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Septic shock High-dose corticosteroid therapy for septic shock has been abandoned man health tips in urdu order generic casodex from india, because it worsens the outcome man health tonic purchase casodex 50 mg mastercard. Recent studies have documented beneficial effects of low-dose (hydrocortisone 100 mg 8 hourly i prostatic hypertrophy order 50mg casodex with visa. Thyroid storm Many patients in thyroid storm have concomitant adrenal insufficiency mens health shoulder workout discount casodex online visa. To test pituitary-adrenal axis function Dexamethasone suppresses pituitary-adrenal axis at doses which do not contribute to steroid metabolites in urine. Responsiveness of the axis can be tested by measuring daily urinary steroid metabolite excretion after dosing with dexamethasone. Fragile skin, purple striae-typically on thighs and lower abdomen, easy bruising, telangiectasis, hirsutism. Muscular weakness: proximal (shoulder, arm, pelvis, thigh) muscles are primarily affected. Susceptibility to infection: this is nonspecific for all types of pathogenic organisms. Latent tuberculosis may flare; opportunistic infections with low grade pathogens (Candida, etc. Peptic ulceration: risk is doubled; bleeding and silent perforation of ulcers may occur. Compression fractures of vertebrae and spontaneous fracture of long bones can occur, especially in the elderly. Radiological evidence of osteoporosis is an indication for withdrawal of corticoid therapy. Corticosteroid induced osteoporosis can be prevented/arrested by calcium supplements + vit D, and by estrogen/raloxifene or androgen replacement therapy in females and males respectively. Avascular necrosis of head of femur, humerous, or knee joint is an occasional abrupt onset complication of high dose corticosteroid therapy. Posterior subcapsular cataract may develop after several years of use, especially in children. Growth retardation: in children occurs even with small doses if given for long periods. Foetal abnormalities: Cleft palate and other defects are produced in animals, but have not been encountered on clinical use in pregnant women. The risk of abortion, stillbirth or neonatal death is not increased, but intrauterine growth retardation can occur after prolonged therapy, and neurological/ behavioral disturbances in the offspring are feared. Prednisolone appears safer than dexa/ beta methasone, because it is metabolized by placenta, reducing foetal exposure. Prolonged corticosteroid therapy during pregnancy increases the risk of gestational diabetes, pregnancy induced hypertension and preeclampsia. Psychiatric disturbances: mild euphoria frequently accompanies high dose steroid treatment. In time, adrenal cortex atrophies and stoppage of exogenous steroid precipitates withdrawal syndrome consisting of malaise, fever, anorexia, nausea, postural hypotension, electrolyte imbalance, weakness, pain in muscles and joints and reactivation of the disease for which they were used. Subjected to stress, these patients may go into acute adrenal insufficiency leading to cardiovascular collapse. If a patient on steroid therapy develops an infection-the steroid should not be discontinued despite its propensity to weaken host defence and delay healing. Surgery is such a patient should be covered by intraoperative and postoperative i. Alternate-day therapy also resulted in less immunological suppression-lower risk of infection. Since corticosteroids may have to be used as a life-saving measure, all of these are relative contraindications in the presence of which these drugs are to be employed only under compelling circumstances and with due precautions. After 4 weeks, the symptoms subsided and prednisolone dose was tapered at the rate of 10 mg every 2 weeks. When she was taking 10 mg prednisolone/ day, she met with a road-side accident and suffered compound fracture of both bones of the right leg. Internal fixation of the fracture and suturing of wounds under general anaesthesia is planned. That testes are responsible for the male characters is known since prehistoric times.

