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The additional cidal effect of rising diagnostic samples may be taken by resistant order malegra dxt plus no prescription erectile dysfunction drugs class, colonising concentrations of the antibiotic which has concentration- bacteria which obscure the true causative pathogen purchase malegra dxt plus 160mg overnight delivery erectile dysfunction pump rings. It should always be remembered that drugs are seldom the It is inconsistent that the assessment of new antibiotics sole instruments of cure but act together with the natural for therapeutic use is very much more rigorously controlled defences of the body purchase malegra dxt plus with a visa erectile dysfunction at age 30. Antimicrobials may acThat different than is the introduction of diagnostic tests that direct their sites in the target organism, and these are characteristically use – Gluud and Gluud propose a harmonised approach structures or metabolic pathways that differ from those in to the assessment and regulation of new diagnostic pro- the human host – this allows for ‘selective toxicity’: cedures in clinical microbiology. Bacterial multiplication involves breakdown and extension of the cell wall; interference with these pro- 10Gluud C G, Gluud L L 2005 Evidence based diagnostics. British Medical cesses prevents the organism from resisting osmotic Journal 330:724–726 164 Chemotherapy of infections Chapter | 12 | Remove barriers to cure, e. Carriers of pathogenic or resistant organisms should Chronic abscesses or empyemata respond poorly to antibi- not routinely be treated to remove the organisms for it otics alone and require surgical drainage, although chemo- may be better to allow natural re-establishment of a normal therapeutic cover may be essential if surgery is undertaken flora. The potential benefits of clearing carriage must be in order to avoid dissemination of infection during the op- weighed carefully against the inevitable risks of adverse eration. This involves consideration of the Identification of the microbe and performing susceptibility following factors: tests take time, and therapy at least of the more serious • Specificity: indiscriminate use of broad-spectrum drugs infections must usually be started on the basis of the promotes antimicrobial resistance and encourages informed ‘best guess’ (i. The spectrum knowledge of local antimicrobial resistance rates is there- may be narrowed once these are microbiologically fore an essential prerequisite. Choice of antimicrobial follows automatically from the by the most appropriate route(s). Inadequate doses may en- clinical diagnosis because the causative organism is courage the development of microbial resistance. In general, always the same, and is virtually always sensitive to the on grounds of practicability, intermittent dosing is preferred same drug, e. Plasma concentration monitoring (benzylpenicillin), some haemolytic streptococcal can be performed to optimise therapy and reduce adverse infections, e. The infecting organism is identified by the clinical many exceptions to this, such as typhoid fever, tuberculosis diagnosis, but no safe assumption can be made as to its and infective endocarditis, in which relapse is possible long sensitivity to any one antimicrobial, e. A single infecting organism is not identified by the for a longer period determined by comparative or observa- clinical diagnosis, e. In some infections, microbiological proof Knowledge of the likely pathogens (and their current lo- of cure is desirable because disappearance of symptoms cal susceptibility rates to antimicrobials) in the clinical situ- and signs occurs before the organisms are eradicated. Thus co-amoxiclav might be a reasonable first choice This is generally restricted to especially susceptible hosts, for lower urinary tract infection (coliform organisms – e. Confirmatory depending on the prevalence of resistance locally), culture must be done, of course, after withdrawal of and benzylpenicillin for meningitis in the adult (meningo- chemotherapy. The costs of centrations rise in the serum within a few hours of the com- hospital stays and some risks of health-care-associated in- mencementofseriousbacterialinfections,anditappearsthat fections are avoided, but this type of management is clinical decisions on antimicrobial use based on algorithms suitable only when the patient’s clinical state is stable, oral that include the results of such assays may be more accurate, therapy is not suitable, and the infection is amenable to and may spare some patients from antibiotic exposure. Classically, antimicrobials were selected after direct sequently greater risks of antibiotic-associated diarrhoea. These methods are already widely used fibrosis (twice-daily tobramycin), monthly pentamidine for diagnosing meningitis (detecting Neisseria meningitidis, for pneumocystis prophylaxis and zanamivir for influenza Streptococcus pneumoniae and Haemophilus influenzae), A and B (if commenced within 48 h). In addition, there is tuberculosis (including detection of rifampicin resistance) probable benefit for colistin in cystic fibrosis and as an and most viral infections. Modification of treatment can be made later if necessary, Combinations