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A nulligravida is one who is not pregnant now but may have had a pregnancy before b kamagra gold 100mg for sale erectile dysfunction and testosterone injections. Gravida denotes a pregnant state order generic kamagra gold from india erectile dysfunction at 55, both present and past purchase kamagra gold with a visa erectile dysfunction treatment centers, irrespective of period of gestation Q. During contraction, the transverse diameter of the uterus is reduced but the longitudinal diameter increases d. The baby is put flat or at 15° head down position with the face turned to one side b. Measurement of brachial artery pressure reflects the pressure in the uterine artery d. Visualization of internal cervical os is more accurate with transabdominal than with transvaginal sonography b. It helps sperm transport to the fallopian tube from the vagina within two minutes (hypermotility) Q. Distal parts of the obliterated umbilical arteries form superior vesical arteries b. Disproportionate increase in relative brain size b Disproportionate increase in relative liver size c. Architecture of maternal bony pelvis is extremely important to understand the mechanism of labor and to assess the success of the vaginal delivery. Articulated pelvis is composed of four bones— innominate bones–2, the sacrum and the coccyx. There are four joints that unite the four bones—sacroiliac joints–2, symphysis pubis in front and the sacrococcygeal joint posteriorly and inferiorly. Anatomically the pelvis is divided into: False pelvis: The part that lies above the pelvic brim. Brim of the pelvis (inlet): The important landmarks on the brim of the pelvis from anterior to posterior on each side are (Figs 4. This plane extends from the lower border of the symphysis pubis to the tip of ischial spine and posteriorly it extends upto the tip of 5th sacral verterbra. Station of the presenting part is expressed in either – or + in relation to this plane. Based upon the shape of the inlet (brim), the female pelvis is divided into four parent types: � Gynecoid (50%) � Anthropoid (25%) � Android (20%) � Platypelloid (5%). It is the distance between the lower border of the symphysis pubis and the midpoint on the sacral promontory. Two fingers of gloved right hand are introduced into the vagina along the sacral curvature to reach the sacral promontory. The radial border of the fingers are then mobilized underneath the symphysis pubis and a mark is made over the gloved index finger. The distance between the marking and the tip of the middle finger is the measurement of diagonal conjugate. The anterior superior iliac spine and the pubic tubercle are in the same vertical plane. Clinically it is measured by placing the four knuckles of the clinched fist placed between the two ischial tuberosities. The apex of the anterior triangle (Urogenital) is formed by the inferior border of the pubic arch. Mention the different engaging diameters of the skull that come into play from the attitude of complete flexion to complete extension. Suboccipitofrontal—extends from the nape 10 cm (4") Incomplete Vertex of the neck to the anterior end of the anterior flexion fontanelle or center of the sinciput 3. Mentovertical—extends from the mid- point 14 cm (5½") Partial Brow of the chin to the highest point on the extension sagittal suture 5. On the basis of the shape of the inlet, female pelvis is divided into four parent types: A. It is the series of movements that occur in the fetal head in the process of adaptation during its journey through the pelvis. What are the principal movements that occur on the fetal head during the course of labor (mechanism of labor)? The cardinal movements are: (1) Engagement: Biparietal diameter passes through the pelvic brim. In a primigravida, engagement usually occurs before the onset of labor, whereas in a multigravida the same may occur during the course of labor. The uterine contraction force is directed downward and the forces exerted by the pelvic and perineal floor muscles are upward and forward. Labor is the series of changes that take place in the genital organs in an effort to expel the viable fetus from the womb to the outside world through the vagina. Labor begins when the uterine contractions are of sufficient frequency, intensity and duration to cause progressive effacement and dilatation of the cervix. Delivery is the process of expulsion or extraction of a viable fetus out of the womb. Delivery can take place without labor as in elective cesarean delivery (abdominal). Normal labor fulfills the following criteria: (1) spontaneous onset of term, (2) fetus with vertex presentation, (3) without undue prolongation of labor, (4) spontaneous delivery with minimal aids, and (5) without any complications. The true labor pains are characterized by: (i) Painful uterine contractions (labor pains) at regular intervals. Stages of labor are total three: First stage begins with onset of true labor pains and ends with full dilatation of the cervix (10 cm). Second stage begins with full dilatation of the cervix and ends with delivery of the fetus—duration is 2 hours in a primi and 30 minutes in a multi. Third stage begins after the delivery of the fetus and ends with the delivery of the placenta and the membranes. In a normal labor, the uterine contractions should have adequate: (a) frequency (3–4 contractions every 10 minutes), (b) duration (30–40 seconds for each contraction) and (c) intensity to increase intrauterine pressure. Intensity is considered good when clinically uterine wall cannot be indented by the fingers. The first stage is divided into two phases: (a) Latent phase: It is of variable duration during which cervix becomes pliable and effaced. During the active phase, the uterine contractions become regular in terms of frequency, intensity and duration. Phase 1—quiescence till the end of pregnancy due to the effects of progesterone, prostacycline and relaxin. Phase 2—preparation for labor; Phase 3—active labor process (3 clinical stages); Phase 4—involution (puerperium). Three major changes (events) are: (i) Effacement of the cervix (ii) Dilatation of the cervix (iii) Formation of the lower uterine segment Q. Changes are due to the attachment of the longitudinal muscle fibers of the uterus to the circular muscle fibers of the lower uterine segment and upper part of the cervix.

