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When your finger presses down on the edge of a lipoma, the tumor typically slips out from under it. Increased intestinal gas production due to certain foods may cause mild distention. Gas Tumor A large, solid tumor, usually rising out of the pelvis, is dull to percussion. Fat is the most common cause of a protuberant abdomen and is associated with generalized obesity. Tympany Dullness Tympany Umbilicus may be protuberant Dullness Tympany Dullness Bulging flank Pregnancy Ascitic Fluid Ascitic fluid seeks the lowest point in the abdomen, producing bulging flanks that are dull to percussion. Turn the patient onto one side to detect the shift in position of the fluid level (shifting dullness). Arterial bruits with both systolic and diastolic components suggest partial occlusion of the aorta or large arteries. Bowel sounds may be: I Increased, as from diarrhea or early intestinal obstruction I Decreased, then absent, as in adynamic ileus and peritonitis. Before deciding that bowel sounds are absent, sit down and listen where shown for 2 min or even longer. High-pitched tinkling sounds suggest intestinal fluid and air under tension in a dilated bowel. Rushes of high-pitched sounds coinciding with an abdominal cramp indicate intestinal obstruction. It indicates increased collateral circulation between portal and systemic venous systems, as in hepatic cirrhosis. They indicate inflammation of the peritoneal surface of an organ, as from a liver tumor, chlamydial or gonococcal perihepatitis, recent liver biopsy, or splenic infarct. When a systolic bruit accompanies a hepatic friction rub, suspect carcinoma of the liver. When the patient raises head and shoulders, this tenderness persists, whereas tenderness from a deeper lesion (protected by the tightened muscles) decreases. Usually the discomfort is dull and there is no muscular rigidity or rebound tenderness. Tenderness From Disease in the Chest and Pelvis Unilateral or bilateral, upper or lower abdomen Acute Pleurisy Acute Salpingitis Frequently bilateral, the tenderness of acute salpingitis (inflammation of the fallopian tubes) is usually maximal just above the inguinal ligaments. Muscular rigidity and rebound tenderness are frequently but not necessarily present. Generalized peritonitis causes exquisite tenderness throughout the abdomen, together with boardlike muscular rigidity. Local causes of peritoneal inflammation include: Acute Cholecystitis Acute Pancreatitis Signs are maximal in the right upper quadrant. In acute pancreatitis, epigastric tenderness and rebound tenderness are usually present, but the abdominal wall may be soft. Just below the middle of a line joining the umbilicus and the anterior superior iliac spine Right rectal tenderness Acute Appendicitis Acute Diverticulitis Acute diverticulitis most often involves the sigmoid colon and then resembles a left-sided appendicitis. Clinical estimates of liver size should be based on both percussion and palpation, although even then they are far from perfect. Upper border low Elongated right lobe Height by percussion normal Downward Displacement of the Liver by a Low Diaphragm Normal Variations in Liver Shape In some persons, especially those with a lanky build, the liver tends to be somewhat elongated so that its right lobe is easily palpable as it projects downward toward the iliac crest. We can only estimate the upper and lower borders of an organ that has three dimensions and differing shapes. Percussion, however, reveals a low upper edge also, and the vertical span of the liver is normal. The liver is not always enlarged in this condition, however, and many other diseases may produce similar findings. Smooth Large Tender Liver Large Irregular Liver An enlarged liver that is firm or hard and has an irregular edge or surface suggests malignancy.

