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Obstruction of the bile system causes alkaline (an enlarged tongue-like growth of the right lobe of the phosphatase to rise first and proportionally more than liver which is a normal variant) discount 100mg caverta visa erectile dysfunction treatment in bangladesh. A diseased liver may not always be enlarged effective caverta 50mg impotence fonctionnelle, and in late cirrhosis it is more Clinical features common for it to become small and scarred caverta 50mg sale erectile dysfunction treatment at gnc. Acarefulhistoryshouldbetakenincludingthefollowing: If the liver is palpable, other features should be elicited r Prodromal ‘flu-like’ illness up to 2 weeks before onset such as whether it feels soft or hard, regular and smooth of jaundice suggests viral hepatitis. Examination may reveal hepatomegaly and/or splen- The liver is non-tender and firm. Signs Hepatomegaly Signs of chronic liver disease Hepatomegaly is the term used to describe an enlarged There are many signs of chronic liver disease, but in liver. Normally, the liver edge may be just palpable below some cases examination can be entirely normal, despite the right costal margin on deep inspiration, particularly advanced disease (see Fig. It may also be palpable without being The hands: enlarged due to downward displacement, e. The chest and upper arms: r Dupuytren’s contracture is a thickening of the palmar r Spider naevi are telangiectases that consist of a central fascia which may be palpable as thickening or cords arteriole with radiating small vessels. They blanch if and as it progresses flexes the fingers (most commonly pressure is applied to the centre, then refill outwards. Raised central venous Hepatic vein obstruction r Slate-grey pigmentation of the skin occurs in pressure (Budd–Chiari syndrome) haemochromatosis. Chronic liver disease Pancreatitis r There may be a hepatic flap, which is a flapping tremor Portal vein obstruction Inflammatory bowel disease of the outstretched hands. Congestive cardiac failure The abdomen and lower limbs: r Hepatomegaly and/or splenomegaly (see page 463). A In early cirrhosis liver function is adequate, so that pa- transudate is suggested by a protein of ≥11 g/L below tients are asymptomatic and do not have complications. In more severe disease portal hypertension, low serum r Clear fluid is seen in liver disease and hypoalbu- albumin and other complications occur. Signsofdecompensated cirrhosis: r Ascitic fluid amylase is raised in pancreatic ascites. The progress of ascites can be monitored using repeated Ascites weight and girth measurements. Sodium intake should be restricted but protein and calorie intake should be Definition maintained. Water restriction is only necessary if the Ascites is the accumulation of fluid within the peritoneal serum sodium concentration drops below 128 mmol/L. The combination of spironolactone and furosemide is effective in the majority of patients. Patients who not Aetiology/pathophysiology respond to this treatment may require Ascites may be a transudate or an exudate dependent on r therapeutic paracentesis, the removal of fluid over a the protein content (see Table 5. If more than1Loffluid is removed then intravenous albumin or plasma expander is re- Clinical features quired to prevent hypovolaemia. Chapter 5: Clinical 189 Investigations and procedures Obstruction r Bilirubin: Raised bilirubin levels indicate abnor- Liver function testing malities in its synthesis, metabolism or excretion. It often rises in causes of obstructive (cholestatic) Liver function testing includes blood tests to look for ev- jaundice, but it is not specific for obstruction or idence of hepatocyte necrosis, as well as assessing the even for liver disease (see Table 5. For assessing the synthetic function surement is also raised as it shares a similar pathway of the liver, two other blood tests are needed, the pro- of excretion. Alternatively, it is possible to r Aminotransferases: Two are measured, aspartate differentiate the bone and liver isoenzymes. These are raised by most causes of this enzyme even when there is no liver damage. It liver disease, but paradoxically, in severe necrosis may be used to detect if patients continue to drink or in late cirrhosis levels may fall to normal in- alcohol,butitdoeshavealonghalf-life. It falls Haemolysis in both acute and chronic liver disease, although Bilirubin Haemolysis levels may be normal early in the disease. Other osteomalacia, metastases, causes of hypoalbuminaemia include gastroin- hyperparathyroidism) testinal losses or heavy proteinuria. IgM is Albumin Malnutrition Nephrotic syndrome particularly raised in primary biliary cirrhosis, Congestive cardiac failure whereas IgG is raised in autoimmune hepatitis. Parenteral gallbladder, or may be seen after endoscopic or surgical replacementofvitaminKshouldleadtoimprovementof instrumentation. It is partic- Pancreatic function tests ularly useful in