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Various tion discount kamagra gold generic icd 9 code erectile dysfunction due diabetes, which can demonstrate enhancement on terms are used to describe this granulomatous imaging (Fig buy generic kamagra gold 100 mg line discussing erectile dysfunction doctor. The presence of hemostatic reaction order 100mg kamagra gold mastercard erectile dysfunction pills south africa, such as textilomas, gossypibomas, gau- material at the site of the lesion on baseline imag- zomas, surgicelomas, and muslinomas. Large craniectomy defects predispose to the development of sunken skin fap syndrome, Sunken skin fap syndrome (syndrome of the tre- and brain atrophy accentuates the degree of con- phined) is an uncommon, late complication of cavity. This condition is certainly not cosmeti- craniectomy, usually occurring 1 month after sur- cally pleasing and may even compromise cerebral gery. Furthermore, along with headache, the scalp fap and brain deformity at the site of fatigue, and seizure, sunken skin faps may be a craniectomy (Fig. These out- be atmospheric pressure that exceeds intracranial comes often improve following cranioplasty. There is no associated brain herniation 4 Imaging the Postoperative Scalp and Cranium 175 4. Although some degree of brain expan- sion is expected after craniectomy, extension of brain tissue beyond 1. Extracranial cerebral herniation is more likely to occur with small craniectomy defects. This can produce a characteristic “mush- room cap” appearance of the deformed brain tis- sue (Fig. Extracranial herniation can also lead to venous infarcts sec- ondary to cortical vein compression. This risk of substantial external brain herniation is lower with larger craniectomies. Alternatively, intracranial contents can herniate Although mild remodeling of the bone fap edges through the defects. These patients can ben- This is a delayed complication that occurs in eft from artifcial cranioplasty, and high-resolu- 6–12% of cases. Neurosurgery 58(1):112–119; discussion cated scalp and calvarial defects: report of a series of 112–119 cases and literature review. South Med J 83(2):220–223 Sharony Z, Rissin Y, Ullmann Y (2009) Postburn scalp reconstruction using a self-flling osmotic tissue expander. J Oral Maxillofac Surg 64(1):12–22 Hierner R, van Loon J, Goffn J, van Calenbergh F (2007) Free latissimus dorsi fap transfer for subtotal scalp and cranium defect reconstruction: report of 7 cases. Eplasty 11:e4 (2011) Free-fap reconstruction of the scalp: donor Cumberland L, Dana A, Liegeois N (2009) Mohs micro- selection and outcome. J Craniomaxillofac Surg graphic surgery for the management of nonmelanoma 22(3):974–977 skin cancers. J Biomed Mater Res B Appl Biomater Breakey W, Abela C, Evans R, Jeelani O, Britto J, 83(2):580–588 Hayward R, Dunaway D (2015) Hypertelorism correc- tion with facial bipartition and box osteotomy: does soft tissue translation correlate with bony movement? J Neurosurg 115(3):570–575 subdural tissue reaction and absorption study of absorb- able hemostatic devices. Neurosurgery Transcranial migration of microfxation plates and 59(2):433–434; discussion E433–E4334 screws. J Neurosurg 99(3):484–488 absorbable topical hemostatic agents on the relaxation time of blood: an in vitro study with implications for postoperative magnetic resonance imaging. Plast Reconstr Surg 135(6): Prefabricated prostheses for the reconstruction of skull 1665–1672. Aarabi B, Chesler D, Maulucci C, Blacklock T, Alexander Ann Maxillofac Surg 2(1):4–7. M (2009) Dynamics of subdural hygroma following decompressive craniectomy: a comparative study. Childs doxical herniation, and external brain tamponade: a Nerv Syst 21(2):144–147 review of decompressive craniectomy management. Clin Oncol (R Coll Radiol) Expansile