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The structure of the pharynx the pharynx is made up of mucosa acne jeans mens cheap cleocin 150mg without a prescription, submucosa skin care natural tips buy cheap cleocin 150mg online, muscle and a loose areolar sheath acne zones and meaning discount cleocin 150 mg online. The mucosa is a ciliated columnar epithelium in the nasopharynx but elsewhere it is strati ed and squamous acne practice buy generic cleocin 150mg on-line. Beneath this, the submucosa is thick and brous (the pharyngobasilar fascia) and it is this layer which forms the capsule of the tonsil. Each constrictor muscle is attached anteriorly to the side-wall of these cavities and fans out to insert into a median raphe along the pos terior aspect of the pharynx, extending from the base of the skull to the oesophagus (Fig. Blood supply the pharynx receives its arterial supply mainly from the superior thyroid and ascending pharyngeal branches of the external carotid. The mechanism of deglutition the act of swallowing not only conveys food down the oesophagus but also disposes of mucus loaded with dust and bacteria from the respiratory passages. It is initiated voluntarily but is completed by involuntary re ex actions set up by stimulation of the pharynx. The re exes are coordinated by the deglutition centre in the medulla, which lies near the vagal nucleus and the respiratory centres. During swallowing, the oral, nasal and laryngeal openings must be closed off to prevent regurgitation through them of food or uid; 304 the head and neck each of these openings is guarded by a highly effective sphincter mechanism. The oropharyngeal isthmus is partially blocked by contraction of palatoglossus on each side, which narrows the space between the anterior faucial pillars. The central nervous component of the swallowing re ex is depressed by narcotics, anaesthesia and cerebral trauma. In these circumstances aspiration of foreign material into the pulmonary tree becomes possible, particularly if the patient is lying on his back or in a head-up position. While the larynx is raised and its entrance closed there is re ex inhibition of respiration. The epiglottis acts as a laryngeal lid at this stage to prevent deposition of fragments of food debris over the inlet of the larynx during re-establishment of the airway. The cricopharyngeus then relaxes, allowing the bolus to cross the pharyngo-oesophageal junction. Posteriorly, there is a potential gap between these two compo nents termed the pharyngeal dimple or Killian’s dehiscence. The mucosa and submucosa of the pharynx may bulge through this weak area to form a pharyngeal pouch (Fig. The larynx the larynx has a triple function, that of an open valve in respiration, that of a partially closed valve whose ori ce can be modulated in phonation, and that of a closed valve, protecting the trachea and bronchial tree during deglutition. The hyoid bone itself is attached to the mandible and tongue by the hyoglossus, the mylohy oid, geniohyoid and digastric muscles, to the styloid process by the stylohyoid ligament and muscle and to the pharynx by the middle constrictor. Three of the four strap muscles of the neck, the omohy oid, sternohyoid and thyrohyoid, nd attachment to it, only the sternothyroid failing to gain it. The epiglottis is a leaf-shaped elastic cartilage lying behind the root of the tongue. In addition, there are two small nodules of cartilage at the inlet of the larynx; the corniculate cartilage, a nodule lying at the apex of the arytenoid, and the cuneiform cartilage, a ake of cartilage within the margin of the aryepiglottic fold. The circothyroid membrane (cricovocal membrane) connects the thyroid, cricoid and arytenoid cartilages. Its upper edge is attached anteriorly to the post erior surface of the thyroid cartilage and behind to the vocal process of the arytenoid. Between these two structures, the upper edge of the membrane is thickened slightly to form the vocal ligament. Anteri orly, the membrane thickens, as the cricothyroid ligament; this is sub cutaneous, easily felt and is used in emergency cricothyroid puncture for laryngeal obstruction. The upper is the vestibular fold, containing a small amount of brous tissue and forming on each side the false vocal cord. This accounts for the pearly white, avascular appearance of the vocal cords as seen on laryngoscopy. Oedema of the larynx cannot involve the true cords since there is no submucous tissue in which uid can collect. On either side of the larynx the pharynx forms a recess, the pir iform fossa, in which swallowed foreign bodies tend to lodge. The muscles of the larynx function to open the glottis in