S(9 C'331'()*(6 7,(),3(,CC E*(J,+7*1(F - I166*(,CC 1J C'331'()*(6 7*CC', E<&9 8&P, &;C+,CC J13<&7*1(F - .,, *J &(9 )*C+8&36, J31< 78, '2+,3 ?8,( :&2:&7*(6
]_
M(6'*(&2 =9<:8 G1),C - OC:,+*&229 C1 *J 78, '2+,3 211/C *(J,+7,) 13 *J +1(C*),3*(6 )*JJ )Y 1J <,2&(1<&
e_ `_
.,(C&7*1( - H&3&,C78,C*& H'2C,C - Q,,2 78, )*C7&2 :'2C,C &() ?13/ 91'3 ?&9 :31Y*<&229 - E16=8
W,:137 &C E!F :3,C,(7o E\F 3,)'+,) 13 E"F &;C,(7 *J (17 J,27
!>1?6I8? 52=8? 5;I?2 0>?7218>1 78M86I 5;I?2
=11/ ;,7?,,( &() &7 78, 7*: 1J 78, 71,C !_ p27 – +1<:2*+&7,) ;9 *(J,+7*1( 8&P, *22L),J*(,) C:3,&)*(6 ,)6, \_ !1Q – (17 *(J,+7,) ?,22L),J*(,) ,)6, ),&) 7*CC', <&9 J&22 1JJ E&'71L&<:'7&7*1(F OY7,(7 1J 6&(63,(, – 2*(, 1J ),<&3+&7*1( ./*( ;2*C7,3*(6 <&9 1++'3 D*JJ,3,(7*&2 )*&6(1C*CU &+3&2 2,(7*6*(1'C <,2&(1<&
0>5I8726I 5;I?2
(2H>16I 5;I?2
-
-
!-" ?&9 )1?( & 2*(, 51*(*(6 78, <*):1*(7 1J 78, 7?1 <&22,12* 71 78, !C7 ?,;C:&+, SC/ :&7*,(7 71 :1*(7 ;*6 71, 71 78, C/9 E),<1(C73&7*(6 OV=F – &37,39 2*,C *<<,)*&7,29 2&7,3&2 OY&<*(, ;178 )13C&2*C :,)*C :'2C, C*<'27&(,1'C29 !-" ?&9 )1?( & 2*(, 51*(*(6 78, <,)*&2 <&22,12'C 71 78, 8,,2 OY&<*(, ;178 :1C7,3*13 7*;*&2 :'2C, C*<'27&(,1'C29 SC/ :&7*,(7 71 ;,() 78, /(,, q`dL#d ),63,,C H'2C, *C ;,C7 J,27 ;9 +1<:3,CC*(6 *7 &6&*(C7 78, :1C7,3*13 &C:,+7 1J 78, 7*;*&2 MJ 78, :'2C, *C P,39 ?,22 J,27 j:1:2*7,&2 &(,'39C< !_ H'2C&7*(6 <&CC 78&7 )1,C (17 &27,3 ?*78 +8&(6, * ( :1C*7*1( 1J 78, /(,, \_ edm &3, ;*2&7,3&2 +8,+/ +1(73&2&7,3&2 C*), T edm 8&P, &( SSS "_ MJ )*C7&2 :'2C,C (17 J,27 j7831<;1C,) &(,'39C< N*)L*(6'*(&2 :1*(7 E<*):1*(7 1J 78, 2*(, 51*(*(6 78, :';*+ C9<:89C*C 71 78, &(7,3*13 C':,3*13 *2*&+ C:*(,FK 5'C7 ;,21? 78, *(6'*(&2 2*6&<,(7
EMJ 78, :&7*,(7 8&C )*&;,7,CK <&9 C,, C/*( +8&(6,C – )*&;,7*+ ),3<1:&789 T 51*(7 ),J13<*7*,C – Charcot’s joint F L L
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O3978,<& E+,22'2*7*CF – 78,3, <&9 ;, &( '(),329*(6 &;C+,CC E+1(J*3< 1( :&2:&7*1(F I2*C7,3*(6K :'3:2*C8 +121'3 E:1CC*;*2*79 1J (,+317*C*(6 J&C+**7*CF
H3,C,(+, 1J 6&(63,(, -
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[,(1'C '2+,3C J13< &7 78, <,)*&2 <&22,12'C S37,3*&2 '2+,3C &3, <13, )*C7&2 E*( 78, 2,&C7 ?,22 :,3J'C,) &3,&C &() 1P,3 78, :3,CC'3, :1*(7CF – 2&7,3&2 &C:,+7 1J J117 &() 2&7,3&2 <&22,12* G,'31:&78*+ '2+,3C J13< &7 &3,&C C'+8 &C 78, 8,,2 &() &7 78, <,7&7&3C&2 8,&)C
(22I F56I5672G !_ A,<:,3&7'3, – k&3<78 1J 78,C/*( - 4C, 78, )13C'< 1J 78, J*(6,3C 1J ;178 8&()C 71 C*<'27&(, ously run up the patient’s feet to 78, C8*(C &() 78*68C ;*2&7,3&229 - 01<:&3, 78, 7,<:,3&7'3, 1( ;178 C*),C E(17, *J 1(, C*), *C +112,3F - MJ 1(, 2*<; J,,2C +112K J,,2 J13 78, 2,P,2 ?8,3, 78, C/*( ;,+1<,C ?&3<
D*&;,7*+ D,3<1:&789 &731:8*+ 89:,3L:*6<,(7,) C/*( 2,C*1(C 'C'&229 1( 78, C8*( 08&3+17 %1*(7 0831(*+ :3163,CC*P, ),C73'+7*P, (,'31:&78*+ 51*(7 &37831:&789 C,+1()&39 71 )*C7'3;&(+, 1J C,(C139 *((,3P&7*1( 1J 78, &JJ,+7,) 51*(7
02*(*+&2 0&C,C &() @.0OC *( .'36,39 E\() ,)*7*1(F – 0&C, !!! - !!^ - !\d !#\
/>K2 !_ k,&/(,CC - H&3&29C*C \_ Buerger’s test Buerger’s angle - B,7 :&7*,(7 71 2*, &C +21C, 71 78, C*), 1J 78, ;,) &C :1CC*;2, - D1 1(, C*), &7 & 7*<, - Holding the heel of the foot, with the patient’s lower limb straightened, slowly I8L7 742 2<7812 I>J21 I8HM K 211/*(6 &7 78, +121'3 1J 78, 71,C - .71: ?8,( 78, 71,C ;,+1<,56I2 E?8*7,F - OC7*<&7, 78, &(62, 78, 21?,3 2*<; <&/,C ?*78 78, 813*b1(7&2 – 78*C *C 78, Buerger’s angle G13<&2 21?,3 2*<; +&( ;, 3&*C,) 71 #d ),63,,C ?*781'7 7'3(*(6 ?8*te; if the Buerger’s &(62, *C 2,CC 78&( \d ),63,,CK 78*C *()*+&7,C C,P,3, *C+8,<*& - A8,3, <&9 ;, K2<>;? O;772185 >K21 742 2=O2 >L 742 M2= - =11/ &7 78, 2,6 J13 126978K2 4Q52162H86 EJ117 7'3(C :'3:2,L3,)F
[,(1'C 42+,3C
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H'(+8,) 1'7 +2,&( G1 63&('2&7*1( 7*CC',K I1(, <&9 ;, ,Y:1C,)
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d L2H>16I35>5I8726I >1 78M86I3521><26I F C,6<,(7 ?*7878??;2 I>??