in the light of conventional culture and susceptibility tests. Treatment otherwise should be changed only after ade- Treatment with a single antimicrobial is sufficient for most quate trial, usually 2–3 days, because over-hasty alterations infections. The indications for use of two or more antimi- cause confusion and encourage the emergence of resistant crobials are: organisms. Parenteral therapy (which may (hence the chance of a resistant mutant emerging is be i. Many antibiotics are complicating neutropenia or severe community- well absorbed orally, and the long-held assumption that acquired pneumonia. Attempts to use drugs routinely to prevent infection when a wide and unpredictable range of organisms may Chemoprophylaxis and pre-emptive be involved, e. The basis of effective Attempts routinely to prevent bacterial infection secondary chemoprophylaxis is the use of a drug in a healthy person to virus infections, e. However, the term chemoprophylaxis is com- better to be alert for complications and then to treat them monly extended to include suppression of existing infection. It is essential to know the organisms causing infection and their local resistance patterns, and the period of time the pa- Chemoprophylaxis in surgery tient is at risk. A narrow-spectrum antibiotic regimen should be administered only during this period – ideally for a few The principles governing use of antimicrobials in this con- minutes before until a few hours after the risk period. True prevention of primary infection: rheumatic fever,11 • • When the risk of infection is low but the consequences recurrent urinary tract infection. Note that these are antistaphylococcal prophylaxis for uncomplicated both high-risk situations of short duration; prolonged hernia and breast surgery. Immunocompromised infective endocarditis (see the Guide to further reading patients can benefit from longer-term for illustrative articles). This was based on the lack of convincing • Suppression of existing infection before it causes overt evidence for the efficacy of this time-honoured practice, disease, e. This • Prevention of spread among contacts (in epidemics and/or policy was supported by the subsequent publication of sporadic cases). Recurrent attacks are edge of the likely pathogens at the sites of surgery and their commonly due to infection with different strains of these, all of which are sensitive to penicillin and so chemoprophylaxis is effective. Therefore, chemoprophylaxis is not used (see rectally at the beginning of anaesthesia and for no more also p. A single preoperative dose, given at the time 167 Section | 3 | Infection and inflammation of induction of anaesthesia, has been shown to give opti- have greatness thrust upon them’,12 so microorganisms mal cover for most operations. Resistance may become more prevalent by spread of mi- Specific instances are: croorganisms containing resistance genes, and also by dis- 1. Colorectal surgery: there is a high risk of infection with semination of the resistance genes among different Escherichia coli, Clostridium spp. Gastroduodenal surgery: colonisation of the stomach which can alter the actual diseases suffered by other, un- with gut organisms occurs especially when acid treated individuals. Gynaecological surgery: because the vagina contains Problems of antimicrobial resistance have burgeoned Bacteroides spp. Leg amputation: because there is a risk of gas gangrene in international bodies have been established devoted to an ischaemic limb and the mortality is high the reduction of resistance worldwide: ‘Our mission is (benzylpenicillin, or metronidazole for the patient clear: we must work together to preserve the power of with allergy to penicillin). Insertion of prostheses – joints, heart valves, vessels: their rightful position as effective treatments of disease’ chemoprophylaxis is justified because infection (Dr Stuart Levy, http://www. Others more commonly infect patients in the antibiotics with plasma elimination half-lives of several community, e. General surgery: clearance of Staphylococcus aureus from in hospital but occur also quite commonly in individuals the anterior nares of carriers with mupirocin is known who have never been inpatients. Just as 12Malvolio in Twelfth Night, act 2 scene 5, by William Shakespeare ‘some are born great, some achieve greatness, and some (1564–1616). More is becoming known of the It is to be hoped that our abilities to treat and prevent complex molecular systems which control expression of such infections will continue to increase in parallel with antimicrobial resistance, and this knowledge should soon our abilities to recognise them (laboratory testing method- lead to novel compounds that inhibit resistance mecha- ology also needs to be developed continually because, for nisms at the genetic and phenotypic levels (see Stix13 for example, some of the new coliform beta-lactamases (such an example). Performing ward rounds infections with antibiotic-resistant bacteria are generally on areas of the hospital with high rates of antibiotic use significantly poorer than those with susceptible strains, (e. Some bacteria are innately • Restricting use of antimicrobial combinations to resistant to certain classes of antimicrobial agent, e.

