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“I am having vomiting two to three times a day since three days and discomfort in the upper abdomen”, was the complain of my patient.

There was no loose motion, fever and urinary problem. He was seen and prescribed medicines for gastritis one day back by my good friend, the medicine specialist. I thought he should remain in the treatment for some more time. So, I advised him to continue the same treatment and contact medicine specialist for further advice. At this point the patient says that he had a long standing inguinal hernia. Now, my surgeon mind became skeptical and alert to think that everything might not be well. I asked about the reducibility of the hernia, and very much to my expectation, it was not reducing since two days. So, that is the hazard of inguinal hernia. It, many a times becomes irreducible after coming out to the scrotal sac. Now, I examined the patient and found the irreducible hernia in the scrotal sac. But, to the good luck of the patient, it reduced with a little difficulty, aborting an emergency surgery. Now the patient gets relaxed so also me. The patient confesses that he had been advised earlier to undergo surgery, but it got delayed due to his bronchitis problem.

Chronic cough due to various chest diseases, and diseases like stricture of urethra or an enlarged prostate which increase resistance to smooth flow of urine, raise  intra-abdominal pressure and the contents of abdomen may find their way out through a potential weakness in the abdominal wall, what is called inguinal canal. That is termed as inguinal hernia. The contents may get struck to the scrotal sac and become irreducible or obstructed warranting an emergency surgery to release the same. This is potentially a life threatening condition, if timely intervention is not done. The content may become dead, what is called gangrene. Now, as the patient is having an exacerbation of bronchitis, has been prescribed a course of antibiotics with an advice to keep the contents of hernia inside the abdomen and return for an elective surgery after the symptoms of bronchitis alleviates.

There are minimal removal of breast tissue to total removal of tissue in breast cancer depending on the extent or stage of disease. You may go through the url to read more along with the quotes text.

http://www.mayoclinic.com/

Quoted.

“Who is mastectomy for?

Mastectomy is an effective treatment for breast cancer. Your doctor may recommended mastectomy over other treatment options — such as surgery to remove the tumor only (lumpectomy) plus radiation therapy — if:

• You’re in the first or second trimester of pregnancy, when radiation creates an unacceptable risk to your unborn child.
• You have two or more tumors in separate areas of the breast.
• You have widespread or malignant-appearing microcalcifications throughout the breast.
• You’ve previously had radiation treatment to the breast region.
• You have a strong family history of breast cancer.
• You carry a gene mutation that confers a high risk of developing another breast cancer.

You might also choose mastectomy if:

• You have a large tumor relative to the overall size of your breast. You may not have enough healthy tissue left after lumpectomy to achieve an acceptable cosmetic result.
• You have a history of connective tissue disease, such as systemic lupus erythematosus, and may not tolerate the side effects of radiation, particularly to the skin.
• The tumor is located beneath the nipple and may involve the nipple, making it more difficult to preserve the nipple and areola.
• You live a long distance from a radiation facility and being there every day for five to six weeks would be too large a hardship.

You may also consider mastectomy may if you don’t have breast cancer but are at high risk of developing the disease. This procedure, called preventive (prophylactic) or risk-reducing mastectomy, removes one or both of your breasts in hopes of preventing or reducing your risk of developing breast cancer in the future.”

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I was very much surprised by seeing a boy tolerating the pain of shoulder dislocation for some hours. Dislocation of shoulder is a very painful condition. The person who has experienced it will only be able to understand the plight of the patient. It usually occurs due to a fall hitting the shoulder directly or fall on a out stretched hand. Some have inherent weakness in the ligaments and capsule of the joint, and dislocate is frequently called a recurrent shoulder dislocation. Some develop weakness around the joint in some diseases like SLE or due to long term consumption of steroids. Sudden jerky movement of arm may dislocate it if one is prone for it.