MC+8,<*+ 42+,3C H&*(J'2
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A*: 1J 71,C &() :3,CC'3, &3,& [&39*(6 C*b,K J,? << 71 +<
G,'31:&78*+ 42+,3C H&*(2,CC V,,2K <,7&7&3C&2 8,&)C E:3,CC'3, ;,&3*(6 &3,&CF .,P,3&2 +< W,6'2&3 1'72*(,K J1221?C C/*( +1(71'3 – ‘punchedLout’ 02,&( @J7,( ,Y:1C*(6 ;1(,
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0&22'C,C &;C,(7 - *(J3,a',(7 0122&:C,) [,*(
R S,7*12169 1J DN J117 '2+,3CU E!F (,'31:&78*+ – ]eL`dmo E\F *C+8,<*+ – !dmo E"F <*Y,) (,'31L*C+8,<*+ – \eL]em E+133,2&7, +2*(*+&229F
)Q52 >L %H5;7678>
Chopard’s (Midtarsal) Syme’s (through ankle) IiS A831'68 i(,, E.71/,CLB3*77*F SiS V*: )*C&37*+'2&7*1( V*()a'&37,3 &<:'7&7*1( E8,<*:,2P,+71<9F
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M(7,3:3,7*(6 78, P&2',C G13<&2 SIM *C X d_# E+&( ;, X !_d &C &(/2, :3,CC'3,C 7,() 71 ;, 8*68,3 78&( ;3&+8*&2F SIM ;,7?,,( d_e L d_#– 1++2'C*1(K 1J7,( &CC1+*&7,) ?*78 +2&')*+&7*1( SIM hd_eU 03*7*+&2 MC+8,<*& W,C7 :&*( *J X!_]dK C'66,C7C (1(L+1<:3,CC*;2, +&2+*J*,) P,CC,2 ,C:_ C,,( *( DN :&7*,(7C D1 )>2 512??;12? 8<=2R F)0"G *(C7,&) E&( &;(13<&2 AIM *C hd_ndF
-
S++'3&+9 1J 78, *(),Y SIHM ≤d_# C731(629 +133,2&7,) ?*78 &22L+&'C, <137&2*79 *(),:,(),(7 1J Q3&<*(68&< 3*C/ C+13, SIHM ≤d_# – #em C,(C T ##m C:,+_ *( ),7,+7*(6 &(6*163&< :1C*7*P, )*C,&C, HSD &() *C &-? Xedm C7,(1C*C *( 1(, 13 <13, <&513 P,CC,2C ABI ↓by 0.10 associated with ↑10% of major vascular event
-
OY,3+*C, 73,&)<*22 7,C7*(6 Q13 :&7*,(7C ?*78 (13<&2 SIM &7 3,C7 *( +1<;*(&7*1( ?*78 +2&CC*+ C9<:71
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%O16H J874 =8O876I ?;M716978>< – 78, *<&6,C 1J 78, '(),329*(6 ;1(, &3, 3,<1P,) C1 &C 71 ;,77,3 P*C'&2*C, 78, &37,3*,C 612) C7&()&3) J13 ,P&2'&7*(6 &37,3*&2 73,, ;,J13, :2&((,) 3,P&C+'2&3*b&7*1( VW
+6?89 I6M>167>1Q 8< 0LW,&+7*P, H317,*( – *J ↑*( &C9<:71<&7*+ :&7*,(7C 8*68,3 3*C/ 1J ),P,21:*(6 HSD *( C';C,a',(7 e 9,&3C]` QI0K 4-O-03K HA-HAAK C,:7*+ ?13/':U ;211) +-CK ?1'() +-C E&C *()*+&7,)F
%172186I !;5I2R ;I716?>;<= - !C7 2*(, *<&6*(6 71 &22 :,1:2, ?*78 HSD - @:,3&713 ),:,(),(7K (1(L*(P&C*P, 7,C7K 2*<*7,) ;9 )*JJ*+'279 71 P*C'&2*b, *2*&+ &37,3*,C &() ,Y7,(C*P, +&2+*J*+&7*1( <&9 +1<:31<*C, ,Y&<*(&7*1( - D':2,Y E<,&(C 7?1 <1)&2*7*,CF s \D '273&C1'() E2*/, 78, (13<&2 /*()F :2'C D1::2,3 '273&C1'() E<,&C'3,C J21? &() ?&P,J13
O'3 % [&C+ O()1P&C+ .'36_ \ddno"" !#]
`^ /%C%E$/$C)– 'K21K82J >L )1267H2<7 %551>694
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0&3)*1P&C+'2&3 W*C/ Q&+713 N1)*J*+&7*1(]^ -
.<1/*(6 0,CC&7*1(R ↓ progression of disease ! Doctor’s advice alone = YZ 92??678>< 67 Y Q261? ! Doctor’s advice + formal cessation program + nicotine replacement = \\Z 92??678>< 1672 67 Y Q261? ! E&;1P,F l ;':31:*1( E&(7*L),:3,CC&(7F s ;,C7 +,CC&7*1( 3&7,Cp ! SC/ :&7*,(7 &;1'7 C7&7'C 1J C<1/*(6 &7 ,P,39 P*C*7p
R C<1/*(6 +,CC&7*1( (17 :31P,( 71 C9<:71<&7*+&229 *<:31P, C9<:71
-
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SCC,CC<,(7 &() 73,&7<,(7 71 1:7*<*C, +1(7312 1J 0[. 3*C/ J&+713C – +&3)*1216*C7 ! k,*687 W,)'+7*1( ! =*:*) 01(7312– ,!, k \WVHH>Id, K *J 8*68 3*C/ =D= h!_^ <<12-=– *_,_ C7&7*(C ! VAG +1(7312 – +0 k D`cdbcHH*O K *J DN - 0WQ IH 7&36,7 k DTcdXcHH*O – *_,_ S0O* D*&;,7,C 01(7312 ! Advise to “take care of foot as good as his/her face!” – :1)*&73*C7 ! *M%D9 k^WcZ =*J,21(6 S(7*:2&7,2,7 &() S(7*7831<;17*+ D3'6C ! %?5818< DccHO13 @I>58=>O12I ^YHO– 3,)'+, 3*C/ 1J NMK C731/, 13 P&C+'2&3 ),&78 *( *()*P*)'&2C ?*78 C9<:71<&7*+ &78,31C+2,317*+ 21?,3 2*<; HSD ! H&7*,(7C ?*78 <'27*:2, &78,31C+2,317*+ 3*C/ J&+713C 13 ,C7&;2*C8,) 0[D &() (17 &7 *(+3,&C,) 3*C/ 1J ;2,,)*(6 – h"B =;6I 6<785I672I27 E0VSWM.NS 73*&2F]# ! G1 ;,(,J*7 1J &))*(6 ?&3J&3*(p
02&')*+&7*1( .':,3P*C,) 2R2198?2 7168<8
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0*3+'2&7*1(_ \d!" S:3 \o!\nE!"FU!]\eL]"_ G O(62 % N,) \dd`o "e]U!nd`L!n!n !#e
M(7,3P,(7*1( E,()1P&C+'2&3 13 C'36*+&2F – J13 0831(*+ =*<; MC+8,<*&
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Indications (4 D’s) D,&) E*C+8,<*+FU :,3*:8,3&2 P&C+'2&3 )*C,&C, E^dL#dm 1J &22 +&C,CF D&<&6,) E73&'<&FU '(C&2P&6,&;2, 2*<;K ;'3(C D&(6,31'CU B&(63,(,K &C+,()*(6 C,:C*CK <&2*6(&(+9 EC1J7 7*CC', - ;1(,F D&<( ('*C&(+, E*(J,+7*1(-(,'31:&789FU 1C7,1<9,2*7*CK (,+317*b*(6 J&C+**7*C
01<:2*+&7*1(C C-: &<:'7&7*1(U A8,C, :&7*,(7C 1J7,( 8&P, 178,3 <,)*+&2 :31;2,
.:,+*J*+ O&329 01<:2*+&7*1(C
G,? <,781)U ?;M8<78H6I 65I6?7Q – *J 2'<,( *C C1 1++2'),) 78&7 6'*), ?*3, +&((17 :&CC 7831'68K 78, 6'*), ?*3, *C 783,&),) *(71 78, C';*(7*<&2 C:&+, 71 +3,&7, & )*CC,+7*1( &31'() 78, 1++2'),) C,6<,(7K &() 78*C C:&+, *C 78,( &(6*1:2&C7*,) 71 +3,&7, & +8&((,2 :&3&22,2 71 78, &+7'&2 2'<,( J13 ;211) 71 J21? 7831'68 EC,, ;,21?F
.:,+*J*+ =&7, 01<:2*+&7*1(C
+Q56?? O16L78
01(C*),3 ;9:&CC ?8,( 2,C*1(C +&((17 ;, 73,&7,) ;9 &(6*1:2&C79 * _,_ 2,C*1( ,Y7,()C J13 21(6 )*C7&(+, 7831'68 78, P,CC,2 &()-13 (1 2'<,( J13 6'*), ? *3, 71 :&CC 7831'68 E+1<:2,7, 1++2'C*1(F
ed
S1371L*2*&+ 1++2'C*P, )*C,&C, EC,, ;,21?F *_ S1371L;*J,<13&2 63&J7*(6 – 3,:137,) :&7,(+9 ': 71 #em &7 e 9,&3C E7Y 1J +81*+,pF **_ M2*&+ &(6*1:2&C79 &() J,<13&2LJ,<13&2 +31CC1P,3 ;9:&CC ***_ SY*221L;*J,<13&2 ;9:&CC – &27,3(&7*P, J13 8*68 3*C/ :&7*,(7C
M(J3&L*(6'*(&2 1++2'C*P, )*C,&C, *_ S;1P, /(,, 1++2'C*1( J,<13&2L:1:2*7,&2 ;9:&CC **_ I,21? /(,, 1++2'C*1( J,<13&2 71 ;,21? /(,, :1:2*7,&2 - :1C7,3*13 7*;*&2 &(7,3*13 7*;*&2 - J*;'2&3 &37,3*,C ***_ Needs a good “landing zone” for graft distally – *J P,CC,2 *C )*JJ'C,29 )*C,&C,)K )*JJ*+'27 71 :,3J13< ;9:&CC
A8, k&C8*(671( N&('&2 1J .'36,39 E\() O)*7*1(F – :6_ ]]`
-
N,)*+&2 V,<&71<& &() ?1'() *(J,+7*1( E3&3,U 6&C 6&(63,(,F D,,: P,*( 7831<;1C*C &() :'2<1(&39 ,<;12*C< H8&(71< 2*<; :&*( ./*( (,+31C*C – \ d 71 :113 :,3J'C*1( 1J C7'<: – 3,a'*3, 3,LJ&C8*1(*(6 HC9+81216*+&2 T .1+*&2 @C7,1<9,2*7*C .7'<: '2+,3&7*1( – \ d 71 :3,CC'3, J31< :31C78,C*C .7'<: (,'31<& Q*Y,) Q2,Y*1( ),J13<*79 D*JJ*+'279 <1;*2*b*(6 .:'3C &() 1C7,1:897,C *( '(),329*(6 ;1(,
@'7+1<, &J7,3 &<:'7&7*1(U I,21? i(,, S<:'7&7*1(U #dm 1J :&7*,(7 ?*22 ,P,(7'&229 ;, &;2, 71 ?&2/ &6&*( 4(*2&7,3&2 IiS *(+3,&C, ,(,369 ,Y:,()*7'3, ;9 `cZ I*2&7,3&2 IiS *(+3,&C, ,(,369 ,Y:,()*7'3, ;9 Vc3^cZ S;1P, i(,, S<:'7&7*1(U edm 1J :&7*,(7C ?*22 ,P,(7'&229 ;, &;2, 71 ?&2/ &6&*( 4(*2&7,3&2 SiS *(+3,&C, ,(,369 ,Y:,()*7'3, ;9 DccZ
e!