inspira tion, close the vestibule and glottis in deglutition and alter the tone of the true vocal cords in phonation. The cricothyroid is the only external muscle of the larynx and tenses the vocal cord (the only muscle to do so), by a slight tilting action on the cricoid. The larynx 309 Lymph drainage Above the vocal cords the larynx drains to the upper deep cervical and then to the mediastinal lymph nodes, some lymphatics passing via small nodes lying on the thyrohyoid membrane. Below the cords, drainage is to the lower deep cervical nodes, par tially via nodes on the front of the larynx and trachea. The vocal cords themselves act as a complete barrier separating the two lymphatic areas, but posteriorly there is free communication between them; a laryngeal carcinoma may thus seed throughout the lymphatic drainage area of the larynx. Nerve supply the nerve supply of the larynx is of great practical importance and comprises the superior and recurrent laryngeal branches of the vagus nerve. The superior laryngeal nerve passes deep to the internal and exter nal carotid arteries where it divides; its internal branch pierces the thyrohyoid membrane together with the superior laryngeal vessels to supply the mucosa of the larynx down to the vocal cords. The left nerve arises on the arch of the aorta, winds below it, deep to the ligamentum arteriosum, and ascends to the trachea. It then lies in the tracheo-oesophageal groove and is distributed as on the right side. The recurrent nerves supply all the intrinsic laryngeal muscles, apart from the cricothyroid, and the mucosa below the vocal cords. Clinical features • 1 The laryngeal nerves bear relationships to the thyroid arteries which are of considerable practical importance in thyroidectomy. To avoid nerve damage during ligation of the inferior thyroid artery, this proce dure should be carried out well laterally, just as the artery emerges from behind the carotid sheath and before it takes up its intimate and inconstant relationship to the nerve. In bilateral incomplete paralysis, therefore, the cords come together, stridor is intense and tracheotomy may become essential. Either nerve, in the neck, may be damaged by an extending thyroid carcinoma or malignant lymph nodes. The base of the tongue, valleculae, epiglottis, aryepiglottic folds and piriform fossae are viewed, then the false cords, which are red and widely apart, then, between these, the pearly white true cords (Fig. For the passage of the laryngoscope, endotracheal tube or bron choscope it is essential to know the position which brings the axes of the salivary glands 311 Fig. The gland itself is enclosed in a split in the investing fascia, lying both on and below which are the parotid lymph nodes. Antero inferiorly, this parotid fascia is thickened and is the only structure sep arating the parotid from the submandibular gland (the stylomandibu lar ligament). Traversing the gland (from without in) are: 1 the facial nerve (see below); 312 the head and neck Fig. The duct can easily be felt by a nger rolled over the masseter if this muscle is tensed by clenching the teeth. The relations of the facial nerve to the parotid the facial nerve is unique in traversing the substance of a gland, a fact of considerable importance to the surgeon. As the gland enlarges it overlaps these nerve trunks, the super cial and deep parts fuse and the nerve comes to lie buried within the gland. The salivary glands 313 the facial nerve emerges from the stylomastoid foramen, winds laterally to the styloid process and can then be exposed surgically in the inverted V between the bony part of the external auditory meatus and the mastoid process. This has a useful surface marking, the inter tragic notch of the ear, which is situated directly over the facial nerve. Just beyond this point the nerve dives into the posterior aspect of the parotid gland and bifurcates almost immediately into its two main divisions (occasionally it divides before entering the gland). The upper division divides into temporal and zygomatic branches; the lower division gives the buccal, mandibular and cervical branches (Fig. These two divisions may remain completely separate within the parotid, may form a plexus of intermingling connections, or, most usually, display a number of cross-communications which can be safely divided during dissection without jeopardy. It is then traced into the gland, its main divisions de ned and the tumour excised with a wide margin of normal gland, carefully preserving the exposed nerves. It is interesting that giant mixed tumours ‘extrude’ clear away from the facial nerve and can be excised with an adequate margin without even seeing the nerve.