cranioplasty for massive occipital encepha- 12(2):118–120 locele. J Neurosurg after burr-hole evacuation for the treatment of chronic 97(4):821–826 subdural haematoma in adults. Eur J Anaesthesiol Suppl 42:192–195 Joseph V, Reilly P (2009) Syndrome of the trephined. J Clin Neurosci hematoma: a 5-year survey and identifcation of 15(3):305–307 avoidable risk factors. Neurosurgery 35(6):1061– Tokoro K, Chiba Y, Tsubone K (1989) Late infection after 1064; discussion 1064–1065 cranioplasty-review of 14 cases. Serial post- to resection of the tumor, as well as intracranial contrast T1-weighted images can be useful for pressure changes that result from craniotomy and depicting residual enhancing tumor. Hyperacute Laser interstitial thermal therapy comprises intraparenchymal hemorrhage typically appears various minimally invasive procedures that are as isointense to the surrounding parenchyma increasingly used to treat selected brain tumors, on T1-weighted sequences, but hyperintense neuropsychiatric disorders, and epileptogenic on T2-weighted sequences due to the presence foci. Some of these fnd- low T1 and high T2 signal due to edema with ings are exemplifed in subsequent sections of rim enhancement, which eventually transforms this chapter. Faint enhancement along the mar- obtained after the frst resection attempt shows a punctate gins of the resection cavity represents contrast leakage focus of nodular enhancement in the medial resection bed (arrowheads) 186 D. The hemostatic agent in the extradural space images obtained at the end of right frontal lobe tumor along the right frontal convexity surgical bed displays resection show a small left parietal convexity subdural high T1 and T2 signal (arrowheads) Fig. Axial size of the enhancing tumor 5 Imaging the Intraoperative and Postoperative Brain 189 5. Although off-target dure that is commonly performed to obtain tissue biopsy can yield tumor cells if the lesion is an samples of intracranial lesions. Hemorrhage is infltrative tumor, the grade may be underesti- one of the most common fndings after stereotac- mated. Ideally, biopsy of the enhancing portion of tic brain biopsy, occurring in up to 9% of cases. Rather, such fndings path is often encountered on early postoperative serve to delineate the path of the biopsy needle imaging as an incidental fnding that typically and can help account for new neurological defcits resolves within a couple of months (Fig. The patient experienced new right-sided abducens palsy after right transfrontal biopsy of a medulla lesion. Follow-up coronal (arrow) 5 Imaging the Intraoperative and Postoperative Brain 191 5. The as cranial nerves or major arteries, can limit the resection cavity is often lined or packed with extent of tumor resection. Ultimately, products, especially during the early postopera- there is often a trade-off between removing as tive period (Fig. Oftentimes, resection much tumor as possible versus preserving as cavities eventually shrink and collapse, becom- much normal tissue and avoiding complications. Variable amounts of tumor may remain adja- Surgically induced parenchymal injury, post- cent to the cavity depending on whether gross operative hemorrhage, and enhancing conditions total, near-total, or subtotal resection was per- related to brain tumor surgery and adjunctive formed. The extent of tumor resection depends treatments are discussed in the following sections. Furthermore, this phenomenon can involved, the contralateral olivary nucleus is lead to overestimation of residual non-enhancing affected. Thus, bilateral hypertrophic olivary tumor volume due to the presence of swelling and degeneration results from disruption of the cen- high signal on T2-weighted sequences during the tral tegmental tract and superior cerebellar early postoperative period.