The vulva and anus should be inspected externally and laceration mens health internship buy casodex 50 mg low price, swelling prostate cancer 34 year old cheap casodex 50mg without a prescription, bruising androgen hormone replacement therapy order casodex toronto, bleeding and discharge noted prostate radiation side effects purchase generic casodex on line. Any blood or suspected semen stains anywhere on the body or clothing should be sampled either by the pathologist or by the forensic scientist or scene of crime police officer. The pubic hair should be examined for foreign material, hairs, vegetation and dried seminal stains, and samples of hair and combings taken. The hair may be combed using a fine comb with the base of the teeth packed with cotton-wool to trap any loose fibres. Dried stains on hair may be cut away and placed in clean folded paper in an envelope, or plastic bag for transit to the laboratory. In forcible rapes, especially in young persons, there may be external signs of perineal tears, with laceration of the margin of the vaginal introitus or anus, sometimes causing a complete rip between the two orifices. Caution must be used in interpreting the degree of dilatation of the anus in a dead body, as the sphincter can become patulous and wide open as a normal post-mortem change. Unless the dilatation is very marked, the sole finding of an open anus in the absence of abrasion, bruising, or semen is difficult to sustain as proof of anal penetration. If any fluid is running from the vulva or anus, it should be picked up with clean pipettes and preserved in the smallest available tube, to prevent drying from evaporation. Then cotton-wool swabs on sticks (ensuring that those used for semen detection are plain swabs, not those containing albumin or other media) should be used to take the following samples by touching gently on to the mucosal surfaces: the interior of the vulval labia and around the vaginal orifice the margins and interior of the anus the mid-vagina, using a speculum or broad handle of a dissecting forceps to part the lower vaginal walls gently to allow the swab to reach the area without contamination from the lower vagina the upper vagina, cervix and posterior fornix, again using a spatulate instrument to open the canal to give access to the swab. If more fluid contents are seen higher in the vagina, either now or during the later dissection, they should be recovered by pipette. After samples are taken, the interior of the anus, vulva and vagina, as far as can be seen from the exterior, should be examined. Lacerations, abrasions, bruises and bleeding may be evaluated, though they can be seen in more detail at dissection. Where injuries are gross, especially in children, fistulae between the vagina and the rectum or even peritoneal cavity may be seen. The autopsy incision should be similar to that described for the examination of deaths associated with pregnancy, with an incision circumscribing the perineum, removal of the anterior part of the pelvic bones and the extraction of all the pelvic organs in continuity from ovaries to vulva and anus. Before this is done, the bladder should first be emptied of urine (either by catheter or through a small incision in the fundus) and the fluid retained for toxicological analysis, especially for alcohol. The vagina should be opened with large scissors, the track of the cut depending on the assessment of any injuries seen on external examination. If there are tears or bruises in the vulva or vagina, the cut should be orientated to avoid them wherever possible; the anus is later dealt with in a similar way. The vagina is laid open to the posterior fornix and all injuries carefully examined and photographed. Injuries may be of all types, from mere reddening or swelling to complete disruption of the vaginal canal. This may occur in small children from sheer brutality of penetration, especially if there is gross disproportion between the adult penis and infantile canal. It may also occur from instrumental injury, as it is by no means uncommon for deliberate incised wounds to be made. Vaginal injuries, especially by instrument, may continue up into the abdominal cavity, either via the posterior fornix or lateral vaginal walls. This will have been examined through the abdominal autopsy incision before removal of the pelvic organs. This does not exclude sexual activity short of penetration and technically rape can occur from even the minimal passage of a glans between the labia, which does not affect the hymen. Evidence of previous pregnancy, such as abdominal striae, old damage to the cervix and breast changes are almost incontrovertible evidence of previous sexual intercourse. A recently ruptured hymen, with swelling, a raw unepithelialized edge and bleeding may be found, though admittedly it is relatively uncommon except in children and previously virginal young persons.