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Additional cardiac lesions associated with Turner syndrome include septal defects acne cleanser buy cleocin 150 mg amex, valvular stenosis skin care games purchase cleocin 150mg fast delivery, and anomalies of the great vessels anti-acne buy cleocin 150 mg visa. Their presentation is consistent with overproduction of catecholamines acne hacks buy cleocin 150mg free shipping, resulting in paroxysmal or sustained hypertension. Thymomas are associated with myasthenia gravis, agammaglobulinemia, and red blood cell aplasia. Most thymic lesions associated with myasthenia gravis are hyperplastic rather than neoplastic. Other disorders sometimes associated with hyperparathyroidism include peptic ulcers, pancreatitis, and bone disease; central nervous system symptoms may also arise in connection with hyperparathyroidism. Occasionally, parathyroid adenomas occur in conjunction with neoplasms of other endocrine organs, a condition known as multiple endocrine adenomatosis. Persons afflicted with Hodgkin disease have impaired cell-mediated immunity and are particularly susceptible to mycotic infections and tuberculosis. The nodular sclerosing variant of primary mediastinal Hodgkin disease is the most common type. Cystic teratomas, or dermoid cysts, include endodermal, ectodermal, and mesodermal elements. They are characteristically cystic and contain poorly pigmented hair, sebaceous material, and, occasionally, teeth. If there is a connection between the teratoma and the tracheobronchial tree, the patient may present with symptoms of coughing up hair or sebaceous material. Dermoid cysts occur in the gonads and central nervous system, as well as in the mediastinum. Phenylephrine is often used as a first-line agent in the treatment of neurogenic shock (where there is a loss of sympathetic tone) or as a secondary agent for refractory hypotension in the setting of tachycardia which limits increases in other medications such as dopamine. Epinephrine is used as a short-term agent given in intravenous boluses during cardiac arrests and in patients with cardiac dysfunction refractory to other agents such as dobutamine. Nitroprusside can be used in severe cardiogenic shock to reduce afterload or to treat severe hypertension. Epinephrine is a circulating endogenous catecholamine, released mainly from the adrenal medulla, whose effects are mediated by binding of free circulating hormone to and receptors, with lesser1 2 effects on adrenoreceptors. At low infusion rates the adrenergic effects predominate causing1 increased heart rate, stroke volume, and contractility. At higher infusion rates, adrenergic receptors are stimulated, resulting in an increase in blood pressure and systemic vascular resistance. Prolonged use of high-dose epinephrine is limited by renal and splanchnic vasoconstriction, cardiac dysrhythmias, and increased myocardial oxygen demand. Norepinephrine is also endogenously produced, but acts locally through release at nerve synapses. It acts on adrenergic and adrenergic receptors, resulting in an increase in afterload and glomerular perfusion pressure with preservation of cardiac output. Norepinephrine is associated with increase in urine output in hypotensive, septic patients. Dopamine is an endogenous catecholamine that is released into the circulation and acts by binding to receptors as well as to specific dopamine receptors in the renal, mesenteric, coronary, 1 and intracerebral vascular beds, causing vasodilation. It has effects that change with increasing doses by binding to different receptors. At low serum concentrations, dopamine binds to dopaminergic receptors in the renal and splanchnic beds leading to increased urine output and natriuresis. At modest concentrations, dopamine binds to cardiac adrenergic receptors leading to increased myocardial1 contractility and increased heart rate. At high doses, dopamine binds to adrenergic receptors and causes an increase in blood pressure and peripheral vascular resistance. Dopamine is an effective agent in increasing blood pressure in hypotensive patients with adequate fluid resuscitation. Dobutamine is a synthetic catecholamine that predominately binds to adrenergic receptors and enhances myocardial contractility with minimal changes in heart rate. It is often used in treatment of cardiogenic shock following myocardial infarction to support myocardial contractility while reducing peripheral resistance. Phenylephrine is a pure agonist and its use results in increased peripheral vascular resistance and blood pressure. The increase in afterload increases left ventricular work and oxygen demand, and may cause a decrease in stroke volume and cardiac output. Continuous infusions of nitroprusside require monitoring of serum thiocyanate levels and arterial pH for cyanide toxicity. It is an effective treatment for myocardial ischemia because it diminishes myocardial oxygen demand by reducing excessive preload and ventricular end-diastolic pressure. She recently