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The right main stem bronchus lies are responsible for inspiration; expiration is gener- in a more vertical orientation relative to the trachea order kamagra gold in india erectile dysfunction under 35, ally passive discount kamagra gold 100 mg overnight delivery erectile dysfunction doctor lexington ky. With increasing efort purchase discount kamagra gold on-line erectile dysfunction questions and answers, the sternoclei- whereas the lef main stem bronchus lies in a more domastoid, scalene, and pectoralis muscles can be horizontal orientation. The sternocleidomas- chus continues as the bronchus intermedius afer toid muscles assist in elevating the rib cage, whereas the take-of of the right upper lobe bronchus. The the scalene muscles prevent inward displacement distance from the tracheal carina to the take-of of of the upper ribs during inspiration. Expiration is normally every 250 individuals in the general population may passive in the supine position, but becomes active have an abnormal take-of of the right upper lobe in the upright position and with increased efort. The lef main stem bronchus is muscles (rectus abdominis, external and internal longer than the right main stem bronchus and mea- oblique, and transversus) and perhaps the internal sures an average of 5. Tonic and functions of the upper airway (nose, mouth, and refex inspiratory activity in the genioglossus keeps pharynx). The function of the tracheobronchial the tongue away from the posterior pharyngeal wall. Tonic activity in the levator palati, tensor palati, pal- Dichotomous division (each branch dividing into atopharyngeus, and palatoglossus prevents the sof two smaller branches), starting with the trachea and palate from falling back against the posterior phar- ending in alveolar sacs, is estimated to involve 23 ynx, particularly in the supine position. An estimated 300 million alveoli provide an The trachea serves as a conduit for ventilation enormous membrane (50–100 m2) for gas exchange 1 and the clearance of tracheal and bronchial in the average adult. The trachea begins at the lower border of With each successive division, the mucosal epi- the cricoid cartilage and extends to the level of the thelium and supporting structures of the airways carina and has an average length of 10–13 cm. The mucosa makes a gradual composed of C-shaped cartilaginous rings, which transition from ciliated columnar to cuboidal and form the anterior and lateral walls of the trachea and fnally to fat alveolar epithelium. Gas exchange are connected posteriorly by the membranous wall can occur only across the fat epithelium, which of the trachea. The external diameters of the trachea begins to appear on respiratory bronchioles (gen- measure approximately 2. Loss of cartilaginous lage is the narrowest part of the trachea, with an aver- support causes the patency of smaller airways to age diameter of 17 mm in men and 13 mm in women. The tracheal lumen airway diameter becomes dependent on total lung narrows slightly as it progresses toward the carina, volume. The pulmonary interstitial space contains the mucus produced by the secretory glands lining mainly elastin, collagen, and perhaps nerve fbers. Alveolar size is a function of both gravity and lung The pulmonary epithelium contains at least two volume. Tese tight tion, the largest alveoli are at the pulmonary apex, junctions are important in preventing the passage whereas the smallest tend to be at the base. With of large oncotically active molecules such as albu- inspiration, discrepancies in alveolar size diminish. The walls of each alveolus because of their shape occupy less than 10% of the are asymmetrically arranged (Figure 23–2). On the alveolar space), are round cells that contain promi- thin side, where gas exchange occurs, the alveolar nent cytoplasmic inclusions (lamellar bodies). Tese epithelium and capillary endothelium are separated inclusions contain surfactant, an important sub- only by their respective cellular and basement mem- stance necessary for normal pulmonary mechanics branes; on the thick side, where fuid and solute (see below). Tey are blood fow (ie, less than 4% of the cardiac out- also resistant to O2 toxicity. Branches of the bronchial artery supply the Other cell types present in the lower airways wall of the bronchi and follow the airways as far include pulmonary alveolar macrophages, mast as the terminal bronchioles. Neutrophils are also nary arterial circulation and continue as far as the typically present in smokers and patients with acute alveolar duct. Pulmonary Circulation & Lymphatics carried by the bronchial arteries enters the pulmo- The lungs are supplied by two circulations, pul- nary circulation. The bronchial circula- The pulmonary circulation normally receives tion arises from the lef heart and sustains the the total output of the right heart via the pulmonary metabolic needs of the tracheobronchial tree. The artery, which divides into right and lef branches bronchial circulation provides a small amount of to supply each lung. The oxygenated Lymphatic channels in the lung originate in the blood is then returned to the lef heart by four main interstitial spaces of large septa and are close to the pulmonary veins (two from each lung). Bronchial lymphatics return fu- fows through the systemic and pulmonary circula- ids, lost proteins, and various cells that have escaped tions are equal, the lower pulmonary vascular resis- in the peribronchovascular