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The extrinsic muscles of the tongue order malegra dxt plus erectile dysfunction treatment comparison, pterygoid residual or recurrent disease after radiation therapy cheap malegra dxt plus 160 mg line erectile dysfunction kits. The largest node is recommended in patients with advanced neck dis- about 4 cm in diameter and is presenThat right level ease (N2 or N3) generic 160 mg malegra dxt plus with amex erectile dysfunction gel. The patient is referred to the radiation oncology de- partment for radiation therapy, and external beam therapy is planned for the primary lesion and the Recommendation neck bilaterally. The tumor bed receives a total dose of 72 Gy in 6 weeks, with 65 Gy in wide field by op- Patient is advised to undergo external beam radia- posing lateral portals and a 7-Gy boost to the tumor tion to the primary lesion as well as the neck, fol- bed by a submental, mandible-sparing portal. Discussion Discussion Most patients with oropharynx carcinoma present with locally advanced tumors with cervical nodal Various modifications to the radiation therapy pro- metastasis. Treatment of carcinoma of the base of tocol are recommended to increase locoregional the tongue is controversial; most patients need to control without added morbidity. Improvement in Case 2 7 disease control rate has been reported with solved and pathological interpretation is more reli- brachytherapy boost. Radical neck dissection, in which all ipsilateral Attempts have been made to use concurrent lymph node groups from level I to V are removed chemotherapy and radiation therapy, a technique along with the sternocleidomastoid muscle, internal found to have improved the loco regional control jugular vein, and accessory nerve. The technique is often associated with tures are removed, as in radical neck dissection, increased short-term and long-term complications, along with preservation of one or more nonlym- and its superiority over radiation therapy alone is phatic structures (i. The patient is evaluated again 2 ease of the base of the tongue is reported to be in the weeks after completion of radiation therapy; there range of about 30% to 50% of patients. Radiation mucositis changes are seen in the oral Among patients who have recurrence, most experi- cavity and minimal edema over the base of the ence it within 2 years; therefore, a regular monthly tongue. A bilateral comprehensive neck dissection follow-up is recommended in the first year, with fol- is planned for the patient after 4 weeks. Bilateral Schobinger’s incision is placed, and skin flaps are elevated in the subplatys- mal plane. The base of the the management of oropharyngeal carcinomas: the Trento ex- perience. Combined surgery The patient has an uneventful postoperative period; and postoperative radiation for carcinoma of the base of tongue. Analysis of treatment outcome and prognostic valve the skin sutures are removed after the 10th postop- of margin status. The pa- vival, and functional outcome after multimodal treatment for advanced-stage tongue base cancer. Head Neck 2004;26(7): tient is discharged after suture removal and is ad- 561–572. Is radiation ther- apy a preferred alternative to surgery for squamous cell carci- noma of the base of tongue? Squamous cell car- cinoma of the oropharynx: surgery, radiation therapy, or The dissection is generally carried out 4 to 6 weeks both. Arch Otolaryngol Head Neck Surg 2002; 128(7): time, the acute radiation reaction would have re- 751–758. He has no sig- nificant past medical or family history and is a non- Differential Diagnosis smoker. On physical examination, the only significant The differential diagnosis for nasopharyngeal masses finding is an enlarged, firm left upper cervical in the adult includes primary nasopharyngeal carci- lymph node measuring 4 3 cm in diameter. The prevalence is highest in Southern China, where as many as 80 (range 10 to 150) cases per 100,000 pop- ulation are reported each year. The prevalence is lowest in North America, western Europe, and Japan (one case per 100,000 population per year), where the disease is linked to tobacco and alcohol use. Tumors limited to the nasopharynx may result in nasal symptoms such as epistaxis or obstruction. As the tumor invades the nearby soft tissues, symptoms such as tinnitus, deafness, and recurrent otitis media result- ing from eustachian tube obstruction may occur. Advanced tumors invading the base of the skull or the infratemporal fossa may lead to headaches or multiple cranial nerve palsies. Histological confir- mation is made primarily via biopsy of the nasopharynx with a fiberoptic nasopharyngoscope. There is inferior not sensitive tools for distinguishing locally recur- extension of the tumor into the oropharynx along rent or residual disease following radical radiother- the left lateral wall. Retropharyngeal rent or residual