patients who have r jaundice or abnormal liver function tests where it is Exocrine function r Serum amylase is a marker for pancreatic damage. Ultrasound may also be the more complex triglyceride is not, then the steator- used for liver biopsy, and doppler ultrasound is used to rhea is caused by pancreatic disease. Tests for endocrine function in this context taken in case of allergy or risk of contrast nephrotoxicity. Pancreatic polypeptide is raised in all of useful for assessing focal lesions of the liver, staging of these types of tumour and see page 222 for specific malignancy, and it is more sensitive for pancreatic le- tests. Pancreaticcalcificationmay times used as a non-invasive alternative to endoscopic be seen in chronic pancreatitis. Complications include haemorrhage, patients suspected of having biliary obstruction, stone bile leakage, bacteraemia and septicaemia. This is followed by checked and a sample sent to transfusion for group real-time radiography. Hepatitis B and C surface antigen sta- Further diagnostic and therapeutic manoeuvres: r tus should be known. Percutaneous aspiration of an abscess is approximately 1%, but this rises with any therapeutic occasionally performed. Haemorrhage and perforation occur less cedure the patient should rest on their right side for 2 commonly. Ascending cholangitis may be prevented by hours in bed and should gently mobilise after bed rest antibiotics, which are given prophylactically to all pa- for a further 4 hours. However, in many cases of Percutaneous transhepatic cholangiography is used to malignant tumours only complete removal of the liver image the biliary tree, particularly the upper part, which and liver transplantation is curative. Localised metas- is not well outlined by endoscopic retrograde cholan- tases may also be resected. For example in obstruc- The liver is composed of several segments, as defined tive jaundice with obstruction of the upper biliary tree by the blood supply and drainage, this is important in and when malignancy of the biliary tract is suspected liver resection. Prior to the procedure the clotting have a left and right branch and these supply the left and profile is checked and the patient is given prophylactic righthemi-livers respectively. The im- comprises of the remainder of the right lobe and is also age can be followed by real-time radiography and still further divided into four segments (see Fig. The T-tube allows drainage of Right lobe Left lobe bile and also allows a cholangiogram later. Laparoscopic cholecystectomy requires three or four cannulae inserted through the anterior abdominal wall, Caudate and for visualisation and access with operative instruments.

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When medieval translators looked for gyne- cological material to render into the vernacular generic caverta 50mg with amex treatment for erectile dysfunction before viagra, it was to the Trotula texts that they most frequently turned 50mg caverta with mastercard doctor for erectile dysfunction in ahmedabad. Of ten gynecological texts composed in Middle English between the fourteenth and fifteenth centuries trusted 100mg caverta erectile dysfunction pumps cost, for example, five are renditions of the Trotula. The Latin texts probably only rarely made their way into women’s hands in the early years after their composition, perhaps not at all after the thirteenth century. The Laon manuscript just mentioned, for example, passed from that anonymous male surgeon into the holdings of the cathedral of Laon, where it was annotated and used by the canons of the cathedral for the rest of the Middle Ages. Every other manuscript whose provenance is known is similarly found passing exclusively through the hands of men. Its early provenance is not known, but it has the distinction among the Latin Trotula manuscripts in being the smallest codex, a handbook less than six by four inches in size. It also contains only one other text: a brief tract on useful and harmful foods, which could, conceivably, be used for self-medication by controlling diet. There are no contemporary annotations to confirm owner- ship by a woman, but its small size (similar to that of the books of hours owned by many upper-class women in this period) and the absence of any other, more technical medical literature may suggest use by a layperson and so, perhaps, by a woman. The author of the earliest English translation, writ- ing in the late fourteenth or early fifteenth century, went so far as to demand of any male reader who happened upon the text that ‘‘he read it not in spite nor [in order to] slander any woman nor for any reason but for healing and helping them. It seems, then, that relative to their widespread popularity among male practitioners and intellectuals, it was only very infrequently that the Trotula found their way into the hands of women. Despite the recognition by the author of Conditions of Women that women often did not want to turn