interstitium into the tance results in pulmonary vascular pressures that blood circulation, thus ensuring homeostasis and are one-sixth of those in the systemic circulation; permitting lung function. Because of the large endo- as a result, both pulmonary arteries and veins nor- thelial junctions, pulmonary lymph has a relatively mally have thinner walls than systemic vessels with high protein content, and total pulmonary lymph less smooth muscle. Large lymphatic T ere are connections between the bronchial vessels travel upward alongside the airways, form- and the pulmonary circulations. The importance of the bronchial circulation in contributing to the normal venous admixture is 4. The diaphragm is innervated by the phrenic nerves, which arise from the C3–C5 nerve roots. Unilateral Pulmonary Capillaries phrenic nerve block or palsy only modestly reduces Pulmonary capillaries are incorporated into the most indices of pulmonary function (about 25%) in walls of alveoli. Although bilateral phrenic nerve illaries (about 10 µm) is barely enough to allow palsies produce more severe impairment, accessory passage of a single red cell. Because each capillary muscle activity may maintain adequate ventilation network supplies more than one alveolus, blood in some patients. Intercostal muscles are innervated may pass through several alveoli before reaching by their respective thoracic nerve roots. Because of the relatively low cord injuries above C5 are incompatible with spon- pressure in the pulmonary circulation, the amount taneous ventilation because both phrenic and inter- of blood fowing through a given capillary network costal nerves are afected. Large The vagus nerves provide sensory innervation alveoli have a smaller capillary cross-sectional area to the tracheobronchial tree. Sympathetic activity (T1–T4) medi- tively large junctions (5 nm wide), allowing the pas- ates bronchodilation and also decreases secretions sage of large molecules such as albumin. Circulating macrophages and neutrophils are Both α- and β-adrenergic receptors are present able to pass through the endothelium, as well as the in the pulmonary vasculature, but the sympathetic smaller alveolar epithelial junctions, with relative system normally has little efect on pulmonary ease. Parasympathetic to prevent bacterial infection and to scavenge for- vasodilatory activity seems to be mediated via the eign particles. During mechanical ventilation, they are produced by inter- the expiratory phase of the ventilator, the positive mittent positive pressure in the upper airway. The pressure The movement of the lungs is passive and deter- within alveoli is always greater than the surrounding mined by the impedance of the respiratory system, (intrathoracic) pressure unless the alveoli are col- which can be divided into the elastic resistance of lapsed. Alveolar pressure is normally atmospheric tissues and the gas–liquid interface and the nonelas- (zero for reference) at end-inspiration and end- tic resistance to gas fow. By convention in pulmonary physiology, lung volume and the associated pressures under pleural pressure is used as a measure of intrathoracic static conditions (no gas fow). Although it may not be entirely correct to relates to frictional resistance to airfow and tissue refer to the pressure in a potential space, the concept deformation. The work necessary to overcome elas- allows the calculation of transpulmonary pressure. P transpulmonary= Palveolar − Pintrapleural At end-expiration, intrapleural pressure nor- 1. Elastic Resistance mally averages about –5 cm H2O, and because alveo- Both the lungs and the chest have elastic proper- lar pressure is 0 (no fow), transpulmonary pressure ties.

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The resting position of both feet can be inspected and internal rotation due to femoral anteversion may be apparent discount 100mg kamagra gold overnight delivery erectile dysfunction dx code. Neurological examination The mask-like facies and resting pill-rolling tremor of Parkinson’s disease may be apparent on inspection order kamagra gold 100 mg fast delivery erectile dysfunction enlarged prostate, and examination of the limbs will reveal cogwheel or lead pipe rigidity order generic kamagra gold on line erectile dysfunction doctors in richmond va. Patients with cerebellar disease will exhibit an intention tremor when performing the fnger–nose test; in addition to their broad-based ataxic gait, they may also exhibit nystagmus, dysdiadochokinesia and dysarthria. With frontal lobe disorders, primitive refexes such as the grasping (the hand of the examiner is grasped when placed or stroked along the patient’s palm), sucking (sucking action is produced on stroking on side of the mouth) and palmomental refexes (gentle stroke of the thenar eminence produces dimpling of the chin) are released. Examination of the sensory system may reveal loss of light touch, vibration and proprioception in a glove and stocking distribution with peripheral neuropathy. Unilateral upper motor neurone weakness, hyperrefexia and clasp knife rigidity are features of cortical strokes. Specifc examination Once the diagnosis of a gait disorder is made, a specifc examination is now undertaken to determine the underlying aetiology. For example, with apraxic gait due to frontal lobe disorder, a mental state examination is performed to screen for dementia, and fundoscopy is performed to screen for papilloedema, which may be indicative of raised intracranial pressure from a