It may be anterior or posterior type. Dislocation diagnosis is obvious from the clinical examination by observing the loss of convexity of shoulder joint. The axillary fold is also deformed. Some may fracture the humerus, the underlying bone along with the dislocation in a trauma. X-rays of the shoulder will prove the diagnosis.

The anterior shoulder can be reduced under a general anesthesia or under sedation. I prefer to do it under sedation, because calling the anesthetist and arranging operation theatre takes time in our set up. So, with a little discomfort the long waiting period can be cut short which in turn will cut short the plight of the patient. There are several methods to do it. I employ a method where the patient sleeps on his abdomen on a high table, hanging the limb down whose shoulder has been dislocated. A weight of about 10 kilograms is tied to the hand, and cares is taken so that the weight hangs freely and gives a continuous traction. Within a short time the contour of shoulder returns with a sound of reduction. And the patient is free of pain. He will express it with a relaxing moan. The shoulder will be immobilized at least for two weeks and some analgesic prescription will complete the treatment. Recurrent dislocation is treated by surgery.

The man was very much worried.” A bone was growing over the wrist since a few months” was his complain. The swelling was nearly circular, painless, almost defined boarders, does not move in any direction, hard to feel, almost fixed in the depth and was very slowly growing in size. So, he thought it to be a bony growth and must be dangerous.

I examined the swelling. It sits over the wrist with the characteristics as described above. Frequently I encounter this sort of complain. Mostly ladies are affected. This is also a beauty concern for them. Though most commonly seen near the wrist, it is also seen over the back of hand, forearm and near the tendons. That was diagnosed to be a ganglion.

A ganglion forms because of degenerative changes in the tissue covering of a tendon or that of a joint called synovial capsule. This may be termed as pseudoganglion or ganglion. When originates from the tendon sheath it is called pseudoganglion and when comes from the joint capsule is called a ganglion. A thick gelatinous material is found enclosed in a capsule. Many times the capsule is thin and sometimes it is thick. Diagnosed is based on clinical findings. Sometimes an x-rays examination is ordered to eliminate a bony growth.

The ganglion or the pseudoganglion is pressed hard so that it bursts and that gives a dramatic cure evidenced by sudden disappearance of the swelling. If thick walled it may not burst under pressure. In that case a wide bore needle is inserted into it and the gelatinous material is aspirated. Sometimes about 1 ml. of steroid is injected to the cavity. These procedures cure majority of patients. Sometimes larger ones require surgery by removing as much of capsule as possible. Ganglion is notorious for its recurrence. But it is an innocent disease.

                           This is a very nasty disease to me.Somehow I am not comfortable to treat this one.Patient comes with a painful swelling near to anus,fever and prostration .On examination a painful swelling will be found near the anal opening.Once drained a large amount of foul swelling pus will  come out and relief the patient to a considerable extent. And this cycle goes on unless the patient is not  throughly investigated for possibility of Fistula-In-Ano.
It is a condition where there is build up of a   tunnelled connection ,of course small in caliber between interior of lower gut and the exterior i.e. skin.This occurs from an infection of anal glands located inside the anus and rectum and gradually enlarge to burst to the out side.With  passing of time the inside of the fistula or tunnel matures and continuously discharges pus.That is why I call a nasty disease.
Fistula may also manifestation of some diseases like TB,Ulcerative Colitis,Chron’s Disease ,A rectal cancer and some other diseases.These are of various types and classified in various manner.
                                                                         Most accepted being superficiel,deep,intershincteric,transphencteric and high etc.which is required for the treating doctors.Treatment of more complex fistulas are not very much satisfactioy.A fistulogram gives good idea of it’s extension to help in operation.Besides trans rectal ultrasonogram is helpful.Tuberculosis if suspected should be searched for the primary site of infection .A simple per rectal examination is helpful to supect a cancer inside.
Surgery is the option for most of fistulas except TB and some other diseases.Here the whole tract is excised leaving a raw area to heal from the depth. And if dressing done properly and wound heals fromthe depth probably the surgeon should be able to sleep cmfortably.The excised specimen is to be subjected to histopathological study to exclude associated cancer and TB in the  tract.And in that case furhter treatment for the specific disease to be taken up.