disease at the nasopharynx, com- and supraclavicular nodes are not enlarged. Diagnosis and Recommendation The following blood tests were performed: According to the American Joint Committee on Thyroid-stimulating hormone (0. Staging of nasopharyngeal carcinoma Testosterone (10–35 nmol/L): 18 nmol/L is based on tumor invasion of the soft tissue (e. Distant metastases tend to involve the lungs, mediastinal nodes, liver, and bony skeleton. Progressive impairment in hypothal- selected cases of locoregional disease recurrence (in amic–pituitary function leading to endocrine dys- discussion section). This bimodality approach is supported by the an atrophic mucosa, and random biopsies of the results of several randomized clinical trials, demon- nasopharynx do not show malignant cells. J Clin Oncol is associated with the presence of residual cancer 1998;16:1310–1317. Concurrent chemotherapy- may also indicate the presence of local or distant radiotherapy compared with radiotherapy alone in locore- relapse. J Clin Oncol 1998; to the adjacent, previously irradiated, normal tissue 16:3550–3555. Retrospective analysis of 5037 nasopharynx that spare the eustachian tubes and patients with nasopharyngeal carcinoma treated during nasal septum, salvage options may include intersti- 1976–1985: overall survival and patterns of failure. Int J Radiat tial brachytherapy using 198Au or nasopharyngec- Oncol Biol Phys 1992;23:261–270. Several surgical approaches are available, classification of tumors of the upper respiratory tract and ear. A including the transcervical, transoral, transpalatal, commentary on the second edition. Significant prognosticators after pri- mary radiotherapy in 903 nondisseminated nasopharyngeal ing approach. Int J Radiat approach, and surgery should be individually tai- Oncol Biol Phys 1996;36:291–304. Epstein-Barr virus detection in nasopharyngeal tissues of patients with suspected nasopha- managed with radical neck dissection. It is usually A 55-year-old teacher presents with hoarseness that associated with active pulmonary tuberculosis. He has a history of smok- hyperemic mucosa involving the posterior third of ing 10 cigarettes per day for around 20 years. Using the larynx or granular exophytic lesions that may the indirect laryngeal mirror and flexible laryngo- mimic carcinoma. It can be obtained during the panendoscopy, which is necessary to evaluate for synchronous cancer. Features on clinical ex- Case Continued amination include erythema of the posterior third Biopsy reveals a well-differentiated invasive squa- of the vocal folds and arytenoids, diffuse edema, mous cell carcinoma.

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Anuria Before diagnosing anuria order malegra dxt plus amex erectile dysfunction pump medicare, make sure that the patient does not have a palpable bladder (if he or she is not catheterised) and is not therefore in acute retention order malegra dxt plus 160mg with amex erectile dysfunction treatment natural way, or order malegra dxt plus with american express erectile dysfunction causes & most effective treatment, if the patient is catheterised, that the catheter is not blocked. As indicated above, anuria is more likely to be a symptom of an obstructive lesion rather than one of renal hypoperfusion or an intrinsic renal lesion. If the patient does not have a catheter in situ, palpate the lower abdomen for a distended bladder associated with acute retention. Palpate the abdomen to exclude swelling of the kidneys and perform a rectal examination to exclude prostatic hypertrophy. The patient will be dyspnoeic due to pulmonary oedema and will either have sacral oedema (if confned to bed) or ankle oedema (if ambulant). The patient will be nauseated, may be vomiting, have hiccups and there may be evidence of gastrointestinal haemorrhage. Urine Physiological oliguria Acute renal failure Specifc gravity >1020 <1010 Osmolality (mmol/kg) >500 <350 Sodium (mmol/l) <15 >40 Urine/serum creatinine >40 <20 Fractional sodium excretiona <1 >2 Renal failure indexb <1 >2 aFractional sodium excretion = (urine sodium × plasma creatinine/plasma sodium × urine creatinine) × 100. Asking the patient to tap the rate and rhythm of the palpitation (on a table for example) can be very informative. However, it PalPitations 371 is vitally important that an organic cause is excluded as it is common for anxiety disorders to co-exist in a patient with supraventricular tachycardia. Exercise is associated with excess catecholamines and also a precipitator of arrhythmia (supraventricular tachycardia, atrial fbrillation and ventricular tachycardia usually originating from the right ventricle). Excessive caffeine, smoking and alcohol intake are also thought to be precipitators of arrhythmia. A history of any underlying heart disorder is important, as arrhythmia is associated with ischaemic heart disease (ventricular arrhythmia), hypertensive