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These are molecules that play important roles in the life of the cell or intercellular communication. Practical consequences arise from this growing knowledge about the receptors: on the one hand, it aids in the development of antiviral therapeutics designed to inhibit the adsorption of the viruses to their target cells. On the other hand, the genetic information that codes for certain receptors can be implanted into cells or experimental animals, rendering them susceptible to viruses to which they would normally be resistant. An example of this application is the use in experimental studies of transgenic mice rendered susceptible to polioviruses instead of primates. Viruses adsorbed to the cell surface receptors then penetrate into the cell by means of pinocytosis (a process also known as viropexis). In enveloped viruses, the envelope may also fuse with the cell membrane, releasing the virus into the cytoplasm. Adsorption of such an enveloped virus to two cells at the same time may result in cell fusion. The next step, known as uncoating, involves the release of the nucleic acid from the capsid and is apparently (except in the smallpox virus) activated by cellular enzymes, possibly with a contribution from cell membranes as well. The exact mechanism, which would have to include preservation of the nucleic acid in toto, is not known for all viruses. Different processes are observed corresponding to the types and configurations of the viral genome. These enzymes are thus in any case virus-coded proteins, and in some cases are actually components of the virus particle. In this case, the polymerase for the first transcription is contained in the mature virion and delivered into the cell. They therefore once again show the same polarity as the viral genome and are used in assembly of the new viral progeny. An exception to this procedure is the poxviruses, which use their own enzymes to replicate in the cytoplasm. These proteins frequently possess enzymatic properties (polymerases, proteases) and must therefore be produced early on in the replication cycle. A separate nucleic acid segment is present for each protein (example: reoviruses). This process involves proteolytic cutting of the primary translation product into functional subunits. Viral proteases that recognize specific amino acid sequences are responsible for this. In this step, the viral capsid proteins and genomes (present in multiple copies after the replication process) are assembled into new, infectious virus particles. The release of viral progeny in some cases correlates closely with viral maturation, whereby envelopes or components of them are acquired when the particles "bud off" of the cytoplasmic membrane and are expelled from the cell. In nonenveloped viruses, release of viral progeny is realized either by means of lysis of the infected cell or more or less continuous exocytosis of the viral particles. Genetics 7 & Just as in higher life forms, viral genetic material is subject to change by mutation. Furthermore, a potential for recombination of genetic material is also inherent in the replication process, not only material from different viruses but also from host cell and virus. Functional modifications arising from interactions between different viral species in mixed infections-e. Lasting genetic changes in viruses are caused, as in the higher life forms, either by mutation or recombination of genetic material. Temporary nongenetic interactions between viruses in some cases may mimic genetic changes. Mutations are changes in the base sequence of a nucleic acid, resulting in a more or less radical alteration of the resulting protein. So-called "silent mutations" (in the second or third nucleotide of a codon) do not influence the amino acid sequence of the protein. Medically important are mutants with weakened virulence that have retained their antigenicity and replication capabilities intact. The viral replication process includes production of a large number of copies of the viral nucleic acid. In cases where two different viral strains are replicating in the same cell, there is a chance that strand breakage and reunion will lead to new combinations of nucleic acid segments or exchanges of genome segments (influenza), so that the genetic material is redistributed among the viral strains (recombination).

Humans are infected by in haling Chlamydia l aden dust from feathers or dried-out feces. This infection is an occupational hazard for breeders of carrier pigeons, veterinarians, and workers in pet-shops or poultry slaughterhouses. Infection most commonly results in an atypical pneumonia called psittacosis, which occurs 1-3 weeks after exposure. However, Rickettsia differs from Chlamydia in a number of ways: 1) Rickettsia requires an arthropod vector (except for Q fever). Atypical Pneumonia Pneumonia caused by viruses, Mycoplasma pneumo niae, and Chylamydophila species have frequently been called atypical pneumonias because it was felt that they presented clinically and radiographically differ ently from a typical bacterial pneumonia such as that caused by Streptococcus pneumoniae. The classic teach ing is that patients infected with atypical organisms present more often with a dry cough, fever, and are less sick appearing than those infected with "typical organ isms. He rides a tick in Rocky Mountain spotted fever, a louse in epidemic typhus, and a flea in endemic typhus. Some Rickettsia share antigenic characteristics with certain strains of Proteus vulgaris bacteria. The Weil-Felix reaction is a classic test that uses these cross-reacting Proteus vulgaris antigens to help confirm a diagnosis of a rickettsial infection. This test is done by mixing the serum of a patient suspected of having a rickettsial disease, with antigens from specific strains