to male physicians, the Trotula seem to have functioned as a prime tool by which male practitioners did, in fact, come to have significant control over the practice of gynecology and cosmetics. Note on This Edition and Translation T E The following edition of the Trotula ensemble represents the standardized text as it circulated in the latter half of the thirteenth century through the turn of the fourteenth century. The nine manuscripts collated here were chosen on the basis of their early date and the integrity of their text. The text, including orthography, reflects that of the Basel manuscript, including the hand of the original scribe (B), that scribe’s own corrections (B1), and the corrections of a second, slightly later hand (B2). I have deviated from B’s text only in those cases where the orthography seemed misleading, or where the unanimous agreement of the other manuscripts suggested a lacuna or an error in B. Where B’s reading is unique but not necessarily erroneous, however, I have retained it despite the unanimity of the other manuscripts. All variants are noted in the apparatus with the following two exceptions: varia- tions in word order and orthography, except in those cases where they seemed potentially meaningful, and the presence orabsence of et except, again, in those cases where it might be important to the sense. Corrections or expunctions in the hand of the original scribes have not been specially flagged; the text has simply been read as corrected. It is meant not only to indicate the obvi- ous grammatical and topical breaks (and in this I have respected the manu- scripts’ readings as much as possible) but also to reflect the original compo- nent parts of the texts. Thus, strings of recipes will often be separated except in those instances (such as ¶) where they all come uninterrupted from a single source. More detailed information on when, exactly, this material entered the ensemble and on internal transpositions of material within the texts can be found in my  essay on the subject. B’s orthography displays certain Italianate features, such as a characteristic doubling of consonants (e. The text has been carefully corrected by a contemporary hand (B2), who notes a few omissions in the margins or interlinearly. The original scribe entered the text of the rubrics at the bottom of the page; these were then written in by the same hand. Contents: Johannes de Sancto Paolo, De simpli- cium medicinarum virtutibus; treatise on preparation of colors; Petrus His- panus, Liber de egritudinibus oculorum; idem, Tractatus secundus, i. Zacharias, Tractatus de passionibus oculorum; Trotula, standardized ensemble; Magister Petrus Lumbardus, Cure. Owner: original owner(s) unknown; apparently owned in the late fif- teenth century by Henricus de Sutton, who added some additional reme- dies at the end of the book, including one that he claims to have employed for pain in the penis and breasts. Contents: Isaac Israeli, De dietis particularibus; list of prebends in Laon, held predominantly by Italian canons, between  and ; Trotula, standardized ensemble; Richardus Anglicus, Anathomia. Owners: an unidentified male surgeon (partially erased owner’s mark: Iste liber est. Contents: Bernard de Gordon, Lilium medi-  Introduction cine; table of contents of whole codex; Alphita; Nicholaus, Synonima; Quid pro quo; Tabule Salerni; Nicholaus, De dosibus; Walter, De dosibus; Johannes Stephanus, De medicinis purgantibus; Trotula, standardized en- semble; Thadeus, Experimenta; idem, Practica disputata (an. Contents: Antidotarium Nicolai; Additiones Anthidotarii; Walter, De dosibus; Johannes Stephanus, De dosibus; Walter, De febribus; De conferentibus et nocentibus; He ben Mesue, De simplicibus medicinis; De medicinis solutivis in speciali; He ben Mesue, Liber graduum, followed by list of Arabic words and their definitions; Johannes Damascenus Nafra- nus, filius Mesuhe Calbdei, Agregatio vel antidotarium electuorum con- fectionum; Avicenna, Flebotomia; Rhazes, Flebotomia; Constantinus Afri- canus, Flebotomia; Lectura Johannis de Sancto Amando supra Antidotarium Nicolai; Ricardus Anglicus, De signis pronosticis; Rogerina maior; Rogerina minor; Trotula, standardized ensemble; Practica puerorum (inc. Contents: Mattheus Platearius, Circa instans;WalterAgi- lon, Conferentibus et nocentibus; Gerard of Montpellier, Summa de modo medendi; Walter Agilon, De dosibus; Trotula, standardized ensemble; Rhazes, Passiones sive Practica puerorum;RogerBaron,Rogerina maior; idem, Rogerina minor; Johannes de S. Because they reflect nothing about the thirteenth-century uses of the text, the rubrics of this Introduction  manuscript (which frequently agree little with the sense of the chapters) have not been noted in the apparatus. Contents: consists of five separate manuscripts, brought together by the fifteenth century at the latest. Owner: whole codex of five manuscripts owned in the fifteenth century by Johannes Spenlin of Rothenburg (d. Many