02*(*+&2 0&C,C &() @.0OC *( .'36,39 E\() O)*7*1(F – +&C, !!" !#`
I9:&CC B3&J7*(6
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%@A) $,"/+ "#@*$/"%Y\ S+'7, 2*<; *C+8,<*& *C ),J*(,) &C & ?;==2< =29126?2 8< I8HM 521L;?8>< 7467 7412672L 742 I8HME<&(*J,C7,) ;9 *C+8,<*+ 3,C7 :&*(K *C+8,<*+ '2+,3CK &()-13 6&(63,(,F *( :&7*,(7C ?81 :3,C,(7 J8748< \dY\1J 78, &+'7, ,P,(7 E*J X\-e\K + 1(C*),3,) +831(*+ *C+8,<*&F_
@%A#$#[ DW %172186I 2HM>I8?H - />?7 9>HH>< 96;?2 1J &+'7, 2*<; *C+8,<*& E`dL^dm 1J 78, 7*<,F - A8, <1C7 2*/,29 C1'3+, 1J ,<;12'C *C 78, 42617 E^dmFK 1J ?8*+8 ndm *C )', 71 &73*&2 J*;3*22&7*1(K \dm 71 SNM ?*78 2,J7 P,(73*+'2&3 <'3&2 7831<;'CK &() & C<&22 :31:137*1( 71 :31C78,7*+ 8,&37 P&2P,C E?81 &3, (17 3,+,*P*(6 &(7*+1&6'2&(7 78,3&:9F
A8, ),+3,&C, *( :,3J'C*1( *C 'C'&229 )', 71 C')),( +,CC&7*1( 1J ;211) C'::29 &() ('73*,(7C 71 <,7&;12*+&229 &+7*P, 7*CC',C 1J 78, 2*<;_ A8*C <&9 ;, *( & C,77*(6 1J &23,&)9 (&331?,) P,CC,2 2'<,( E&+'7, 1( +831(*+ *C+8,<*&F 13 *( & (13<&2 2'<,(_
-
G1(L+&3)*&+ ,<;12* &3*C, J31< 178,3 &37,3*,C ?8,3, 78,3, &3, &78,31C+2,317*+ :2&a',C 13 &( &(,'39C< E78, ,<;12*+ <&7,3*&2 <&9 ;, 7831<;'C 13 :&37 1J & :2&a',K ;'7 &78,31,<;12* &3, 2,CC 2*/,29 71 +&'C, +1<:2,7, &37,3*&2 1++2'C*1(F
MJ &),a'&7, +122&7,3&2 +*3+'2&7*1( *C &;C,(7K *33,P,3C*;2, +8&(6,C <&9 &::,&3 ]L`81'3C &J7,3 1(C,7 ,<,36,(7 ,P&2'&7*1( 78&7 ),J*(,C &(&71<*+&2 2,P,2 1J 1;C73'+7*1( &() :31<:7 3,P&C+'2&3*b&7*1( E,()1P&C+'2&3 13 C'36*+&2F
-
N1C7 +1<<1( C*7,C ?8,3, ,<;12* 21)6,U I*J'3+&7*1( 1J 78, J,<13&2 &37,39 E<1C7 +1<<1( C*7,F A3*J'3+&7*1( 1J 78, :1:2*7,&2 &37,39 E(,Y7 <1C7 +1<<1( C*7, *( 78, 21?,3 2*<;F S137*+ ;*J'3+&7*1( OY7,3(&2 &() *(7,3(&2 *2*&+C S3< E&;1'7 \dm 1J ,<;12*F
-
O<;12* 'C'&229 +&'C, 21?,3 2*<; *C+8,<*& <1C729 SJ7,3 ,<;12* 1;C73'+7C 78, P,CC,2K 7831<;'C +&( :31:&6&7, )*C7&229 E)', 71 C7&C*C 1J ;211)F &() :31Y*<&229 E)', 71 7'3;'2,(+, 1J *(+1<*(6 ;211) 8*77*(6 ,<;12'CF ;9 ),3&(6,<,(7C *( the Virchow’s triad
!!R[ - S+'7, D[AU H82,6<&C*& +,3'2,&( )12,(C s :&*(J'2 ;2', ,),<& - I2', 71, C9()31<,U &78,31,<;12*C< J31< SSS 13 <13, :31Y*<&2 - H'3:2, 71, C9()31<,U 0Y 1J ?&3J&3*( 78,3&:9 - [,(1'C *(C'JJ*+*,(+9 - [,(1'C 1++2'C*1( - S+31+9&(1C*C
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W,2*,P,) ;9 :2&+*(6 J117 *( ),:,(),(7 :1C*7*1( 02&CC*+&2 ,Y&<*(&7*1( J*()*(6C D,+3,&C,) - &;C,(7 )*C7&2 :'2C,C D,:,(),(7 3';13 A31:8*+ +8&(6,C EC,, &;1P,F
-
0&2J +2&')*+&7*1( &JJ,+7C C':,3J*+*&2 J,<13&2 (,&3 71 78, &))'+713 8*&7'CK 13 :1:2*7,&2 &37,39 Q117 +2&')*+&7*1( 7*;*&2 &() :,31(,&2 &37,3*&2 )*C,&C,K ;'7 3&3,29 )1 :&7*,(7C ?*78 claudication due to atherosclerosis get foot pain alone (more common in Buerger’s) A8*68 +2&')*+&7*1( &JJ,+7C +1<<1( J,<13&2 &37,39 13 &1371*2*&+ )*C,&C, Important to determine the “ 9I6;=89678>< =8?76<92 ” – ?*78*( & C8137 :,3*1) 1J 7*<, 78, )*C7&(+, *C 'C'&229 J&*329 +1(C7&(7K ;'7 +&( C8137,( &C 78, )*C,&C, :3163,CC,C G,,) 71 )*JJ,3,(7*&7, 78, P&3*1'C +&'C,CU P&C+'2&3 PC_ (,'316,(*+ PC_ <'C+'21C/,2,7&2
C$A-'E$C"@ @,%A!"@%)"'C – \c #0"C%, #)$C'#"# [&C+'2&3 *(7,3<*77,(7 +2&')*+&7*1( (,,)C 71 ;, )*JJ,3,(7*&7,) J31< (,'316,(*+ +2&')*+&7*1( ?8*+8 +&( &2C1 :3,C,(7 &C :&*( *( 78, 21?,3 2*<; 1( ,Y,37*1( A8, +8&3&+7,3*C7*+ 1J (,'316,(*+ +2&')*+&7*1( *C “park bench to park bench” ?8,3, 78, :&7*,(7 8&C 71 C*7 )1?( &() LI2R 742 ?58<2 7> 12I82K2 742 568< E:&*( 3,C'27C J31< +1<:3,CC*1( 1J 78, +13) &() C:*(&2 (,3P,C *( C:*(&2 C7,(1C*Co ,Y7,(C*1( 1J 78, C:*(, J'378,3 (&331?C 78, C:*(&2 +&(&2 ?8*2, J2,Y*1( ?*),(C *7F “Claudication distance” of neurogenic claudication is more variable H&*( ,P,( 1( C7&()*(6 – :&7*,(7 :3,J,3C 71 C7&() *( C2*687 J2,Y*1( H'2C,C ?*22 ;, &;C,(7-)*<*(*C8,) *( P&C+'2&3 ;'7 (17 *( (,'316,(*+ +2&')*+&7*1( G1 :&*( &7 (*687– :&7*,(7 C2,,:C 1( 2&7,3&2 ),+';*7'C :1C*7*1( H&3&,C78,C*& *C +1<<1( *( (,'316,(*+ +2&')*+&7*1(
%##$##/$C) '( #$B$-"). The three L’s of 521854216I 6172186I =8?26?2[ E*F ,8L2 – )1,C )*C,&C, 783,&7,( 2*J, E,_6_ C,:C*Co 178,3 +1<:2*+&7*1(C 1J &78,31C+2,31C*C ,_6_ C731/,K SNMoF 13 ?*22 *(7,3P,(7*1( +&'C, 3*C/C E**F ,8HM – ?*22 :&7*,(7 21C, 78, 2*<; E***F ,8L2?7QI2– *C 78, 2*J,C792, 1J 78, :&7*,(7 C,P,3,29 8&()*+&::,)K )1,C *7 3,a'*3, *(7,3P,(7*1(
/%C%E/$C$) ('- "C)$-/"))$C) @,%A!"@%)"'C N1C7 :&7*,(7 (,P,3 3,a'*3, C'36,39 0&3)*1P&C+'2&3 WQ +1(7312 EC,, &;1P,F k&2/*(6 ,Y,3+*C, :3163&< l :8&3<&+1216*+&2 78,3&:9 EC,, &;1P,F .<1/*(6 0,CC&7*1( &() C73*+7 DN +1(7312 EC,, &;1P,F
Fontaine’s Stages
#76O2 U" SC9<:71<&7*+ #76O2 ""6U N*2) +2&')*+&7*1( #76O2 ""MU N1),3&7, 71 C,P,3, + 2&')*+&7*1( #76O2 """U MC+8&,<*+ 3,C7 :&*( #76O2 "BU 42+,3&7*1( 13 6&(63,(,