of Proteus vulgaris. If the serum has antirick ettsial antibodies, latex beads coated with Proteus antigens will agglutinate, indicating a positive Weil116 Felix test. Unfortunately the Weil Felix test is neither sensitive nor specific, leading most experts to recommend against its use. Antigenic differences among the Rick Diagnosis of a rickettsial infection can also be made with specific serologic tests documenting a rise in anti Rickettsial antibody titers over time. Therapy for all rickettsial diseases consists primarily of doxycycline and chloramphenicol. Rocky Mountain spotted fever presents within a week after a person is bitten by either the wood tick Dermacentor a ndersoni or the dog tick Der macentor variabilis. This figure illustrates the spotted Rocky Mountains behind a boy with headache, fever, palmar rash, and tick infestation. This disease should be called Appalachian spotted fever, as most cases currently occur in the south Atlantic and south central states such as North Carolina, South Carolina, Tennessee, and Oklahoma. The organisms proliferate in the endothelial lining of small blood vessels and capillaries, causing small hem orrhages and thrombi. Although this disease often resolves in about 3 weeks, it can progress to death (especially when antibiotic therapy is delayed). Since the tick transmits this bacteria during its 6-10 hours of feeding, early discovery and removal of ticks will prevent infection (Spach, 1993). Rickettsia akari causes rickettsialpox and is transmitted to humans via mites that live on house mice. Imagine Ricky, with pox marks, playing Atari (old type of Nintendo) with his rodent friend mit ey mouse. Rickettsialpox is a mild, self-limited, febrile disease that starts with an initial localized red skin bump (papule) at the site of the mite bite. The bump turns into a blister (vesicle) and days later fever and headache develop, and other vesicles appear over the body (similar to chickenpox). Although this disease is self-limiting, there is a dramatic response to doxycycline. Elimina tion of nearby rodents, which can serve as a reservoir for Rickettsia akari, is important in preventing this disease. An e pi d e m ic is the sudden onset and rapid spread of an infection that affects a large proportion of a population. Endemic refers to an infectious disease that exists constantly throughout a population. Rickettsia prowazekii causes an epidemic form, while Rickettsia typhi is responsible for endemic typhus.

When a seronegative test result is confirmed it means that an individual has tested negative for a rheumatoid factor autoantibody. Ankylosing spondylitis may also affect organs, such as the eyes, bowel, and more rarely, the heart and lungs. The presenting symptoms include pain and loss of flexibility in the affected area. Ankylosing spondylitis typically begins in adolescents and young adults, but has lifelong impacts. Approximately, 80% of people who have the disorder develop symptoms before age 30. Factors such as infections or normal bacteria that live in the intestines may trigger the disease in people who are genetically susceptible. Long-term inflammation leads to calcification that causes two or more bones, especially in the spine, to fuse and may be demonstrated by radiography examinations of the affected structures. Conventional, non-contrast radiography may be able to 158 demonstrate changes in the spine and sacroiliac joints that indicate ankylosing spondylitis; however, it may take years of inflammation to cause damage that is visible on the images. Also the condition may affect one organ or body system first and others may become involved later. Radiography indications of infection include cartilage loss, joint effusion, and progressive bone loss. Bone scintigraphy may be requested to illustrate the extent of bone 159 infections. Bone and bone marrow infection caused by blood-borne organisms is common in children and occurs more frequently in boys than girls. In children, the infection is most common in the metaphysis or epiphysis of the long bones and more common in the lower extremity than the upper extremity. The most common organisms include Staphylococcus aureus, gram-negative bacilli, and group B streptococcus. Radiography evidence of osteomyelitic bone changes often take 7 to 14 days to develop. Magnetic resonance imaging and 3-phase bone scan may be used to diagnose acute osteomyelitis. Image detection of sinus tracts and sequestra is also improved after gadolinium administration. A sequestrum is a fragment of necrotic bone that is separate from the living parent bone. A sequestrum may be absorbed, be discharged through a sinus tract, or persist as a focus of infection. It may merge with the parent bone or become perforated with tracts through which pus can escape. A choaca is an opening in the involucrum through which granulation tissue and the sequestra may be discharged. A sinus tract is a channel extending from the bone to the skin surface that is lined with granulation tissue. A Brodie abscess is a bone abscess found characteristically in subacute pyogenic osteomyelitis, but which also may be identified in chronic osteomyelitis. A Brodie abscess typically occurs near the ends of tubular bones and may present as single or multiple lesions, and is especially common in children. On radiography images, a Brodie abscess appears as a well-defined circular or elliptic radiolucency with adjacent sclerosis. The type of surgery depends on which bone is infected and may include drainage of the infected area, removal of diseased bone and tissue, or bone and tissue grafting. Tuberculosis Tuberculosis is an infectious disease caused by the tubercle bacillus. Mycobacterium tuberculosis is pathologically characterized by inflammatory infiltration, formation of tubercles, necrosis, abscesses, fibrosis, and calcification.