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Increasing numbers of cases are being described with positive evidence of a blow on the side of the neck or head and a large fatal subarachnoid haemorrhage man health muscle building fitness casodex 50mg overnight delivery, but with completely intact vertebral arteries androgen hormone knives order 50 mg casodex free shipping. Thus man health tonic purchase cheap casodex on-line, if sudden tilting and rotational forces acting on the upper spine and head can lead to subarachnoid haemorrhage without damage to the vertebral vessels androgen hormone action buy cheap casodex 50 mg on-line, then the causative link is destroyed. Even where vertebral damage is demonstrable, this may be merely a concomitant event, the mechanical forces which primarily led to subarachnoid haemorrhage by direct injury to intracranial vessels also having caused the vertebral artery damage. There may well be a further concomitant effect, in that direct occult brain damage, manifested later by diffuse axonal injury, is the major cause of cerebral dysfunction, both the subarachnoid haemorrhage and the vertebral artery lesion (if there is one) being merely markers of a heavy impact. Occasionally, this is quite obvious and is situated in the intracranial vertebrobasilar vessels. Both these cases arose as a result of trauma to the side of the neck, and both had a massive subarachnoid haemorrhage with no damage to vessels outside the cranium. The demonstration of intracranial bleeding from the vertebrobasilar system is difficult, as the very process of opening the skull at autopsy and removing the brain, however carefully performed, inevitably causes vascular damage. These artefacts cannot be distinguished from original bleeding points due to ante-mortem trauma. The use of post-mortem angiography by the injection of radio-opaque constrast medium into the lower vertebral and carotid arteries has not lived up to its original claims. There is almost always diffuse leakage of contrast medium from apparently artefactual defects, and localization of true 200 Rotational trauma to the head and upper neck bleeding points is often obscured by a haze of contrast opacity. However, occasionally the method reveals a specific leak, usually within the posterior cranial fossa. The original descriptions of and claims for vertebral artery damage as the cause of traumatic subarachnoid haemorrhage were published by Cameron and Mant (1972), Coast and Gee (1984), Contostavlos (1971, 1995), Simonsen (167, 1976) and others. Leadbeatter (1994) drew attention to the problems of a universal cause-and-effect relationship; Contostavlos (1995) refuted these claims, but did not satisfactorily dispose of the concomitant hypothesis. Pathologists, both from their dissection experience and reading of the literature must make up their own minds on the matter, but should make a critical evaluation of the practicality of a massive subarachnoid bleed appearing, sometimes within minutes, from a tiny dissection of a small artery outside the dural membrane. As many pathologists still adhere to the original concept of a subcranial vertebral artery causation for traumatic subarachnoid haemorrhage (and in a small number of instances, the evidence is persuasive), the topic is further pursued here, with the over-riding qualification that most traumatic massive meningeal bleeds are due to intracranial causes consequent upon a tilting, rotatory impact upon the head and/or neck, with or without concomitant damage to a vertebral vessel. Basilar artery Most vulnerable area Foramina in transverse processes C1 C2 C3 C4 C5 C6 Subclavian artery C7 T1 Forensic anatomy the two vertebral arteries arise from each subclavian artery in the region behind the sternoclavicular joints. Each artery ascends behind the common carotid to reach the transverse process of the sixth cervical vertebra. It enters the foramen in that process and passes upwards through each similar foramen until it emerges from the upper edge of the second (axis) vertebrae. The artery then bends laterally and enters the final foramen in the atlas vertebrae. Emerging on the upper surface, the artery bends back and medially around the superior articular process, and penetrates the posterolateral aspect of the atlanto-occipital membrane and the underlying spinal dura and arachnoid, emerging on the lateral side of the spinal canal just below the foramen magnum. Both arteries then ascend and converge on the ventral surface of the medulla and pons to fuse in the midline to become the basilar artery. They arise from the subclavian arteries at the level of the sternoclavicular joints and ascent via the foramina in the transverse process. Autopsy appearances With the caveats expressed earlier, the possibility of vertebral artery trauma, concomitant or otherwise, should always be borne in mind when an external bruise is seen on the side of the neck of the victim of a fatal assault. A blow from a fist, foot or blunt weapon may land in the region between the angle of the jaw to the side of the back of the neck, the area below the ear being the most common place to find an injury. There may be no external sign at all, but on dissection of the neck, a subcutaneous or deep bruise may be found. Unfortunately, this is an area that is not routinely dissected at autopsy, the usual incision for the removal of the neck organs being too far anterior to reveal many of these injuries, which usually lie in the strong neck muscles. No doubt a number of subarachnoid bleeds are due to rupture of non-aneurysmal vessels or to an aneurysm too small to find, but equally, unrecognized head trauma, with or without vertebral artery damage, must have accounted for some of the remainder. In some autopsies, there is no external neck injury and the cause of death is unknown until the cranium is opened, 201 5: Head and spinal injuries and a fresh subarachnoid haemorrhage discovered.