heart disease (atrial fbrillation), heart failure (ventricular arrhythmia), heart valve disease. Early age of onset of arrhythmia (childhood or teenage years) suggests the presence of a congenital abnormality such as a bypass tract that can lead to supraventricular tachycardia. Auscultation of the rate at the cardiac apex is more accurate as not all beats are conducted to the pulse (e. It is important to measure the blood pressure and screen for any evidence of underlying structural heart disease, especially mitral valve prolapse (systolic murmur and a systolic click), as this condition is associated with supraventricular tachycardia and atrial fbrillation. It is very unlikely that any arrhythmia can be picked up during this investigation; however, conditions that predispose to arrhythmia may be diagnosed. Also, the presence of left ventricular hypertrophy can indicate underlying structural heart disease (hypertensive heart disease, hypertrophic obstructive cardiomyopathy). Occasionally, atrial or ventricular premature contractions (ectopic beats) may be evident. Upon further investigation, ventricular and atrial premature contractions (ectopic beats) are the most commonly identifed arrhythmia. The majority of surgical conditions of the penis relate to problems with the foreskin and glans and the need for circumcision. The foreskin has been tight since birth and the patient complains that it will not retract over the glans. In children, this may cause ballooning of the foreskin during micturition, with resulting balanoposthitis. The foreskin is pulled back over the glans while washing and then is not returned. In hospital practice, it may occur while the patient is being catheterised and the foreskin is not returned to its correct place following this procedure. The foreskin forms a tight constriction around the glans, interfering with venous return and causing swelling of the glans and foreskin. It may be associated with poor hygiene, but in children it is often associated with phimosis and collection of urine under the foreskin. Balanitis xerotica obliterans The patient will complain of thickening and tightening of the foreskin, and the inability to retract it. Herpes genitalis The patient will complain of painful vesicles on the foreskin or glans penis. Condylomata (warts) The patient may present with warts on the glans and contiguous surface of the prepuce. Penile lesions 375 Trauma There may be a history of trauma, often of an unusual nature. In uncircumcised patients who cannot retract the foreskin, there may be a bloodstained purulent discharge from under the foreskin. Erythroplasia of Queyrat The patient will present having noticed a dark, velvety, red, fat patch on the skin of the glans. Shaft Peyronie’s disease The patient may have noticed a subcutaneous lump along the penis. There may be a history of leukaemia, sickle cell disease, disseminated pelvic malignancy, or the patient may be on haemodialysis. The patient, a baby or child, usually presents with the urethra opening on the dorsal surface of the glans penis. Hypospadias This is more common than epispadias, the patient presenting with the urethral opening on the ventral or undersurface of the penis. In both epispadias and hypospadias, the patient will complain of a problem with micturition. The glans penis is swollen and oedematous and there is a deep groove just proximal to the corona glandis, where there is a tight constricting ring of skin. Balanoposthitis There is infammation of the glans (balanitis) and often associated infammation of the foreskin (posthitis). Balanitis xerotica obliterans The foreskin is thickened, with loss of elasticity and fbrosis. Herpes genitalis Initially, there will be itchy vesicles but these develop into shallow, painful erosions. Condylomata (warts) There will be a bunch of warts, usually around the junction between the foreskin and the glans and extending onto the glans. The inguinal lymph nodes may be affected, either by metastases or by secondary infection. In patients in whom the foreskin cannot be retracted, it may be necessary to carry out circumcision to make the diagnosis. Erythroplasia of Queyrat There is a dark-red, fat, velvety, indurated patch on the glans penis. Penile lesions 377 Shaft Peyronie’s disease There are plaques of fbrosis in the corpora cavernosa. The patient will volunteer the information that the penis becomes bent on erection. In hypospadias, the opening of the urethra may be anywhere along the line of the urethra, from a few millimetres from the tip of the penis to the perineum. In epispadias, which is rare, the urethral opening is on the dorsal surface of the glans penis. Polyuria is arbitrarily defned as urine output of more than three litres in 24 hours. Frequency of micturition (frequent passing of small amounts of urine) should be differentiated from polyuria (frequent passing of large amounts of urine).

