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Test the patient’s abduction by having the patient abduct the arm against resistance (Photo 5) singulair 10mg with visa. This tests the middle portion of the deltoid, which is innervated by the axillary nerve (C5–C6); and the supraspina- tus, which is innervated by the suprascapular nerve (C5–C6). Therefore, it is important to test abduction by resisting the movement throughout its range of motion (or at least to 90°). Test the patient’s adduction by having the patient adduct the upper arm against resistance (Photo 6). This tests the patient’s pectoralis major, which is innervated by the medial and lateral anterior thoracic nerves (C5–T1); the latissimus dorsi, which is innervated by the thoracodorsal 24 Musculoskeletal Diagnosis Photo 6. Test the patient’s external rotation by having the patient externally rotate the arm against resistance (Photo 7). This tests the infraspinatus muscle, which is innervated by the suprascapular nerve (C5–C6); and the teres minor, which is innervated by the axillary nerve (C5). Test the patient’s internal rotation by having the patient internally rotate against resistance (Photo 8). This tests the patient’s subscapularis muscle, which is innervated by the upper and lower subscapular nerves (C5–C6); the pectoralis major muscle, which is innervated by the medial and lateral anterior thoracic nerves (C5–T1); the latissimus dorsi, which is innervated by the thoracodorsal nerve (C6–C8); and the teres major, which is innervated by the lower subscapular nerve (C5–C6). Test the patient’s scapular elevation by having the patient shrug his or her shoulders against resistance (Photo 9). This tests the patient’s trapezius—which is innervated by the spinal accessory nerve (cranial nerve XI)—and the levator scapulae—which is innervated by branches of the dorsal scapular nerve (C5). It is possible, although not routinely done, to test the patient’s scapular retraction by having the patient stand “at attention” by throw- ing the shoulders back against the examiner’s resistance. The examiner should provide resistance in this instance by trying to bend the patient’s shoulders forward. This tests the patient’s rhomboid major and minor muscles, both of which are innervated by the dorsal scapu- lar nerve (C5). Test for scapular protraction by having the patient push with two hands against a wall (Photo 10). This tests the patient’s serratus ante- rior muscle, which is innervated by the long thoracic nerve (C5–C7).

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The patient is fasted for 12 hours prior to examination cheap 4mg singulair overnight delivery, although they may take small sips of clear fluids. Any antispasmodic drugs should be withheld for 24 hours prior to examination. If not already in situ, a nasogastric tube is passed and advanced into the fourth part of the duodenum. The position of the tube is checked under fluoroscopic control prior to the administration of contrast. Dilute barium sulphate is administered rapidly through the nasogastric tube and monitored under fluoroscopic control. Localised fluoro- scopic and full-length images are taken as required to demonstrate the anatomy of the small bowel. During the withdrawal of the nasogastric tube, the contrast agent is aspirated to decrease the risk of inhalation20. When examining very young infants, water-soluble contrast agents should be used in preference to barium suspensions. The small bowel enema examination is contraindicated if the child is unwill- ing or unable to co-operate, as compliance is essential for a successful study. The patient should refrain from eating or drinking for 4 hours post-examination or until the effects of the sedation have worn off and the guardian should be warned that the child may subsequently have diarrhoea. Barium enema There is no specific physical preparation for the barium enema examination for babies less than 1 year old, patients suffering from Hirschprung’s disease or those with active colitis. For all other patients, the colon should be cleared of faecal matter and this can be achieved with a low residue diet and administra- tion of a mild laxative for up to 48 hours prior to the examination. It is impor- tant that young children are well hydrated and encouraged to drink plenty of fluids before and after the examination. Children over the age of 5 years may be fasted for 12 hours prior to the examination but should be given the earliest avail- able morning appointment to minimise inconvenience and distress.