The form of the autopsy report Reports fall into two main types described below androgen hormone jacksonville order casodex 50mg on line, and local practice and indeed legislation may determine which is used androgen hormone 0 discount casodex 50 mg online, irrespective of the wishes of the pathologist prostate kidney stones order casodex 50 mg. This type is usually used in criminal deaths and cases in which litigation is likely androgen hormone imbalance generic casodex 50mg. It has the advantage that any part of the autopsy can be 33 1: the forensic autopsy expanded without constraint; also the form of the report can be turned into a legal statement or a deposition for the court with little alteration. A printed proforma, in which the various sections of the examination and organ systems are already set out by title, leaving blank spaces for the insertion of the findings. One disadvantage is that the spacing prevents flexibility of description unless the proforma is large, when much of the space may be left blank. Also there is rarely enough space at the end of the form for an expansive discussion and opinion about the preceding factual findings. Concentrating upon the more serious cases, the report, whatever the format, must contain certain information in some logical order. Consecutive numeration, computer codings and other administrative aspects are naturally conditioned by local practice, but the following matters must be catered for in all autopsy reports, though not necessarily in this sequence: Full personal details of the deceased subject, unless unidentified. It also justifies his eventual cause of death in those cases where the morphological findings are scanty or even absent, as his conclusions will be strongly influenced by his pre-knowledge of the mode of death. When the autopsy report is converted to a statement or deposition for legal use, this history may be omitted by those legal authorities responsible for transcribing the document. Those handed to other agencies, such as the forensic science laboratory, should be formally identified by means of serial numbers and the name of the person to whom they were handed. The results of further examinations such as histology, microbiology, toxicology and serology. When the main report is issued soon after the autopsy, these will not yet be available and a supplementary report will be necessary. A summary of the lesions displayed by the autopsy (often coded for departmental computer retrieval). An opinion as to the definite or most likely sequence of events leading to the death. A formal cause of death, in the format recommended by the World Health Organization, suitable for the completion of a death certificate. The presence of natural disease such as oedema, abdominal swelling, cutaneous disease, senile changes, etc. Identifying features such as skin colour, tattoos, scars, congenital or acquired deformities, dentures, eye colour and hair colour. The condition of the eyes, including petechiae, arcus senilis, pupil size, and the condition of iris and lens. Condition of mouth and lips, including injuries, teeth and presence of foreign material. The internal examination records all abnormalities, usually in a conventional sequence such as: Cardiovascular system: heart weight, any dilatation, ventricular preponderance, congenital defects, the pericardium, epicardium, endocardium, valves, coronary arteries, myocardium, aorta, other great vessels and peripheral vessels. Gastrointestinal system: mouth, pharynx, oesophagus, peritoneal cavity, omentum, stomach, duodenum, small and large intestine, liver (weight), pancreas, gall bladder and rectum. Genitourinary system: kidneys (weight), ureters, bladder, prostate, uterus, ovaries and testes. Musculoskeletal system: skull, spine, remaining skeleton and musculature where necessary. Central nervous system: scalp, skull, meninges, cerebral vessels, brain (weight), middle ears, venous sinuses and spinal cord (when examined). The timing of the report As with the format, there are two schools of practice in this respect. One advocates the issue of as full a report as possible on the gross findings as soon as the autopsy is completed, usually within a day or two. Obviously this can only be a preliminary, provisional report, as it may have to be modified (sometimes radically) by the results of ancillary investigations that may take days or weeks to return. Virological cultures, for instance, may take up to 6 weeks before a growth can be reported.