underwent an uncomplicated left hemicolectomy for diverticular disease. For the first 6 hours following a long and difficult surgical repair of a 7-cm abdominal aortic aneurysm, a 70-year-old man has a total urinary output of 25 mL since the operation. Which of the following is the most appropriate diagnostic test to evaluate the cause of his oliguria A 72-year-old man undergoes an aortobifemoral graft for symptomatic aortoiliac occlusive disease. Twenty-four hours after surgery the patient has abdominal distention, fever, and bloody diarrhea. A 25-year-old woman presents to the emergency room complaining of redness and pain in her right foot up to the level of the midcalf. She reports that her right lower extremity has been swollen for at least 15 years, but her left leg has been normal. A 76-year-old woman presents with acute onset of persistent back pain and hypotension. Three days after surgery she complains of abdominal pain and bloody mucus per rectum. Which of the following is the most frequent and lethal complication of this condition A 75-year-old man is found by his internist to have an asymptomatic carotid bruit. Angioplasty of the carotid lesion followed by carotid endarterectomy if the angioplasty is unsuccessful d. Medical risk factor management and carotid endarterectomy if neurologic symptoms develop 421. A 55-year-old man with recent onset of atrial fibrillation presents with a cold, numb, pulseless left lower extremity. He is immediately taken to the operating room for an embolectomy of the left popliteal artery. A 58-year-old man presents with pain in the left leg after walking more than one block that is relieved with rest. On physical examination, distal pulses are not palpable in the left foot and there is dry gangrene on the tip of his left fifth toe. Which of the patient’s symptoms or signs of arterial insufficiency qualifies him for reconstructive arterial surgery of the left lower extremity A 64-year-old man with a history of a triple coronary artery bypass 2 years ago presents with peripheral arterial occlusive disease. Which of the following medications would be most appropriate in the medical management of his atherosclerosis A patient who has had angina as well as claudication reports feeling light-headed on exertion, especially when lifting and working with his arms. The subclavian steal syndrome is associated with which of the following hemodynamic abnormalities Surgery is considered, but her hypertension, smoking, and diabetes puts her at risk for associated coronary heart disease. What test is most predictive of postoperative ischemic cardiac events following surgery A 60-year-old man is admitted to the coronary care unit with a large anterior wall myocardial infarction. On his second hospital day, he begins to complain of the sudden onset of numbness in his right foot and an inability to move his right foot.

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For example acne in your 30s order cleocin 150 mg line, in cases of acute pain in the right hypochondrium acne infection cleocin 150mg on-line, ultrasound is the most appropriate procedure to skin care blog order cleocin 150mg visa rule out a gallstone acne glycolic acid cleocin 150 mg for sale, biliary obstruction, or acute pancreatitis; however, if a hiatal hernia or peptic ulcer is suspected, an upper gastrointestinal barium study should be performed. Therefore, a wide range of imaging techniques is useful in the study of the abdomen. The role of the different imaging procedures in abdominal radiology can be simply summarized as: Abdominal X-ray: to rule out gastrointestinal obstruction and to detect radiopaque stones within the gallbladder and urinary system Barium swallow and upper gastrointestinal series: to study the esophagus, stomach, and duodenum. It is most commonly used in cases of ulcer or gastric re ux Barium enema: to study the rectum and colon. Its great exibility makes it suitable for studying most of the abdominal systems and for solving speci c diagnostic problems. Abdominal radiology is one of the fastest growing and most dynamic elds in radiology and has much to offer adventurous residents and young radiologists who are not afraid to face challenging diagnostic problems. Ribes Case 1 Acute Cholecystitis and Choledocholithiasis with Secondary Pancreatitis and Hepatic Abscess Fig. Blood test revealed leukocytosis with left shift and biochemical markers of cholestasis. Acute cholecystitis is the most common cause of acute pain in the right upper quadrant. Comments It occurs in one of every three patients with cholelithiasis and is usually caused by cystic duct obstruction by impacted calculus (95%). The pathogenic mechanism is increased internal pressure in the gallbladder secondary to obstruction, with chemical irritation from concentrated bile and wall ischemia, and nally associated bacterial infection. Complications of acute cholecystitis are: gangrene, perforation, and gallbladder em pyema. As in this case, its association to