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Temporomandibular joint Temporomandibular joint pain dysfunction syndrome results from grinding and clenching the teeth cheap generic malegra dxt plus canada erectile dysfunction drugs nz. Pain arises in the region of the temporomandibular 264 Jaw Pain and SwellingS joint or ear order discount malegra dxt plus on line erectile dysfunction under 35, which may be associated with a clicking noise and is aggravated by wide opening of the mouth cheap malegra dxt plus 160mg line what causes erectile dysfunction cure, as with yawning and chewing. The patient’s mouth remains open and cannot be closed following yawning, tooth extraction or general anaesthesia. The patient presents with an open mouth, which he or she cannot close, and pain due to muscle spasm. If the cyst becomes infected, the patient presents with pain, swelling and discharge. A dental cyst is attached to the root of a normally erupted but decayed tooth; the swelling grows slowly. Neoplastic The patient presents with a jaw swelling which grows steadily and often painlessly. Giant cell granuloma may erode through bone to produce a soft-tissue purplish swelling on the gum. Ameloblastomas usually occur around the age of 30–50 years and are symptomless until the swelling becomes obtrusive. Secondary deposits in the jaw are uncommon but may arise from lung, breast, thyroid, prostate or kidney. Others With post-herpetic neuralgia, there is usually a history of herpes zoster in the distribution of the trigeminal nerve. Pain may involve a large area of the face, rather than just the region of the jaw. The patient usually complains of associated chest pain and radiation of the pain down the left arm. With giant cell arteritis, there will be pain in the jaw on chewing (jaw claudication). In addition, there will be other Jaw Pain and SwellingS 265 symptoms of temporal arteritis, e. With osteonecrosis of the jaw, ask about steroid and bisphosphonate therapy for osteoporosis and past history of radiotherapy. Infective With dental abscesses, there is reddening of the mucosa with a frm, hot, acutely tender, boggy swelling. With acute osteomyelitis, there is usually diffculty in opening the mouth and swallowing due to muscle oedema. In actinomycosis, there may be multiple discharging sinuses, usually near the angle of the jaw, on which characteristic ‘sulphur granules’ may be seen discharging. Temporomandibular joint Diagnosis of temporomandibular joint dysfunction syndrome is usually made from the history. In osteoarthritis, there may be swelling over the joint and limitation of movement. In temporomandibular joint dislocation, the condyles are palpable anterior to the articular eminence. Sometimes the bone is so thin that it crackles when touched, like a broken eggshell. With dentigerous cysts, the tooth remains unerupted and therefore a tooth will be missing when the teeth are counted. Neoplastic Often the only abnormality is a bony swelling, which grows steadily, initially without pain. With giant cell granuloma it may rarely erode through the bone to produce soft-tissue purplish swelling on the gum. Osteogenic sarcoma is initially painless but as it grows, it may loosen the teeth. Other The diagnosis of post-herpetic neuralgia is usually made on the history, as is referred pain from myocardial ischaemia. They may be acute, as in gout or rheumatic fever, or chronic, as in osteoarthritis. The frst part of this section deals with causes of arthropathy in general; the second part deals with disorders of specifc joints. The list of causes of arthropathies is legion and only the more common ones will be mentioned. In Ehlers– Danlos syndrome, a genetic disorder of connective tissue, patients display hypermobile joints and hyperextensible skin. They may present with joint subluxation, dislocation and swelling due to effusions. In Marfan’s syndrome, generalised joint laxity occurs with patients presenting with joint pain and swelling due to effusions. Acquired Infective Septic arthritis usually presents as a monoarthritis with a red, swollen, painful, immobile joint. Spread has usually occurred by the haematogenous route but may occur from adjacent osteomyelitis. Organisms responsible include Staphylococcus aureus streptococci, gonococcus, Brucella and Salmonella spp. Patients on steroids or who are immunosuppressed are particularly at risk from infective arthritis. Viral arthritis may occur with rubella, mumps, hepatitis and certain enteroviruses. There is a migratory polyarthritis, together with carditis, erythematous skin lesions and subcutaneous nodules. Infammatory Rheumatoid arthritis most often presents with swollen, painful, stiff hands and feet. Eventually characteristic hand deformities with swelling of the metacarpophalangeal joints, swan-neck and boutonnière deformities, and ulnar deviation occur. A history of gastrointestinal or genitourinary infection is present with associated urethritis and conjunctivitis. Ankylosing spondylitis most commonly affects young males and initially presents with morning stiffness in the lower spine. Henoch– Schönlein purpura presents with a purpuric rash, often over the buttocks and extensor surfaces. Pain, swelling and stiffness in the joints, usually the ankles and knees, is transient. Degenerative Osteoarthritis usually occurs after the age of 50 years, unless it is secondary to previous joint pathology. The patient complains of pain on movement, worse at the end of the day, together with stiffness and instability of joints. The patient will usually complain of other symptoms, namely enlarged hands and feet (increase in shoe size) and deepening of the voice. Metabolic Gout usually presents with severe pain, redness and swelling in the frst metatarsophalangeal joint; however, any joint may be affected.