rubrics illegible on film; upper parts of several folios damaged by water or acid, thus occasionally obscuring the text of the top – lines. Codex composed of two sepa- rate sections that were brought together by Johannes Medici alias Patz- ker, master of arts from Paris, provost and canon of Sanctus Johannes Maior, and cantor of the Church of the Holy Cross in Wrocław in the fif- teenth century. T T In the translation that follows, I have aimed for clarity above all. I have resisted the temptation to ‘‘diagnose’’ the conditions described and have preferred to replicate the sometimes loose phrasing of the Latin rather than offer more pre-  Introduction cise readings that presume the ideological framework of modern western bi- ology and medicine. Readers can decide for themselves if, for example, they wish to interpret infertility accompanied by dry lips and incessant thirst (¶) as a description of diabetes. I have also retained the grammatical voice of most instructions—that is, I have rendered passive constructions passivelyand active actively. Although admittedly this results in a somewhat uneven text, it has the virtue of reflecting some remnants of the distinctive tone of address of the three original texts. On the one hand, the names used by the authors of the origi- nal Trotula texts in twelfth-century southern Italy often became deformed in transmission (I have flagged only the major deviations in the notes to the edi- tion), or they may have referred to several different plants. Some species may now be extinct or their chemical properties may have changed slightly over the past eight hundred years. On the other hand, there are instances when mul- tiple Latin names seem to refer to the same plant, for example, altea, bismalua, euiscus, malua, and maluauiscus, all of which seem to refer to marsh mallow (Althaea officinalis L. Having said this, I also feel my objective as translator is to attempt to bring a world long since disappeared back to life for the reader. This, it seems to me, can best be accomplished byattempting to identify plants, animals, and other materia medica by signifiers we use today. Since I am neither a botanist nor a phytopharmacologist, I have availed myself of the work of linguists and historical botanists in translating the medieval Latin terms with modern English common names (and, for the sake of readers whose native language may not be English, in cross-identifying those common names with their Linnaean classifications in the Index Verborum). Any investi- gators, either historical or pharmaceutical, who wish to use these texts as the basis for scientific research should refer to the Latin text. Needless to say, I can in no sense endorse the therapeutic use of these prescriptions by lay readers.

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This occurs because of the desire on the part of the physi- cian not to miss an important disease caverta 50mg line impotence with beta blockers. Therefore buy caverta 50mg line erectile dysfunction symptoms, each disease should be con- sidered by itself when determining the probability of its occurrence order caverta 50 mg erectile dysfunction over 80. This proba- bility takes into account how much the history and physical examination of the patient resemble the diseases on the differential diagnosis. The assigned proba- bility value based on this resemblance is very high, high, moderate, low, or very low. In our desire not to miss an important disease, probabilities that may be much greater than the true prevalence of the disease are often assigned to some diagnoses on the list. Physicians must take the individual patient’s qualities into consideration when assigning pretest probabilities. For example, a patient with chest pain can have coronary artery disease, gastroesophageal reflux disease, panic disorder, or a combination of the three. In general, panic disorder is much more likely in a 20- year-old, while coronary artery disease is more likely in a 50-year-old. When con- sidering this aspect of pretest probabilities, it becomes evident that a more real- istic way of assigning probabilities is to have them reflect the likelihood of that disease in a single patient rather than the prevalence in a population. This allows the clinician to consider the unique aspects of a patient’s history and physical examination when making the differential diagnosis. Constructing the differential diagnosis The differential diagnosis begins with diseases that are very likely and for which the patient has many of the classical symptoms and signs. Next, diseases that are pos- sible are included on the list if they are serious and potentially life- or limb- threatening. These are the active alternatives to the working diagnoses and must be ruled out of the list. This means that the clinicians must be relatively certain from the history and physical examination that these alternative diagnoses are not present. Put another way, the pretest probability