choledocholithiasis and acute pancreatitis is common. Pyogenic hepatic abscesses are most commonly due to ascending cholangitis from obstructive biliary tract disease, as is shown in this case. The most sensitive and speci c imaging method for the detection of acute cholecystitis is ultrasound. It is used routinely in the clinical work-up of acute cholecystitis to establish the diagnosis. The triad of cholelithiasis, gallbladder wall thickening, and positive sono graphic Murphy sign (focal tenderness over the gallbladder) is almost pathognomonic. Additional signs are: hazy delineation of the gallbladder wall, edema of the gallbladder wall, striated wall thickening, gallbladder hydrops, pseudomembranes, sludge, crescent shaped pericholecystic uid, and increased peripheral ow (visualization of the cystic artery) in color Doppler ultrasound. It is more complicated to choose an imaging method for the study of ascending cholan gitis secondary to choledocholithiasis. Conventional cholangiography is the most speci c technique for visualizing the cause of obstruction. In acute pancreatitis, imaging is necessary for staging and determining the prognosis. Other signs to look for are: enlargement of the pancreas with convex margins, parenchymal inhomogeneity, thickening of anterior pararenal fascia, peripancre atic fat stranding, peripancreatic uid and uid collection, and pseudocyst formation. Abdominal ultrasound demonstrated clear signs of acute cholecystitis: cholelithiasis, stri Imaging Findings ated wall thickening, positive sonographic Murphy’s sign, and increased peripheral vas cularization in color Doppler ultrasound (Fig. Moderate bile duct dilatation and a focal lesion in the left liver lobe with “comet-tail artifact” were additional ndings. Laboratory tests showed a sig ni cant hepatic enzymes elevation and alteration of coagulation parameters. At physical examination, there were signs of ascites and caput medusae (collateral super cial veins in the anterior abdominal wall). Cirrhosis is a chronic liver disease characterized by diffuse parenchymal destruction, Comments brosis, and nodular regeneration with abnormal reconstruction of preexisting lobular architecture. The most common causes of cirrhosis are alcohol consumption and viral hepatitis, although there are other many possible causes. Morphologically, cirrhosis can be clas si ed as macronodular (alcoholism), macronodular (hepatitis B), or mixed (bile duct obstruction). Portal hypertension is commonly associated to advanced cirrhosis and occurs despite the formation of portal collateral vessels. Signs of portal hypertension are: dilatation of portal and splanchnic veins, portal vein thrombosis, cavernomatous transformation of the portal vein, portosystemic collaterals, Cruveilhier-von Baumgarten syndrome (re canalized paraumbilical vein), splenomegaly, Gamna-Gandy nodules (microhemor rhages within the spleen), and ascites. Radiological signs of cirrhosis are: enlarged (early stage) or shrunken (late stage) liver, caudate lobe hypertrophy, shrinkage of the right lobe, peripheral liver nodularity, fatty in ltration, thickening of ssures and porta hepatis, ascites, splenomegaly, and signs of portal hypertension. Ultrasound is most commonly used as a rst-step technique in the evalu ation of cirrhosis. Doppler ultrasound is very valuable in the assessment of portal hyper tension and portal vein thrombosis. Occasionally, hepatic Comments metastasis may be solitary or con ned to one segment or lobe. The most common liver metastases originate from lung, colon, pancreas, breast, or stomach carcinomas, and the most common tumors developing hepatic metastases are colorectal, uveal melanoma, neuroendocrine, and gastrointestinal tumors. Imaging has different roles in the diagnosis and management of hepatic metastases. First of all, cross-sectional imaging techniques are able to detect them and to determine their extension. After detection and characterization, it is also important to de termine the extension and number of lesions. Limited extension to one segment or lobe and absence of vascular structures compromise would make curative surgical resection possible. Percutaneous biopsy may be necessary in cases where the diagnosis is uncertain or when a de nitive diagnosis is necessary. It is dif cult to determine the primary tumor on the basis of the imaging character istics of the hepatic metastasis, although some patterns may help resolve this issue. The size, number, presence of necrosis, and behavior of the lesions in a dynamic enhanced series are key factors in the characterization of the metastases and in determining their origin. However, these patterns usually change after treatment, especially after chemo therapy. Smaller nodules were hypervascular and larger masses demon strated peripheral enhancement with central hypovascular areas representing necrosis and/or brosis. The incidence of islet cell tumors is around one case per million population per year. These tumors are usually homogeneous masses detected