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@-") "@%,,"/+ "#@*$/"%Y` 03*7*+&2 2*<; *C+8,<*& E0=MF s :&7*,(7C ?*78 +831(*+ *C+8,<*+ 3,C7 :&*( X\ ?,,/CK '2+,3C 13 6&(63,(, &773*;'7&;2, 71 1;5,+7*P,29 :31P,( &37,3*&2 1++2'C*P, )*C,&C, @," 8? 6 9I8<896I =86O<>?8? 6<= ?4>;I= M2 ?;55>172= MQ >Mm2978K2 72?78
($%)A-$#[ !_ -2?7 568<3,a'*3*(6 3,6'2&3 >58>8= 6<6IO2?86 E,_6_ +1),*(,F 2&C7*(6 a\ J22g? SGD-@W \_ E6< 1J :113 P&C+'2&3 C'::29 71 78, 21?,3 2*<;C E;F S(/2, ;3&+8*&2 :3,CC'3, *(),Y hd_e E+F A1, :3,CC'3, *(),Y h d_" E)F A1, :3,CC'3, h"d <
"W -2?7 568< - .,P,3, :&*( *( 78, )*C7&2 :137*1( 1J 78, 21?,3 2*<; E'C'&229 71,CK J117 ;'7 <&9 *(P12P, <13, :31Y*<&2 &3,&C *J )*C,&C, *C C,P,3,F 1++'33*(6 67 12?7 - M( <1C7 +&C,CK ?&2/*(6 +&:&+*79 *C C,P,3,29 2*<*7,) 13 *<:1CC*;2, - W,C7 :&*( 79:*+&229 1++'3C &7 (*687 – ;211) C'::29 &C :&7*,(7 *C (17 *( ),:,(),(7 :1C*7*1( &() ),+3,&C, IH )'3*(6 C2,,: ?&/,C :&7*,(7 J31< C2,,: E6,7C ;,77,3 &J7,3 & C8137 ?&2/ -
&31'() 78, 311
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
!-. – 8&3)K )39 7,Y7'3,_ @J7,( 8&C & +2,&3 ),<&3+&7*1( ;,7?,,( P*&;2, &() (,+317*+ 7*CC',K 1++'3C *( :&7*,(7C ?*78 &78,31C+2,317*+ )*C,&C,_ #6L2 &() +&( ;, &221?,) 71 &'71 &<:'7&7, &J7,3 ),<&3+&7*1( ?*78 :3,+&'7*1(C &6&*(C7 *(J,+7*1(_ p$) – <1*C7K C?122,(K J3,a',(729 ;2*C7,3,)K ;&+7,3*&2 *(J,+7*1( &() :'73,J&+7*1( 1++'3CK 6&(63,(, C:3,&)C :31Y*<&229K 1J7,( 1++'3C *( )*&;,7*+C ?*78 ),+3,&C,) C,(C&7*1( &() '(3,+16(*C,) 73&'<&K 3,a'*3*(6 &( 2H21O2<9QC'36*+&2 ),;3*),<,(7 13 &<:'7&7*1( – :31Y*<&2 &<:'7&7*1( *C 3,a'*3,) ?8,3, ;211) C'::29 *C ;,77,3 -8?g (697>1? L>1 =2K2I>5H2<7 >L @187896I ,8HM "?942H86 D*&;,7*+ – ]Y .<1/,3 – "Y SIHM h d_n– \Y SIHM h d_e– \_eY S6, X `e93 – \Y =*:*) &;(13<&2*7*,C – \Y !8LL212<786I !86O<>?8? >L 8?942H89 12?7 568< D*&;,7*+ G,'31:&789 01<:2,Y W,6*1(&2 H&*( .9()31<, G,3P, W117 01<:3,CC*1( H,3*:8,3&2 .,(C139 G,'31:&789 E178,3 78&( )*&;,7*+ (,'31:&789F G*687 03&<:C -
Buerger’s Disease (thromboangitis obliterans)
/%C%E/$C$) ('- @-")"@%, ,"/+ "#@*$/"% N'27*)*C+*:2*(&39 &::31&+8 71 1:7*<*b, E!F :&*( + 1(7312 E\F 0[. 3*C/ J&+713C E"F 178,3 +1L<13;*)C O&329 C'36*+&2 3,J,33&2 J13 &+7*P, *(7,3P,(7*1( T P&C+'2&3 3,+1(C73'+7*1( 0&()*)&7, J13 3,P&C+'2&3*b&7*1( &(6*163&:8*+ ,P&2'&7*1( 1:,( - ,()1P&C+'2&3 78,3&:9 G1( +&()*)&7, J13 3,P&C+'2&3*b&7*1( .7&;2, :&*( &() 2,C*1( <,)*+&2 73,&7<,(7 G17L712,3&;2, :&*(K C:3,&)*(6 *(J,+7*1( &<:'7&7*1(
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"C!"@%)"'C#– 0-$3'0$-%)"'C $B%,A%)"'C H&7*,(7C ?*78 3,(&2 *(C'JJ*+*,(+9 – 3,J,33,) J13 C'36*+&2 ,P&2'&7*1( ! 9,&3 ;,J13, 78, &(7*+*:&7,) (,,) J13 )*&29C*C ! M()*+&7,) ?8,( +3,&7*(*(, +2,&3&(+, *C h \e<=-<*( 13 ?8,( C,3'< 03 X]<6-)= H&7*,(7C EO.WD :&7*,(7CF C81'2) :317,+7 78,*3 J13,&3< P,*(C J31< P,(,:'(+7'3, &() *(73&P,(1'C +&78,7,3C – &P1*) :17,(7*&2 )&<&6, E*_,_ C7,(1C*CF ?8*+8 +1'2) :3,+2'), J'7'3, 'C, D':2,Y 4273&C1'()– 'C,) J13 ),7,3<*(*(6 )*&<,7,3 1J &37,39 &() &),a'&+9 1J C':,3J*+*&2 &() ),,: P,*(C *J 3,a'*3, J'378,3 *<&6*(6 ! 01(73&C7 P,(163&:89 – ,P&2'&7, :&7,(+9 &() &),a'&+9 1J P,(1'C C9C7,< ! 01(P,(7*1(&2 &37,3*163&:89– ,P&2'&7, C'C:,+7,) &37,3*&2 *(J21? C7,(1C*C 13 1++2'C*1( %-)$-"'B$C'A# ("#)A,% 4C'&229 78, 3&)*&2 13 ;3&+8*&2 &37,39 *C 'C,) – C&J,C7 &() 21(6,C7 2&C7*(6 :,3<&(,(7 <,&(C 1J P&C+'2&3 &++,CC – 81?,P,3 – 3,a'*3,C 21(6 <&7'3&7*1( 7*<, E?,,/C 71 <1(78CF 71 :31P*), & J21? C7&7, &),a'&7, 71 C'C7&*( )*&29C*C ! I3,C+*&L0*<*(1 J*C7'2& E,()L,() &(&C71<1C*C ;,7?,,( +,:8&2*+ P,*( &() 3&)*&2 &37,39F ! B3&7b J*C7'2& E&7 ,2;1?U &(&C71<1C*(6 +,:8&2*+ P,*( 71 ;3&+8*&2 &37,39F S)P&(7&6, 1J S[ J*C7'2& E+1<:&3,) 71 S[ 63&J7F ! =1(6 7,3< :&7,(+9 %-)$-"'B$C'A# E-%() S[ 63&J7C +1(C*C7C 1J ;*1216*+ 13 C9(78,7*+ +1()'*7 78&7 +1((,+7 &( &37,39 &() & P,*( &() &3, 7'((,22,) '(),3 78, C/*( &() :2&+,) *( & C';+'7&(,1'C 21+&7*1( S)P&(7&6, 1J S[ 63&J7 E+1<:&3,) 71 S[ J*C7'2&FU ! =&36, C'3J&+, &3,& ! O&C9 +&(('2&7*1( ! .8137 <&7'3&7*1( 7*<, – 3,a'*3, "L` ?,,/C E&221?C J13 <&7,3*&2 71 *(+13:13&7, *(71 C'331'()*(6 C';+'7&(,1'C 7*CC', &() J13 *(J2&<<&7*1( &() ,),<& 71 C';C*),F ! O&C9 C'36*+&2 8&()2*(6 @'/0,"@%)"'C# .7,(1C*C – ?8*+8 +&( 2,&) 71 ':C73,&< :C,')1L&(,'39C< J13<&7*1( A831<;1C*C M(J,+7*1( – 'C'&229 ?*78 %&5#'D0(*(**C% 5C),C% S37,3*&2 .7,&2 .9()31<, – S[ &++,CC )*P,37C 13 C7,&2 ;211) J31< )*C7&2 +*3+'2&7*1( 78*C C9()31<, 1++'3C *( &;1'7 !L]m 1J :&7*,(7C ?*78 )*C7&2 S[ &++,CCee ! H3,C,(7 ?*78U *C+8,<*+ :&*(K (,'31:&789K '2+,3&7*1( &()-13 6&(63,(, [,(1'C V9:,37,(C*1( – C,+1()&39 71 1'7J21? P,(1'C 1;C73'+7*1( ! H3,C,(7 ?*78U C/*( )*C+121'3&7*1( &() 89:,3:*6<,(7&7*1(K E+831(*+ +&C,C '2+,3&7*1(F 01(6,C7*P, 0&3)*&+ Q&*2'3, – C,+1()&39 71 *(+3,&C,) P,(1'C 3,7'3( 2,&)*(6 71 +&3)*1<,6&29 &() 00Q E89:,3L+*3+'2&7*1(F