Most common complication of surgery is inardverent injury to the anal sphincture making the patient incompetent to hold faecal matter.And the next is recurrance.
So this surgey many times brings down the ranking of the surgeon’s popualrity.People taking non-veg diet and suffering fron constipation are prone for this disease.

                   My patient of Appendicular Lump is recovering from the grave situation.Now the fever has subsided,vomiting reduced and appetite is returning.She was on conservative management.But full oral feed has not been allowed .I think she can take normal diet after another two days.
                          In case she has not improved I would have been forced to discontinue the conservative management in favor of intervention.Now the intervention would have meant drainage of pus from the lump and if possible closing of the stump of the apendix.It could have drawn me to the possible worst complications namely perforation of intestine and damage to the nearby structures.

              But as things improved now I plan to go for an interval appendectomy after a lapse of six weeks.By this time the lump of conglomerated intestines would have resolved exposing the appendix.Adhesion if any would have matured to be safely dissected out .Patient’s general condition must have improved a lot .The infection would have gone.
 Let us hope for the best.

The slender ,hanging structure is appendix

Poor, most of the time bear the brunt of disease aggression.One of the serious complications of appendicitis is appendicular lump.After an acute attack if not treated adequately (without Surgery) body tries to contain the infection.In the process the near by intestine and omentum try to isolate the infected appendix by surrounding it from all the sides and in the process a mass or lump is formed in side the abdomen to be felt from lower abdomen.This may in turn progress to abscess (collection of pus) formation,perforation of apendix and even infection of blood called septicemia.

Infected appendix

These patients are usually treated conservatively as surgery at this stage is riskier. But still if the lump progresses the conservstive treatment is abandoned in favor of intervention (Surgery).Again here it may not be possible for the surgeon to treat for cure of disease .He has to amelorate the potentially grave situation and defer a definitive surgery to a later date.

All these carry risk for the patient.And in this part of India there are poor people who do not have any other option rather than to accept the situation.They come late because of various reasons.One important aspect being their financial status.Initially they they expect this pain in abdomen may not be severe and go away automatically,better to wait rather than to go to a doctor and spend money which is a wastage .That amount can be used to feed themselves.But in the long run when it aggravates they even sell all their property to get treated.
Treatment facilities in terms of man power and infrastructure is lacking in this part .Added to it is the high pricing of drugs and indifferent attitude of Govt. service providing agencies compels the poor to sit at home expecting auto cure , go to quack or indulge in folk remedies.

This grim situation should improve to claim that India is a welfare state.

The thicker slice is the left side and and the separator is the mitral valve.

“It leaves joints and bites the heart” is well said.Rheumatic arthritis has this notorious reputation.Most commonly affects a female of younger age group,usually having a history of long standing throat infection in the past.Bigger joints such as knees,elbows,ankles and hips are affected. Both sides are affected and shifts from one to other.Affected joints are greatly swollen,extremely painful and crippling associated with fever.This arthritis may occur several times to subside even without treatment.This is classified under the group of collagen diseases.The arthritis is diagnosed and confirmed basing on the Jone’s criteria.

After some time, over years it may affect the one way valve of left side of heart which regulates blood flow collected from the lungs after addition of oxygen and removal of carbon dioxide.The valve becomes rigid and narrowed in the course of disease to hamper the easy flow of blood. So swelling of face followed by extremities even abdomen occur with breathlessness and weakness.The patient may not be able to follow his/her day to day pursuits.This is called Mitral Stenosis.

Treatment to the fullest extent of the throat infection in the childhood is most important.Good treatment options are available even in the arthritic stage.Surgical options are available for mitral stenosis but recurrances do occur as well as other complications of surgery.