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Left upper quadrant pain that a positive heterophil antibody (monospot) test generic 5mg singulair visa. Ten radiates to the left shoulder (Kehr’s sign) suggests percent of IM sufferers will have a negative monospot splenic rupture and demands immediate medical (Bailey, 1994) in which case EBV serology should be attention (McDonald, 1997). Approximately 25% of affected individuals occur in the absence of significant physical exertion, will also have GABHS pharyngitis (Bailey, 1994). CHAPTER 31 INFECTIOUS DISEASE AND THE ATHLETE 179 If indicated by the algorithm in Fig. Regular exer- and Metreweli, 1998) every two weeks can be useful, cise is associated with slower progression to AIDS especially in athletes at the extremes of body habitus. ACUTE DIARRHEA Documented sports transmission of HIV is exceed- ingly rare. The risk of HIV transmission in profes- Diarrhea is >3 loose stools a day for up to 7 days sional football is estimated at one in 85 million game (Mayer and Wanke, 1999) and is most often caused by contacts (Feller and Flanigan, 1997). Other causes to consider include In 1995, the American Medical Society for Sports hyperthyroidism, inflammatory bowel disease, bacte- Medicine (AMSSM) and the American Academy of rial colitis, and antibiotic-induced colitis. Sports Medicine (AASM) stated that mandatory HIV The history should focus on travel, hobbies, animal con- testing should not be a requirement for competitive tacts, antibiotic usage, dietary habits, and ill contacts. Exercise during maximum 16 mg a day), and bismuth subsalicylate such an infection does not alter its length or severity (262 mg, 2 qid prn). Other respiratory viruses, such patients who are toxic, febrile, or are having bloody as influenza virus (Blair et al, 1976; O’Connor et al, diarrhea. Lomotil contains atropine and causes anti- 1979), however, have been shown to impair pul- cholinergic side effects (Fenton, 2000). If symptoms worsen, the workout should orally qid) for 10–14 days (Gilbert, Moellering, and end and the athlete should rest until symptoms Sande, 2002). Exercise should be delayed until below the neck symptoms have resolved (Eichner, 1993). First, training lymphocyte, CD4, and CD8 counts or the CD4:CD8 with below the neck symptoms hampers the workout ratio (Terry, Sprinz and Ribeiro, 1999).

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J Trauma 51: 714–6 Posttraumatic deformities: Persisting volar tilts after meta- 10 generic 5mg singulair overnight delivery. Kensinger DR, Guille JT, Horn BD, Herman MJ (2001) The stubbed tarsal or phalangeal fractures can hinder walking. Varus great toe: importance of early recognition and treatment of and valgus deformities and rotational defects can result in open fractures of the distal phalanx. Leibner ED, Simanovsky N, Abu-Sneinah K, Nyska M, Porat S the problem of overlapping toes. J Detecting a threatened or established compartment Pediatr Orthop 10: 68–72 syndrome requires considerable alertness on the part of 12. Mora S, Thordarson DB, Zionts LE (2001) Pediatric calcaneal frac- the examiner, particularly in patients presenting with tures. Foot Ankle Int 22: 471–7 only slight forefoot swelling initially directly after a crush 13. Owen RJ, Hickey FG, Finlay DB (1995) A study of metatarsal frac- tures in children. Phan VC, Wroten E, Yngve DA (2002) Foot progression angle after in a below-knee cast and elevation with close, clinical distal tibial physeal fractures. Rammelt S, Zwipp H, Gavlik JM (2000) Avascular necrosis after Avascular necrosis is observed in 15–20% of childhood minimally displaced talus fractures in a child. Foot Ankle Int 21: talar neck fractures, even including undisplaced fractures. Vienne P, Schöttle P (2003) Die chronische Rückfußinstabilität: Failure to spot the injury initially and an age of under neue Konzepte in der Diagnostik und in der chirurgischen Be- 9 years are risk factors. Schweiz Z Sportmed Sporttraumatol 51: 107–11 radiological displacement on the trauma x-rays does not rule out the possibility of shifting during the trauma fol- lowed by spontaneous reduction, the risk of a circulatory impairment is not reduced. Osteomyelitis occurs after trivialized open fractures of the great toe that have received inadequate initial treat- ment. Etiology, frequency and site The foot is typically susceptible to exogenous infec- Infections of the foot and ankle have their own distinctive tions, e. The circula- for example) or if congenital or acquired sensory dis- tion is poorer and the temperature lower than in other orders are present in the lower limbs.