ee
EH&*3,) P*C+,3&2 ;3&(+8,CF % – /8==I2 #;51612<6I 61721Q F,DG + – -2<6I 61721Q FM7J ,D3,\G @ – E><6=6I 61721Q F,\G
! – =,J7 +131(&39 &37,39 \ – W*687 +131(&39 &37,39 " – W*687 ;3&+8*1+,:8&2*+ 73'(/ ] – =,J7 *(7,3(&2 +&317*) &37,39 e – =,J7 C';+2&P*&( &37,39 ` – H1C7,3*13 *(7,3+1C7&2C &37,3*,C E"3) – !!78F n – @,C1:8&6,&2 &37,3*,C ^ – H1C7,3*13 N,)*&C7*('< &37,3*,C
!C7 T \() :1C7,3*13 M0 &37,39 J31< C';+2&P*&( &37,3*,C E – /2=86< !C7 – `78 &(7,3*13 M0 J31< *(7,3(&2 7813&+*+ &37,39 `78 – !\78 &(7,3*13 M0 <'C+'21:83,(*+ &37,39 EJ31< *(7,3(&2 7813&+*+ &37,39F
EH&*3,) :&3*,7&2 ;3&(+8,CF ! – "1 0412<89 %172182? F)D\G $ – ` ,;HM61 %172182? F,D – ,`G ( – @>HH>< "I869 %172182? F,`G E4(:&*3,) :&3*,7&2 &37,39F #6916I %1721Q
S(( [&C+ .'36_ \dddo!]E\FU!"^L!]] \d]
%C$A-.#/ S :&781216*+&2K 21+&2*b,)K :,3<&(,(7 )*2&7*1( 1J &( &37,39 71 <13, 78&( !_e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
.';L79:,C .&++'2&3 Q'C*J13< I,339
S78,31<&71'C N9+17*+
S+a'*3,) S(,'39C<
-
.9:8*2*7*+
-
D*CC,+7*(6 E&137*+ )*CC,+7*1(F
-
Q&2C, S37,3*1P,(1'C E&/&_ &(,'39C<&2 P&3*+,CF
-
W,<&3/C Q1+&2 1'7?&3) ;'26, E1(29 :&37 1J 78, +*3+'1= +F – 73,&7 <,)*+&229 MJ *(P12P,C &C+,()*(6 &137& E #761= %F <&9 )*CC,+7 &+31CC +131(19 1C7*'< 2,&)*(6 71 *(J,3*13 NM 13 &+31CC &137*+ P&2P, 2,&)*(6 71 SW 3,a'*3, :3*<&39 C'36*+&2 3,:&*3 H'2C&7*(6 8,<&71<& &-? C7&; ?1'()CK MS *(5,+7*1(C 13 MS 3&)*1216*+&2 :31+,)'3,C D', 71 73&'<& 13 <13, +1<<1(29 J1221?*(6 J13<&7*1( 1J &( S[ J*C7'2& J13 )*&29C*C
%'-) "@!"##$@) "'C @,"C"@%, ($%)A-$# 08,C7 H&*( &-? WQ – i.e. HTN, Marfan’s Syndrome, Pregnancy, Erles LD&(21C .9()31<, .')),(K C,P,3, 7,&3*(6 +8,C7 :&*( - '::,3 &;)1<*(&2 :&*(K <&Y*<&2 &7 78, 1(C,7 08,C7 H&*( &-? (,'31216*+&2 C9<:71
@'/0,"@%)"'C# '( %C$A-.#/# W':7'3, A831<;1C*C ?*78 1++2'C*1( D*C7&2 ,<;12* J31< <'3&2 7831<;'C H3,CC'3, 1( &)5&+,(7 C73'+7'3,C – *_,_ SSS ,31)*(6 P,37,;3&2 ;1)*,CK J,<13&2 &(,'39C< :3,CC*(6 1( J,<13&2 (,3P,
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0-$#$C)%)"'C SC9<:71<&7*+
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N1C7 +1<<1(29 J1'() *(+*),(7&229 )'3*(6 :89C*+&2 ,Y&<*(&7*1( 13 *<&6*(6 - V9:17,(C*1( 61*(6 *(71 C81+/ EJ,&3,) :3,C,(7&7*1(F - M(7,(C, &;)1<*(&2 :&*( 3&)*&7*(6 71 78, ;&+/ - H'2C&7*2, &;)1<*(&2 <&CC - W&)*+'2&3 C9<:71
02&CC*+&2 H3,C,(7&7*1(
.9<:71<&7*+ E3SSSF
0*.#"@%, $P%/"C%)"'C [*7&2 C*6(C – *C :&7*,(7 8,<1)9(&<*+&229 C7&;2, [*C*;2, :'2C&7*1( 1P,3 &;)1<,( H'2C&7*1(C &() <&CC *( ,:*6&C73*+ 3,6*1( J,27 1( ),,: :&2:&7*1( N&CC *C ,Y:&(C*2, – ?8,( J*(6,3C 1J ;178 8&()C &3, :2&+,) &7 78, ,)6,C 1( ,*78,3 C*), 1J 78, <&CCK 78, J*(6,3C &3, :'C8,) ':?&3)C &() 1'7?&3)C S'C+'27&7, J13 ;3'*7 1P,3 78, <&CC 08,+/ 78, 178,3 &37,3*,C – J,<13&2K :1:2*7,&2 – J13 &(9 &(,'39C
/%C%E$/$C) D,:,(),(7 ':1( +2*(*+&2 +1(7,Y7U &C9<:71<&7*+K C9<:71<&7*+K 13 3':7'3,) %?QH57>H6789 %%% A*<, &P&*2&;2, J13 *(P,C7*6&7*1( 1J C*b, 1J SSS &() 3,2&7,) &(&71<9 M()*+&7*1(C J13 C'36,39U E&F S(,'39C< a YWY 9H*( 2&36,C7 )*&<,7,3 E<,&C'3,) ;9 '273&C1(163&:89F E;F H&7*,(7 J*7 J13 C'36,39 E,Y:,+7,) <137&2*79 3&7, h emF E+F "<9126?2 8< =86H2721 1J H>12 746< D9H 521 Q261
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Patient’s fitness for surgery needs to be properly assessed because it is a major operation – (,,) 71 1:7*<*C, +&3)*1P&C+'2&3 J'(+7*1( @:,3&7*1( *C 78, C&<, ,Y+,:7 78&7 *7 *C )1(, '(),3 ,2,+7*P, C,77*(6 N137&2*79 *C hem *( 78, ,2,+7*P, C,77*(6K C,3*1'C <13;*)*79 q!dm A8, 3,:&*3 E*_,_ ,()1P&C+'2&3 13 1:,(F 1J &C9<:71<&7*+ SSS ;,7?,,( ]_d 71 e_e+< *( C*b, +1(J,3C (1 survival benefits = ‘best care’ favours surveillancee^
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#QH57>H6789 %%% M()*+&7*1(C J13 C'36,39U E&F S(,'39C< 1J &(9 C*b, 78&7 *C :&*(J'2 13 7,(),3 E;F S(,'39C< 1J &(9 C*b, 78&7 *C +&'C*(6 )*C7&2 ,<;12*b&7*1( -;57;12= %%% SSS +&( 3':7'3, &(7,3*13 *(71 78, :,3*71(,&2 +&P*79 E\dmF 13 :1C7,312&7,3&229 *(71 78, 3,731:,3*71(,&2 C:&+, E^dmF ! !
S(7,3*13 3':7'3, J3,, ;2,,)*(6 *(71 :,3*71(,&2 +&P*79 J,? :&7*,(7C 3,&+8 81C:*7&2 &2*P, H1C7,312&7,3&2 3':7'3, 3,731:,3*71(,&2 8,<&71<& E7&<:1(&), ,JJ,+7FK h edm 3,&+8 81C:*7&2 &2*P,
V*68 C'C:*+*1( *( '(C7&;2, 89:17,(C*P, :&7*,(7 +1<:2&*(*(6 1J C,P,3, C8&3: :&*( 3&)*&7*(6 71 78, ;&+/o <&9 J,,2 & 7,(),3 :'2C&7*2, <&CC *( 78, &;)1<,( *J 78,3, *C )1';7K &( '273&C1(163&< <&9 8,2:
S+'7, N&(&6,<,(7 E&J7,3 ,&329 )*&6(1C*CF !_ .7&;*2*C, :&7*,(7 – 3,C'C+*7&7*1( ?*78 J2'*) &() ;211) :31)'+7C !