when still small, since the clini cal effects of the excess hormone production appears early in their natural course. On the other hand, clinically silent tumors present as larger locally invasive masses or with distant metastasis. Therefore, clinical presentation is the determinant factor in their differentiation. This is an autosomal dominant disorder that manifests as pituitary ad enoma, parathyroid hyperplasia, and pancreatic islet cell tumors (gastrinomas, or less commonly insulinomas). Insulinomas are typically homogeneous masses <3 cm in size with non-aggressive local features. They may present as either a solitary benign adenoma or diffuse islet cell hyperplasia or even as malignant adenoma. In the diagnostic work-up of insulinomas, the radiologist’s role is to accurately locate the tumor. The presence of a hypervascular nodule in the pancreas in a patient with Whipple’s triad (symptoms known or likely to be caused by hypoglyce mia, low glucose at the time of the symptoms, and relief of symptoms when the glucose is raised to normal) is diagnostic of insulinoma. Intraoperative ultrasound and surgical palpation remains the gold standard to rule out additional nodules. Both Hodgkin and non Comments Hodgkin lymphoma may present in the spleen either as a primary lesion or as a part of systemic involvement. Splenic involvement is present in up to 40% of patients with both Hodgkin and non-Hodgkin lymphoma at the time of initial diagnosis. Patients present with nonspeci c clinical symptoms, usually with splenomegaly and retroperitoneal ad enopathy. Pathologically, lesions range from microscopic foci involving the spleen dif fusely (in ltrative pattern) to gross lesions varying in size from small miliary nodules to a single or multiple large masses. Splenic lymphoma is dif cult to diagnose with imaging techniques because of its wide spectrum of different presentations.

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Migratory arthritis in asso ciation with diarrhea skin care trends trusted 150 mg cleocin, weight loss skin care mask cheap cleocin 150mg with visa, and malabsorption skin care equipment buy 150mg cleocin visa. Usually a chronic arthritis involving one or more joints in association with immunosuppression and/or a particular geographic location skin care myths cleocin 150mg free shipping. Most commonly involves the knee and residence, or recent travel, in the Southwestern United States. Associated with soil or dust exposure con taining decomposed wood (north-central and southern United States). Most viral-related cases are thought to be an immune-mediated process rather than direct viral invasion. Classically, the clinical symptom of fever and an acutely swollen and painful joint with limited range of motion has been asso ciated with bacterial septic arthritis. While any joint may be involved, the most common joint involved is the knee (45%), followed by the hip (15%), ankle (9%), elbow (8%), wrist (6%), and shoulder (5%). Polyarticular arthritis is unusual with nongonococcal septic arthritis; however, it is more likely to occur in association with S. Traditionally, gonococcal septic arthritis symp toms occur in young, sexually active individuals in association with dissemi nated gonococcal infection. Gonococcal septic arthritis occurs with homosexual males, but 75% of cases are associated with menstruating or pregnant women (increased risk of disseminated gonococcal infection). Commonly involves multiple joints (75% of cases), is asymmetric, and migrates from one joint to the next. This is otherwise known as migra tory arthritis and involves the distal joints. The characteristic rash (erythematous papules that progress to vesicle or pustular lesions) only occurs in 40% to 50% of cases. Characterized as pain, swelling, and periarticular erythema and occurs in 21% of cases (most commonly the wrist). Differentiating septic arthritis and other causes of an acutely swollen, painful joint. Physicians must have a high clinical concern for septic arthritis in a patient presenting with acute onset of joint(s) pain, swelling, and restricted motion, as this is a common medical emergency. Comorbid illnesses, medications (especially medications that predispose to immunosuppression or gout such as corticosteroids, chemotherapy, and diuretics), and exposures. A detailed sexual history should be obtained to determine the risk of a sexu ally transmitted infection, especially gonococcal disease. A complete history and physical examination should be performed, but no nding on examination is speci c for septic arthritis. Elevated fever and pulse rate in association with a decreased blood pressure may suggest bacteremia and sepsis. Subconjunctival hemorrhages may suggest staphylococcal bac teremia and endocarditis. It is also important to identify any vascular catheters that may lead to a bloodstream infection. Splenomegaly in association with adenopathy may suggest immunosuppression due to a hematologic malignancy. The ndings of nail-bed splinter