of those alternative diseases is so vanishingly small that it becomes clinically insignificant. If the history and physical examination do not rule out a diagnosis, then a diagnostic test that can reliably rule it out must be performed. Diseases that can be easily treated can also be included in the differential diagnosis and occasionally, the diagnosis is con- firmed by a trial of therapy, which if successful, confirms the diagnosis. Last to be included are diseases that are very unlikely and not serious, or are more difficult and potentially dangerous to treat. These diseases are less possible because they 224 Essential Evidence-Based Medicine Fig. A good example of this would be a patient with chest pain and no risk factors for pulmonary embolism who has a low transcu- taneous oxygen saturation. Now one should begin to look more closely for the diagnosis of pulmonary embolism in this patient. When considering a diagnosis, it is helpful to have a framework for consid- ering likelihood of each disease on one’s list. This only helps to get an overview and does not help one determine the pretest probability of each disease on the differential diagnosis. In this schema, each disease is considered as if the total probability of disease adds up to 100%. One must tailor the probabilities in one’s differential diagnosis to the individ- ual patient. Bear in mind that a patient is more likely to present with a rare or unusual presentation of a common disease, than a common presentation of a rare disease. As stated earlier, the first step in generating a differential diagnosis is to sys- tematically make a list of all the possible causes of a patient’s symptoms. This skill is learned through the intensive study of diseases and reinforced by clinical experience and practice. When medical students first start doing this, it is useful to make the list as exhaustive as possible to avoid missing any diseases. Think of all possible diseases by category that might cause the signs or symptoms. There are several helpful mnemonics that can help get a differential diagnosis started. The values of pretest probability are relative and can be assigned according to the scale shown in Table 20. Physicians are more likely to agree with each other on prioritizing diagnoses if using a relative scale like this, rather than trying to assign a numerical probability to each disease on the list. If the disease is immediately life- or limb-threatening, it needs to be ruled out, regardless of the probability assigned. If the likelihood of a disease is very very low, the diagnostician should look for evidence that the disease might be present, such as an abberrent ele- ment of the history, physical examination or diagnostic tests to suggest that the An overview of decision making in medicine 225 Table 20. Mnemonic to remember classification of dis- ease for a differential diagnosis V Vasc ular I Inflammatory/Infectious N Neoplastic/Neurologic and psychiatric D Degenerative/Dietary I Intoxication/Idiopathic/Iatrogenic C Congenital A Allergic/Autoimmune T T rauma E Endocrine & metabolic Table 20. Useful schema for assigning pretest (a-priori) probabilities Pretest probability Action Interpretation <1% Off the list – for now. But, must Rare disease (rare consider if other diseases later are presentation) found not to be present. This is a unique presentation of this disease, and therefore the patient can only have this disease. We will use this schema for selecting pretest probabilities for the rest of the book. For example, if a 21-year-old man came in to the Emergency Department complaining of chest pain, a physician would first perform a complete his- tory and physical examination. Following this, one might suspect that anxiety 226 Essential Evidence-Based Medicine or a pectoralis muscle strain are the cause of his pain. One should also consider slightly less likely and more serious causes which are easily treatable, such as pericarditis, spon- taneous pneumothorax, pneumonia, or esophageal spasm secondary to acid reflux. Next, there are hypotheses that are much less likely, such as myocardial infarction, dissecting thoracic aortic aneurysm, and pulmonary embolism. Finally, one must consider some disorders, such as lung cancer, that are so rare and not immediately life- or limb-threatening that they are ruled out because of the patient’s age. If a 39-year-old man presented with the same complaint of chest pain, but not the typical sqeezing, pressure-like pain of angina pectoris, one could look up the pretest probability of coronary artery disease in population studies. This can be found in an article by Patterson, which states that the probability that this patient has angina pectoris is about 20%. These data would change one’s list and put myocardial infarction higher up on the differential. Since this is a potentially dangerous disease, additional testing is required to rule it out.

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