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OC7&;2*C8 \ 2&36, ;13, E!]L!`BF M[ +&(('2& ?*78 G-. 521H8??8K2 4Q5>72< *C &)P1+&7,) J13 :&7*,(7C ?*78 +2*(*+&2 )Y 3SSS 71 <&*(7&*( & +2*(*+&229 &2,37 :&7*,(7 &() C9C712*+ IH Xnd<
\_ 0&22 J13 P&C+'2&3 C'36,1(C 13 +&3)*17813&+*+ C'36,1(CK C,(*13K @AK M04-VD *<<,)*&7,29 "_ i,,: GIN BM ),+1<:3,CC*1( ?*78 GB 7';,K +&78,7,3*C, Z 0[H - MS 2*(, ]_ B,7 *(J13<,) +1(C,(7 J13 1:,( SSS 3,:&*3 J31< :&7*,(7 - J&<*29 ,<:8&C*b, 78, 3*C/ &() 8*68
#;1O2> M2 O>J<2= ;5 J874 ?96I52I 8 < 46<=N 126=Q 7> >521672 M2L>12 6<62?74278?7 8<7;M672? 56782<7t S J'22 2,(678 <*)2*(, *(+*C*1( *C <&),_ A8, &137& *C +1(73122,) :31Y*<&229 &() )*C7&229 ?*78 +2&<:C_ E+&( ;, +2&<:,) J13 &;1'7 "d <*('7,C ?*781'7 C*6(*J*+&(7 P*C+,3&2 *C+8,<*&F S(,'39C< C&+ *C 1:,(,) 21(6*7')*(&229o 78, C'331'()*(6 8&,<&71<& &() <'3&2 7831<;'C ?*78*( 78, SSS &3, +2,&3,) 1'7_ .9(78,7*+ 63&J7 ED&+31( – :1297,73&J2'131,7892,(,F *C :2&+,) ?*78*( 78, &137& &() 78, P,CC,2 ?&22 +21C,) ': 1P,3 78, 63&J7 *_,_ 78, 63&J7 J131QE;&C&2 21;, +1(C12*)&7*1(K &7,2,+7&C*CFK 961=869 E*C+8,<*&K *(J&3+7*1(FK 9>I><89 8?942H86 K <2;1>I>O896IEC,Y'&2 )9CJ'(+7*1(K C:*(&2 +13) *C+8,<*&FK 6>17>2<72189 L8?7;I6 E:Y ?*78 8,<&7,<,C*C 13 <,2,(&F &() 51>?742789 8< _
@'/0,"@%)"'C# '( #A-E$-. M(73&L1:,3&7*P,29 V&,<1338&6, D*C7&2 2*<; ,<;12*b&7*1( E73&C8 J117F D*C7&2 2*<; &37,3*&2 7831<;1C*C
-
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=&7, S1371,(7,3*+ J*C7'2& – J3&(/ HW ;2,,)K 7133,(7*&2 H31C78,7*+ 63&J7 *(J,+7*1( Q&2C, &(,'39C< J13<&7*1( .,Y'&2 )9CJ'(+7*1( E*<:17,(+,F
$<=>K6?9;I61 ?72<78LC8&:,) 63&J7 ?*78 7?1 ;3&(+8,C J13 78, *2*&+ &37,3*,C &() & <&*( 73'(/ J13 78, :31Y*<&2 &137&_ M7 is deployed within the aneurysm to form the lumen of the aorta and requires adequate “neck” proximally E!dL !e<< :31Y*<&2 (,+/F &() 611) 2&()*(6 C*7, )*C7&229 E\d<< *2*&+ 2&()*(6 b1(,F
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<137&2*79 3&7,C edLndm e_ W&:*) A3&(CJ,3 71 @A J13 1:,( 3,:&*3 VW @I26< 6<= =1652 6<= M2 126=Q L>1 H8=I8<2 I6561>7>HQ +$('-$ 8<=;978>< >L 6<62?742?86 n_ .7&37 M[ ;31&) C:,+73'< S; l &(&26,C*& E71 :3,P,(7 ,Y&+,3;&7*1( *( IH - VWF
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S27,3(&7*P, 71 1:,( 3,:&*3 – O()1P&C+'2&3 &(,'39C< 3,:&*3 F$B%-G 7186I V\ D ! "dL)&9 <137&2*79 3&7, ?&C 21?,3 *( 78, O[SW 631': &C +1<:&3,) 71 1:,( 3,:&*3 ! ]L9,&3CU &22L+&'C, <137&2*79 ?&C C*<*2&3 *( 78, 7?1 631':C I4A 78,3, ?&C & 3,)'+7*1( *( &(,'39C
=&(+,7_ \dde %'( \eL%'2 !o"`eE#]n^FU\!n#L^`_ =&(+,7_ \dde %'( \eL%'2 !o"`eE#]n^FU\!^nL#\_ \dn
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Runs up the leg posteriorly to pass a hand’s breath behind the medial border of the patella SC+,()C 1;2*a',29 ': 78, <,)*&2 &C:,+7 1J 78, 78*68 H*,3+,C 78, +3*;3*J13< J&C+*& &7 78, C&:8,(1J,<13&2 5'(+7*1(RR E.Q%F 71 )3&*( *(71 78, J,<13&2 P,*( &7 78, C&:8,(1'C 1:,(*(6 E\_e+< *(J,312&7,3&2 71 78, :';*+ 7';,3+2,F
_ A8, 3,2&7*1(C8*: 1J 78, 63,&7 C&:8,(1'C P,*( 71 78, <,)*&2 <&22,12'C *C + 1(C7&(7 iM[ 'C, J13 2*P,LC&P*(6 +&(('2&7*1( RR A8, .Q% *C 78, +1(J2',(+, 1J 78, E!F B.[ E\F C':,3J*+*&2 ,:*6&C73*+ P,*( E"F C':,3J*+*&2 +*3+'
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@>;1?2 >L 742 ?H6II ?6542<>;? K28< F##BG[ S3*C,C J31< 78, 2&7,3&2 C*), 1J 78, )13C&2 P,(1'C &3+8 1J 78, J117 H&CC,C :1C7,3*13 71 78, 2&7,3&2 <&22,12'C SC+,()C ': 78, <*)2*(, 1J 78, +&2J H*,3+,C 78, ),,: J&C+*& 1P,3 78, :1:2*7,&2 J1CC& 71 )3&*( *(71 78, :1:2*7,&2 P,*( S++1<:&(*,) *( *7C +1'3C, ;9 78, C'3&2 (,3P,
- A8, C':,3J*+*&2 C9C7,< &() 78, ),,: C9C7,< +1<<'(*+&7, 7831'68 9>HH;<89678
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Dodd’s perforator: distal thigh Boyd’s perforator: knee 0&2J E:1C7,3*13 7*;*&2F :,3J13&713CU &7 eK !dK &() !e +< &;1P, 78, <,)*&2 <&22,12'C
04Q?8>I>OQ >L K2<>;? =168<6O2[ N&*( <,+8&(*C< *C 78, +&2J <'C+2, :'<: 01(73&+7*1( 1J 78, +&2J <'C+2,C +1<:3,CC,C 2&36, P,(1'C C*('C,C *( 78, <'C+2,CK Ca',,b*(6 78, ;211) *(71 78, :1:2*7,&2 P,*( &() ;&+/ 71 78, 8,&37 A8, ),,: P,*(C 8&P, <&(9 ;*+'C:*) P&2P,C 71 :3,P,(7 ;&+/J21? ;211) 1(29 J21?C 71?&3)C 78, 8,&37 D'3*(6 +&2J <'C+2, 3,2&Y&7*1(K 78, *(73&<'C+'2&3 P,*(C 1:,( &() C'+/ ;211) *( J31< 78, C':,3J*+*&2 C9C7,< 7831'68 78, +1<<'(*+&7*(6 P,*(CK 78'C )3&*(*(6 78, C':,3J*+*&2 P,*(C
- A8, ),,: P,(1'C C9C7,< *C +1<:1C,) 1J P,*(C +133,C:1()*(6 71 78, &37,3*&2 C'::29 ,_6_ &(7,3*13 &() :1C7,3*13 7*;*&2 P,*(CK :1:2*7,&2 P,*(K J,<13&2 P,*( - A8, C':,3J*+*&2 P,(1'C C9C7,< *C +1<:1C,) 1J 7?1 <&513 P,*(CK 78, 63,&7 C&:8,(1'C P,*( &() 78, C<&22 C&:8,(1'C P,*(
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'M?71;978>< 7> K2<>;? LI>J ,_6_ 7'<1'3 +1<:3,CC*1( *( 78, :,2P*CK :3,6(&(+9K ),,: P,*( 7831<;1C*C !Q?L;<978>< >L K2<>;? K6IK2? ,_6_ P&3*+1C, P,*(C (68I;12 >L he 7 “venous pump”– ),:,(),(7 1( &),a'&7, <'C+2, +1(73&+7*1( EC731/,K <'C+'2&3 ?,&/(,CC +&( +&'C, J&*2'3,F &C ?,22 &C +1<:,7,(7 P,(1'C P&2P,C
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B2<>;? ;I921 L>1H678>< - A9:*+&2 21+&7*1( *C 1P,3 78, <,)*&2 <&22,12'C - .8&221?K J2&7 '2+,3 ?*78 C21:*(6 ,)6,Co ;&C, <&9 ;, C21'689 13 63&('2&7*(6K 'C'&229 a'*7, <1*C7L211/*(6 - .'331'()*(6 C/*( ?*22 C81? C*6(C 1J 0[M - M( 21(6L standing ulcer SCC can develop (Marjolin’s ulcer) – MJ '2+,3 ,(2&36,CK ;,+1<,C :&*(J'2 &() <&21)131'CK ,)6, ;,+1<,C 78*+/,(,) 13 3&*C,)K *J *(6'*(&2 29<:8 (1),C &3, ,(2&36,)
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B2<>;? =8I67678>?8782?EP*C*;2,K )*2&7,) 7137'1'C C':,3J*+*&2 P,*(Co J13<,) ;9 <&*( 73*;'7&3*,C 1J 78, C&:8,(1'C P,*(C ;,+&'C, 78,C, )1 (17 8&P, & C731(6 +1&7 1J C<1178 <'C+2, *( 78,*3 ?&22CK '(2*/, 78, C&:8,(1'C P,*(Co 78,9 &3, <13, C':,3J*+*&2 &() (17 ;1'() )1?( 71 78, ),,: J&C+*&F – ≥3mm - @>1><6 54I2M297697896 E& (,7?13/ 1J C<&22 )*2&7,) P,('2,C ;,(,&78 78, 2&7,3&2 &()-13 <,)*&2 <&22,12'C ?*78 C,P,3, P,(1'C 89:,37,(C*1(F
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#g8< 946< 1J 78, C/*( 1P,3 <,)*&2 21?,3 78*3) 1J 78, 2,6 E6&*7,3 &3,&F – )', 71 ,Y73&P&C&7*1( ?*78 8,<1C*),3*( ),:1C*7C - %71>5482 MI6<942– &P&C+'2&3 J*;317*+ C+&3C E*_,_ *P139 ?8*7, &3,&C ?*78 89:,3L:*6<,(7,) ;13),3C &() 7,2&(6*,+7&C*&F H31(, 71 P,(1'C '2+,3&7*1( \d 71 :113 ;211) C'::29 - B2<>;? ?76?8? 29l2H6 – :3'3*7*+K ?,,:*(6K C+&2*(6K ?*78 ,31C*1(C &() +3'C7*(6 - ,85>=21H67>?9I21>?8? – & J*;31C*(6 :&((*+'2*7*C 1J 78, C';+'7&(,1'C 7*CC', 78&7 3,C'27C *( & J*3< &3,& 1J 7,(),3K *()'3&7,)K 89:,3:*6<,(7,) C/*( 78&7 *C J*Y,) 71 C';+'7&(,1'C 7*CC',_ W,C'27C J31< C,P,3, P,(1'C 89:,37,(C*1( .7&37C *( 78, 6&*7,3 &3,& &() ,Y7,()C +*3+'
3,+'<;,(+9
-
If severe can result in an “inverted champagne bottle” appearance of the leg with
;3&?(9 1,),<& &;1P, &() ;,21? 78, &3,& 1J 2*:1),3<&71C+2,31C*C @2II;I878?