brain tumour. It can result from physiological causes such as puberty (due to increased demand for thyroid hormone) which require no treatment, to frank malignant disease requiring urgent diagnosis and treatment. This condition, caused by iodine defciency, is extremely common in isolated mountainous regions. The thyroid may reach enormous size yet the symptoms are minimal and the patient is usually euthyroid. Where the condition is endemic (often in isolated mountainous regions such as Nepal), iodine defciency is the usual cause. The usual presentation is a lump in the neck, which moves on swallowing, but with a very large gland, the patient may complain of dyspnoea or dysphagia. He or she may indicate a preference for cold weather, and may also complain of excessive sweating, tiredness, anxiety, increased appetite, weight loss, diarrhoea, palpitations and tremor. Eventually, the patient becomes hypothyroid, and will complain of intolerance to cold weather, tiredness, a change in voice (hoarseness), weight gain, constipation, dry skin and dry hair. Papillary carcinoma occurs in the younger patient (under 35 years) and, in addition to the goitre, the patient may have noticed lymph node swelling in the neck. Lymphoma of the thyroid is rare and may develop in pre-existing autoimmune (Hashimoto’s) thyroiditis. Infammatory (rare) The patient may present with a painful swelling of the thyroid associated with malaise or myalgia (de Quervain’s thyroiditis). A hard mass associated with dysphagia or dyspnoea may suggest Riedel’s thyroiditis. Where the condition is endemic, the goiters are often asymmetrical and soft to palpation. They are composed of many large hyperplastic nodules and can reach enormous size (Fig. Occasionally only one nodule may be felt – the dominant nodule in a multinodular goitre. Check for tracheal deviation when the gland is large, and percuss for retrosternal extension. Toxic goitre Palpation of the gland may reveal a diffuse goitre, a multinodular goitre or a solitary nodule. These signs include Goitre 179 a pale, waxy skin, periorbital oedema, dry thickened skin and hair, slow pulse, large tongue, peripheral oedema and slow relaxing refexes. Neoplastic goitre There may be a solitary thyroid nodule (papillary carcinoma) or a more diffuse mass (follicular carcinoma). Cervical lymphadenopathy may be present with a papillary carcinoma, when the glands are usually mobile and discrete, and is invariably associated with anaplastic carcinoma, where the glands may be hard and matted. Check for recurrent laryngeal nerve palsy – has the patient got a hoarse voice or is unable to produce an occlusive cough? In Riedel’s thyroiditis, there is a woody, hard goitre, which infltrates into adjacent muscle. Hernias A patient with a groin hernia will present with a lump that disappears on recumbency or may be pushed back (reducible). The patient may present with a tense, tender lump that will not reduce and is accompanied by signs and symptoms of intestinal obstruction. With hernias, there is occasionally a history of sudden straining or trauma, following which a lump may become manifest. Imperfectly descended testis An imperfectly descended testis may present as a groin swelling. The patient, or, if in a young child, the mother, will have noticed absence of a testis from the scrotum. Enlargement and pain may indicate malignant change, which is more common in an imperfectly descended testis. Hydrocele of the cord This may present as a lump in the inguinal region which does not reduce. Hydrocele of the canal of Nuck This is similar to a hydrocele of the spermatic cord but presents in the female. Care must be taken to elicit a full history with inguinal lymphadenopathy, as the nodes drain not only the tissues of the leg but also the penis, the scrotal skin, the lower half of the anal canal, the skin of the buttock and the skin of the lower abdominal wall, up to and including the umbilicus. In the female, they drain the labia, the lower third of the vagina and the fundus of the uterus, via lymphatics accompanying the round ligament down the inguinal canal. Saphena varix A saphena varix is normally associated with varicose veins lower down the leg. The patient will present having noticed a small, soft, bluish mass in the lower part of the groin. Check for a history of arterial surgery at the groin or arteriography via the femoral artery, which may suggest the presence of a false aneurysm. Imperfectly descended testis An imperfectly descended testis may descend into the upper thigh but its descent is arrested by the attachment of Scarpa’s fascia to the deep fascia of the thigh. Neuroma of the femoral nerve This is rare and may be associated with anaesthesia or paraesthesia on the anterior aspect of the thigh and inability to extend the knee. The patient complains of a lump deep in the groin, which may interfere with hip movement. The sac passes through the obturator canal and may present in the groin deep to pectineus. They may be distinguished from hernias, in that they are not reducible and do not have a cough impulse. Irreducible hernias may be: (1) incarcerated – imprisoned in the sac because of adhesions between contents and the wall of the sac; (2) obstructed – small bowel is caught in the sac and intestinal contents cannot pass on; (3) strangulated – the arterial blood supply is cut-off and gangrene of the contents ensues. In the last case, the lump would be tender, the overlying skin may be red and the patient will be pyrexial with a tachycardia.