hemorrhages, Janeway lesions, and Osler nodes may suggest endocarditis. Additional skin lesions to identify that may be helpful in cases of polyarthritis as well as with determining immune status include: psoriatic plaques (this may suggest psoriatic arthritis and is characterized by well-demarcated areas of hyperkeratosis on extensor sur faces), eczema lesions, and acanthosis nigricans (hyperpigment of skin folds associated with diabetes). An infected joint is usually indicated by a single joint in association with rapid uctuant swelling and joint pain and tenderness with diminished range of passive motion. Severe limitation of active range of motion may be involved but tends to suggest involvement of muscles and/or ligaments and tendons. Additionally, evaluation of serial levels may be helpful in monitoring the response to therapy. Electrolyte, renal, and liver tests are routinely ordered but nonspeci c to the diagnosis of septic arthritis. Anticoagulation studies should be evaluated prior to any invasive test or procedure. At least two sets (a set is equal to one aerobic and one anaerobic bottle) should be ordered prior to initiating antibiotics. Positive cultures are found in half the cases of nongonococcal septic arthritis and rarely with gonococcal disease. Nucleic acid detection methods are generally associated with very high sensitivities (97%–98%) and speci cities (99%) but can be associated with a 5% false negative rate. First-void urine samples are commonly used, but swab samples of the urethra, endocervix, vagina (obtained exclusively in prepubertal females), pharynx, and rectum may also be collected for testing. Approximately 80% to 90% of women with gonococcal septic arthritis show positive cultures (grown on chocolate or Thayer–Martin media). Approximately 50% to 75% of men with gonococcal septic arthritis demonstrate positive cultures. Gonococcal nucleic acid ampli cation testing may be helpful if cultures are not obtained (see the preceding). However, 33% of patients with native joint septic arthritis have counts less than 50, 000 cells/mm. Evaluation of synovial uid glucose and protein may be performed, but abnormalities are nonspeci c for septic arthritis. Synovial uid should also be examined by polarizing microscopy for crystals of gout and pseudogout; however, crystal-induced arthropathy and infection can occur simultaneously. The Gram stain and culture of synovial uid is the best diagnostic tool for septic arthritis. Positive in 90% of cases (especially when inoculated into blood culture bottles rather than solid media). May be helpful in cases suspected to be due to Lyme disease, brucellosis, and Q fever. In general, imaging tests are not helpful in the discrimi nation between septic arthritis and nonseptic in ammatory arthritis. This imaging method is commonly ordered and most helpful as the infectious process develops with the most common nd ings to include soft-tissue changes of fat-pad displacement (joint capsule distention) and joint-space widening (due to localized edema). Late changes noted on plain lms may include ndings of joint-space narrowing (due to cartilage destruction) and/or osteomyelitis. The best method of detecting early intra and extra-artic ular effusions as well as guide aspiration and/or drainage procedures, which is also noninvasive and devoid of ionizing radiation. Of limited utility with early septic arthritis but is more sensitive in visual izing soft-tissue changes. Septic arthritis is considered a true medical emergency owing to rapid joint destruction and increased mortality rate (ranging from 7%–15%); there fore, the therapy for nongonococcal septic arthritis consists of antimicrobial ther apy and early joint-space drainage (less than 72 hours) because of the potential for signi cant joint-space destruction. Surgical drainage of gonococcal septic arthri this is rarely indicated, and treatment usually consists of antimicrobial therapy alone. Cipro oxacin is usually not con sidered rst-line therapy owing to the emergence of uoroquinolone-resistant strains. Patients should also receive 1 g azithromycin orally or doxycycline 100 mg orally twice daily for 7 days for dual coverage of gonococcal infection and potential Chlamydia trachomatis coinfection. Usually only required for the initial synovial uid aspi rate needed for analysis. The duration of therapy is usually 21 to 28 days, but if osteomyelitis is present then a duration of 4 to 6 weeks is recommended. Joint drainage through a single or daily arthrocente sis typically drains infected material, resolves effusions, and improves pain. Arthrocentesis improves blood ow for delivery of nutrients and antibiot ics as well as removes bacteria, toxins, and enzymes that can lead to joint destruction. Persistent effusion despite 7 days of arthrocentesis, soft-tissue extension of infection. Joint destruction in infectious arthritis is driven primarily by the in ammatory response to the invading organism.

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