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B%-"@'#$B$"C Varicose veins of the lower limbs: dilated, tortuous subcutaneous vein that are ≥3 mm in diameter <,&C'3,) *( 78, ':3*687 :1C*7*1(_ [&3*+1C*79 +&( *(P12P, 78, <&*( &Y*&2 C':,3J*+*&2 P,*(C E*_,_ B.[ T ..[F 13 &(9 178,3 C':,3J*+*&2 P,*( 73*;'7&3*,C 1J 78, ==_`]
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H3*<&39 M)*1:&78*+ - <'27*J&+713*&2 – <&9 ;, 3,2&7,) 71 :1C7'3, &() +1<:1(,(7C &() C73'+7'3, 1J 78, P,*( ?&22 01(6,(*7&2
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.,+1()&39 H3,P*1'C D[A D,,: [,(1'C @;C73'+7*1( .':,3J*+*&2 A831<;1:82,;*7*C D,C73'+7*1( 1J P&2P,C ;9 7831<;1C*C M(+3,&C, *( J21? &() :3,CC'3, \ d S[Q
0%)*'0*.#"','E. - M(8,3,(7 ?,&/(,CC *( 78, P,*( ?&22K 2,&)*(6 71 )*2&7*1( &() C,:&3&7*1( 1J P&2P, +'C:C C1 78,9 ;,+1<, *(+1<:,7,(7 - A8*C <&9 ;, &663&P&7,) ;9 1;C73'+7*1( 71 P,(1'C 3,7'3( E&C &;1P,F -"#h (%@)'-# - S6, - H&3*79 - @++':&7*1( – 3,a'*3*(6 21(6 :,3*1)C 1J C7&()*(6 - k,*687 - H1C7'3, – +31CC*(6 2,6C &22 78, 7*<, - M(+3,&C,) &;)1<*(&2 :3,CC'3, – +1(C7*:&7*1(K +831(*+ +1'68K ,7+_ - H,2P*+ 7'<1'3 13 178,3 2,C*1( +1<:3,CC*(6 1( 78, ),,: P,*(C - Q&<*29 8*C7139U ! :&3,(7 Eedm 3*C/K ;178 :&3,(7C E': 71 ^dm 3*C/F *"#)'-. SC9<:71<&7*+ – P&3*+,C 1J +1C<,7*+ +1(+,3( .9<:71<&7*+U ! 21+&2 (1(C:,+*J*+ :&*(K 7*(62*(6K &+8*(6K ;'3(*(6K <'C+2, + 3&<:CK C?,22*(6K C,(C&7*1( 1J 7831;;*(6 13 8,&P*(,CCK *7+8*(6 C/*(K 3,C72,CC 2,6K 2,6 7*3,)(,CC k13C,( ?*78 8,&7K ?13C,( 7831'681'7 +1'3C, 1J )&9 E,C:_ *J C7&() J13 21(6 :,3*1)CF W,2*,P,) ;9 3,C7*(6 13 ,2,P&7*(6 2,6C 13 ?,&3*(6 ,2&C7*+ C71+/*(6C 01<:2*+&7*1(C U 7831<;1:82,;*7*CK ;2,,)*(6K 89:,3:*6<,(7&7*1(K ,+b,<&K '2+,3&7*1( SC/ J13 :&C7 8*C7139 1J D[A T 7831<;1:82,;*7*CK 1;C7,73*+C 8*C7139K J&<*29 8*C7139 1J P&3*+1C*79 13 7831<;17*+ )*C13),3C
"<– I>>g 6II 61>;<= 742 I8HMt !_ H3,C,(+, 1J C*6(C 1J + 831(*+ P,(1'C *(C'JJ*+*,(+9R– C,, &;1P, ] <&*( J,&7'3,C - [,(1'C D*2&7&7*1( - H*77*(6 @,),<& - ./*( 08&(6,C - [,(1'C 42+,3 Q13<&7*1( – &(9 C'66,C7*1( 1J N&3512*( '2+,3 \_ .+&3C – *_,_ :3,P*1'C C7&; &P'2C*1(C "_ =11/ &7 9>;1?21J 63,&7 C&:8,(1'C P,*( &() C8137 C&:8,(1'C P,*( J13 P&3*+1C*7*,C ]_ =11/ &7 78, 8
06I5672 !_ Q,,2 J13 &(9 )*2&7,) K6189>?8782? d K2<>;? 6<2;1Q?H \_ H&2:&7, 6I>;1?2 >L 742 ?6542<>;? K281 72<=21<2??E<&9 ;, <13, :&2:&;2, ,C:,+*&229 *( J&7 2,6CF "_ H&2:&7, 78, *(6'*(&2 3,6*1( J13 & ?6542<6 K618RE+1<:3,CC*;2, 2'<: 78&7 3,J*22C ?8,( 3,2,&C,)F ]_ D1 78, 9>;O4 72?771 J,,2 J13 3,J2'Y &7 78, C&:8,(1J,<13&2 5'(+7*1( E\_e +< ;,21? &() 2&7,3&2 71 78, :';*+ 7';,3+2,F e_ 0219;??8>< F765 72?7 F – 7,C7 J13 P&2P'2&3 *(+1<:,7,(+, E(17 & P,39 P&2'&;2, 7,C7F – :1C*7*P, *J 78,
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)*C7&2 8&() +&( J,,2 78, ?&P, 1J ;211) J21?*(6 3,73163&), &J7,3 7&::*(6 78, :31Y*<&2 P&3*+1C*7*,C (22I 742 521854216I 5;I?2? 1J == 71 ,Y+2'), &(9 *C+8,<*& &C 78, <&(&6,<,(7 ?*22 *(P12P, +1<:3,CC*1( 1J 2*<;C ESIM Xd_^F (22I 742 8
/>K2 !_ S(/2, %1*(7– :&7*,(7C ?*78 &)P&(+,) P,(1'C )*C,&C, 8&P, ),+3,&C,) <1;*2*79 *( &(/2, 51*(7C
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0@0) 7186I F51>?7672 96<921 512K2<78>< n^ 7186I G finasteride ↓risk of prostate cancer E;9 \emF ;'7 ?&C &CC1+*&7,) ?*78 &( *(+3,&C,) 3*C/ 1J )*&6(1C*C 1J 8*68L63&), E`_]m PC_ e_!mF :31C7&7, +&(+,3 +1<:&3,) ?*78 :2&+,;1 S)P,3C, OJJ,+7C EQ*(&C7,3*),F ↓libido (erectile dysfunction), ejaculatory dysfuncti 1(K *<:17,(+,K 69(&,+1<&C7*& n# 01<;*(&7*1( 1J SP1)&37 &() A&HM>=617– 76H?;I>?8< cW`HO s =;?76?7218=2 cWYHO FvTd76MG .':,3*13 71 <1(178,3&:9 *( 3,)'+*(6 WW 1J IHV +2*(*+&2 :3163,CC*1( *( <,( ?*78 <1),3&7,L71LC,P,3, =4A. )', 71 IHV &() :31C7&7*+ ,(2&36,<,(7 G17 C':,3*13 71 D'7&C7,3*), <1(178,3&:9 &7 ↓ WW 1J S4W 13 IHV 3,2&7,) C'36,39
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"""W #;1O21Q A9:,C - )16< >L 51>?7672 F)A-0G 8? 742 O>I= ?76<=61= - A3&(C'3,783&2 *(+*C*1( 1J 78, :31C7&7, EA4MHFU ),+*C*1( <&), )'3*(6 A4WH ?8,( 78, :31C7&7, )1,C (17 &::,&3 71 ;, ,(2&36,) <&/, C<&22 +'7C &31'() ;2&)),3 (,+/ &3,& 71 1:,( *7 ':_ -
@78,3 7,+8(*a',CU 2&C,3 :31C7&7,+71<9K :8171LC,2,+7*P, P&:13*b&7*1( 1J :31C7&7*+ 7*CC', EH[HFK ,2,+731L P&:13*b&7*1( EA[HFK 73&(C'3,783&2 (,,)2, &;2&7*1( 1J 78, :31C7&7, EA4GSFK <*+31?&P, 78,3<178,3&:9K 1:,( :31C7&7,+71<9
M()*+&7*1(CU !_ Q&*2,) <,)*+&2 73,&7<,(7 – significant impact on patient’s QOL \_ .*6(*J*+&(7 01<:2*+&7*1(CU ! 4::,3 A3&+7 M(5'39 – *_,_ 3,(&2 *(C'JJ*+*,(+9K 1;C73'+7*P, '31:&789K 89)31(,:831C*C ! =1?,3 A3&+7 *(5'39 – *_,_ 3,J3&+7139 '3*(&39 3,7,(7*1(K 3,+'33,(7 4AMK ;2&)),3 ),+1<:,(C&7*1( E*_,_ 8*68 H[W4F "_ W,+'33,(7-:,3C*C7,(7 631CC 8&,<&7'3*& ]_ I2&)),3 0&2+'2* – C*(+, C,+1()&39 71 IHV 0&'7*1(U N'C7 3'2, 1'7 (,'316,(*+ ;2&)),3 - ),73'C13 89:171(*& ;,J13, A4WHpp D1 4D. !_ M(C,37 (&331? +&78,7,3 ?*78 :3,CC'3, 6&'6, &7 78, ,() *(71 E),73'C13 :3,CC'3, s & – ;F &_ I2&)),3U *(73&P,C*+&2 :3,CC'3, ;_ W,+7'
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!2I6Q2= !_ I2&)),3 (,+/ C7,(1C*C \_ 43,783&2 C73*+7'3, "_ M(+1(7*(,(+, ]_ W,631?78 1J :31C7&7, e_ -271>O16=2 2m69;I678>< Eq]dL`dmF `_ M<:17,(+, EemF – 3&3,29 &CC1+*&7,) ?*78 OD
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H89C*+&2 ,Y&<*(&7*1( C*<*2&3K 5'C7 &))U ! M(C:,+7 – ;1)9 8&;*7'CK &;)1<*(&2 C+&3CK :31<*(,(+, 1J ;'26, ?*78 (,+/ J2,Y*1(K :,3*C7&2C*C 7831'68 78, C/*(K P*C*;2, +1'68 *<:'2C, ! H&2:&;2, – 7,(),3(,CCK C*b, 1J ),J,+7K 3,)'+*;*2*79K +1'68 *<:'2C, ! S'C+'27&7, – ;1?,2 C1'()C 01<:2*+&7*1(C – *_,_ *(7,C7*(&2 1;C73'+7*1(K *(+&3+,3&7*1(K C73&(6'2&7*1(K C/*( ,Y+13*&7*1(K :,3C*C7,(7 :&*( EC*<*2&3 71 <1C7 8,3(*&F W*C/ J&+713CU ! 0-$3'0$-%)"'C &6,K <&2('73*7*1(K +831(*+ )*C,&C, EO.WQK 0=DK N&2*6(&(+9FK C7,31*)CK DM (predispose to infections), morbid obesity, ↑ abdominal pressure 2 d +831(*+ ;31(+8*7*C 13 &C+*7,C ! "C)-%3'0$%)"'C ?31(6 C'7'3, <&7,3*&2K ?31(6 7,+8(*a', – *_,_ 711 C<&22 ;*7,CK :2&+*(6 )3&*(C 7831'68 ?1'() ! 0'#)3'0$-%)"'C ?1'() ;3,&/)1?( - 8,<&71<&K *C+8,<*+ ?1'() )', 71 ,Y+,CC*P, 7,(C*1(K +1<:2*+&7*1(C – *_,_ &(&C71<17*+ 2,&/CK *(J,+7*1(K :1C7L1:,3&7*P, &7,2,+7&C*C &() +8,C7 *(J,+7*1( A3,&7<,(7 1:7*1(CU ! G17 ,P,39 :&7*,(7 C81'2) '(),361 3,:&*3 )', 71 8*68 3*C/ 1J ?1'() 8&,<&71<&K *(J,+7*1(K ),8*C+,(+, &() 3,+'33,(7 8,3(*& – &2C1 <&(9 8&P, +1(+'33,(7 <,)*+&2 :31;2,
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H&3&'<;*2*+&2 V,3(*& @++'3 &31'() 78, '<;*2*+&2 C+&3 4(+1<<1( ;,J13, ]d 93C 12)
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+13C,7 13 73'CC -- @JJ,3 k,*687 21CC &() +1(7312 78, 3*C/ J&+713C .'36*+&2U - @JJ,3 *J +1<:2*+&7*1(C 1J 8,3(*& &3, :3,C,(7 - 01(7312 0[. T 3,C:_ )*C,&C,o ,(+1'3&6, :3,L1: ?,*687 21CC - H3*(+*:2,CU =8??297 742 ?69 6<= 9I>?2 742 =2L297 ;?8K21I6558
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M(P,C7*6&7*1(C ! 4. C+317'< .,<*(1<& s 89:1,+81*+ 2,C*1(C G1(LC,<*(1<& s *(81<16,(,1'C 2,C*1(C ! A'<1'3 N&3/,3C E<1(*713 ,JJ,+7*P,(,CC 1J 78,3&:9 &() C+3,,( J13 3,+'33,(+,F =DVK SQHK I80B ! .7&6*(6 0A SH – &CC,CC :&3&L&137*+ 29<:8 (1),C *(P12P,<,(7 0cW - 4. VI. – )*C7&(7 )*C,&C,
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N&CC &31'() 78, +13)o &77&+8,) )*C7&229 71 78, 7,C7*C D*JJ*+'27 71 )*C7*(6'*C8 J31< *33,)'+*;2, *(6'*(1LC+317&2 8,3(*& – <&9 ,Y7,() ': &() ;,91() A3&+7*1( 1J 78, 7,C7*C +&'C,C & 89)31+,2, 1J 78, +13) 71 ;, :'22,) )1?(?&3)C
H&7,(7 :31+,CC'C P&6*(&2*C J*22,) ?*78 :,3*71(,&2 J2'*) – C&+ +1<<'(*+&7,C )*3,+729 ?*78 78,
:,3*71(,'< H&7*,(7C 6*P, 8Y 1J *(7,3<*77,(7 C+317&2 C?,22*(6 – 'C'&229 3,C12P,C ;9 !93 1J &6,
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.*7'&7*1( *( ;,7?,,( 89)31+,2, 1J +13) &() +1(6,(*7&2 89)31+,2, H31+,CC'C P&6*(&2*C *C 1;2*7,3&7,) &7 78, ),,: 3*(6 &() C1 78, 89)31+,2, )1,C (17 +1<<'(*+&7, ?*78 78, &;)1<,( ;'7 3,<&*(C :&7,(7 *( ;178 +13) &() C+317'<
.,+1()&39 V9)31+,2, ! Q31< 7,C7*+'2&3 7'<1'3 ! Q31< 713C*1( ! Q31< 73&'<& ! Q31< 13+8*7*C E&(9 *(J2&<<&7*1(F ! Q1221?*(6 *(6'*(&2 8,3(*& 3,:&*3 A3,&7<,(7 1:7*1(CU ! 01(C,3P&7*P,U M( +1(6,(*7&2 89)31+,2, – ?&7+8 &() ?&*7K 'C'&229 3,C12P,C ;9 ! 9,&3 1J &6, – *J '(3,C12P,) ;9 \_e 71 " 9,&3C C'36*+&2 +21C'3, k&7+8 T ?&*7 13 SC:*3&7*1( f7,() 71 3,L&++'<'2&7,g 1 N'C7 ,Y+2'), & \ +&'C, – '273&C1'() C+317'< ! .'36*+&2U Lord’s plication of the sac Jaboulay’s operation to evert the sac
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I*2&7,3&2 P&3*+1+,2, 1++'3C *( ""m 1J :&7*,(7CK ?8*2, '(*2&7,3&2 3*687 P&3*+1+,2, &3, P,39 3&3, EC,&3+8 J13 '(),329*(6 :&7812169F
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[,*( 2&36,3 78&( " << 1( '273&C1'()o D1::2,3 3,J2'Y 1( [&2C&2P& <&(,'P,3 H&2:&;2, ?*78 [&2C&2P& <&(,'P,3 1(29 H&2:&;2, &7 3,C7 E?*781'7 [&2C&2P& <&(,'P,3FK *(P*C*;2, O&C*29 P*C*;2,
@6;?2?[ M)*1:&78*+ *( 91'(6,3 <&2,C &31'() :';,379 M( 12),3 <,( ?*78 3,731:,3*71(,&2 )*C,&C,U W00 )1267H2<7[ 01(C,3P&7*P,U 3*C/ 1J *(J,37*2*79 ! .+317&2 .'::137 &() G.SMDC .'36*+&2U ! A3&(CLJ,<13&2 &(6*163&:8*+ ,<;12*b&7*1( ?*78 +1*2 13 C+2,31C&(7 ! .'36*+&2 =*6&7*1(U ,Y+*C, 78, C'331'()*(6 )*2&7,) P,*(C P*& 8*68 3,731:,3*71(,'
#@-') %,%+#@$## *8?7>1Q 6<= 04Q?896I $R6H8<678>< V*C7139 – :113 896*,(, .9<:71H5I89678>IQH891>M86I 8<
$58=2H8>I>OQ[ - WQU )*&;,7*+CK &2+1812*+CK *<<'(1+1<:31<*C,) - .1'3+, 1J *(J,+7*1(U ! ! ! !
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