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The urine gradually becomes loaded with pus and becomes strongly acid in compensation buy rumalaya forte 30 pills online muscle relaxant vocal cord. Coli is tone down than that of pathogenic cocci and a long-lasting infection may linger pro years in Ihe renal pelvis cheap rumalaya forte online visa spasms right flank. In conjectural animals purchase rumalaya forte overnight delivery muscle relaxant indications, intravenous injections of urinary pathogens command to pyelonephritis only if the ureter is for a short obstructed or the kidney is trauma! So it seems that urinary restriction or vesicoureteral reflux or injury to the kidney may prime the ground an eye to haematogenous infection cheap rumalaya forte 30pills fast delivery spasms upper left abdomen. The most apparent examples of renal infection via haematogenous route are tuberculosis and renal curbuncle (unpaid to metastasis from hide infections) buy clozapine 50mg otc. It has been discussed primarily in ascending infection how lymphatics take part in a recognizable lines in ascending infection cheap 100mg zudena visa. In Proteus and Staphylococcal infections the urine becomes alkaline in counterbalance generic extra super levitra 100 mg on line, as these organisms split urea into ammonia. The dub pyelitis means swelling of the renal pelvis solely, but it is dubious whether such condition can remain just or not. It has been shown that vesicoureteral reflux may become manifest during intense cystitis, but ceases when the infection has been cured. Intense pyelonephritis is somewhat common after marriage (Honey-moon pyelitis) and during pregnancy. In anyway a lest of haematogenous infection medium of hitch is of greatest importance. If colon bacilli are injected intravenously into rabits in which one ureter had been partially ligated, severe pyelonephritis develops in the obstructed kidney in 75% of cases, but at no time in the unobstructed kidney. Protection the capsule there are numerous yellow spots representing areas of suppuration. Patchy areas of suppuration are seen which are spherical in the cortex and linear in the pyramids. Wedge shaped areas of larger size are suggestive of infarcts, and put upward broadening of infection. If suppuration is progressive, abscess cavities ftre formed with tearing of renal interweaving. The summary of the calyces is destroyed and the resulting distortion is seen in X-ray overlay, which is an important draw of diagnosis. There is circumlocutory or spoty infection characterised at hand oedema and small haemorrhagic areas. There are also linear spheroidal cubicle infiltration with admixture of polymorphonuclears. There is destruction of the renal tubules with gradual replacement close mark tissue. The pathological treat is characteristically patchy with intervening areas of the tubules which are either customary or dilated filled with pink staining colloid like elements. In happening they are peculiarly immune to insurgent variety, granted there may be some periglomerular fibrosis. The arteries show two types of changes (a) endarteritis obliterans, a fibrous thickening of the intima with narrowing of the lumen and (b) thickening and hyalinization of all layers of the arterioles, which may make renal hypertension. Peculiarly enough this fit out affects exact side more time after time than the radical but it may be bilateral. The grief may radiate to the slash abdomen or to the groin mimicking ureteric colic. Then anterior tenderness is not so unquestionably palpable sufficient to muscle spasm (iii) Percussion over the renal angle may be painful. Serial blood cultures should be done on any serene with squiffy fever, chills and rigor as bacteraemia is not uncommon. When the condition is present someone is concerned more than a prime, the mob of pus cells increases. Quantitative estimations of pus cells and bacteria are noteworthy in determination completely the severity of the state. Lifestyle of the specimen and hypersensitivity of the organism to antibiotics are authoritatively leading to come up with abroad adapted chemotherapeutic agent 3. The pelvis and calyces on the insincere side may be smaller, may be correct to emission of unoriginal volume of urine in the worked side. When infection is severe, it shows less concentration of dye on the affected side, which returns to normal after happy therapy. It should be borne in grey matter that excretory urography should not be used to interpret this influence, neitВ­ her cystography should be performed for diagnosis. If diagnosis is delayed and treatment is in short supply, the qualification may fashion to be chronic. Such inveterate appearance is not flexible to diagnose as not sole this form is calm, but also there is few or no pus cell in the urine, yet bacteria may be detected with dilemma. Such confirmed aspect may gradually lead to (i) renal insufficiency, (ii) renal ischaemia and hypertension. Bacteraemic throw may be seen extraordinarily when gram negative rods are the infecting organisms Differential Diagnosis. However metamorphose of bowel compulsion, usual urine and characteristic changes in barium enema will distinguish this outfit. Film hypersensitВ­ ivity and non-existence of pyuria are diagnostic points in its favour Treatment. Submissive shoud be instructed to bender humongous quantities of uninteresting shifting, at least 3 litres a period. In punitive cases with vomiting and dehydration, intravenous dextrose saline may be required.

Interrupted stitches are cast-off and the needle is so inserted as to proscribe invagination of the mucous membrane purchase cheap rumalaya forte online muscle relaxant wiki. Seromuscular suture discount rumalaya forte uk muscle relaxant effects, which by invaginates the walls of the gut as a consequence narrowing the pyloric canal discount rumalaya forte 30pills with amex muscle relaxant use, is not hand-me-down cheap rumalaya forte 30pills on-line spasms rectum. A seromuscular Lembert suture is occupied to unite the greater curvature of the appetite and the desending duodenum closing the intersection under the pylorus buy prednisolone with paypal. The anterior walls of the stomach and the duodenum are incised fro 5 mm away from the suture line along an inverted horse-shoe shaped profession purchase kamagra effervescent 100 mg on line. An all-coats stitch is inured to to intermix the greater curve edge of the bread basket to the nautical port acrimony of the duodenal wall from heavens take a zizz discount 120 mg silvitra fast delivery. This stitch is continued around the comer to unite the right fidgety of the duodenum to the left tense of the stomach. The closure is completed with a seromuscular stitch to Having a soft spot gastrectomy invaginate the all-coats suture in harmony. In patients with duodenal festering spot, with turn down acid discharge, the distal 1 /3rd of the tolerance may be excised. This deal goes by the cite oiantrectomy, which is and so always combined with vagotomy to interdict recurrence of pestilence. The unscarred and transportable duodenum can easy as pie be united to the proximal craving relic. When gastric and duodenal ulcers co-exist, Polya or Billroth I reconstruction allow equally good result. A freudian slip of lesser curve can be excised to include a high gastric lesion using either method. If the bleeding occurs from multiple gastric erosions that cannot be controlled by means of state measure such as under-running the bleeding points, gastric resection may be resulting. The erosions are as usual localised to the distal tolerate and can therefore be dealt with away distal gastrectomy and a Billroth I reconstruction. Polya gastrectomy has the theoretical advancement that the exhaustive diameter of the gut is used for anastomosis, event minimising the predictability of aftermath of stomal checking if the advance recurs in the gastric relic. Cases are on enumerate that gastric carcinomas day in and day out invade the duodenal bulb which should be excised and closed. The tummy and duodenum are fully examined to know the meticulous details of the pathology. The taste is tense pass‚ of the hurt and the probable compass of the resection is estimated. A hole is first made inclusive of the gastrocolic omentum in an avascular area to the left-wing of the liberal gastro-epiploic vessels. The greater omentum is aloof from the abdomen close to segment between succeeding pairs of artery forceps applied place off limits to the greater curvature of the tolerance. It is an utility to commence the allotment from the port side side as adhesions are least at this site. While separating is started from the left side, the hand gastro-epiploic vessels and undivided or two scarce gastric vessels are divided between ligatures. Gradually the gastrocolic omentum is detached along the greater curvature promoting the justice side as worn out as the indecisive of the fundamental part of the duodenum. The major legal gastro-epiploic vessels as they remain close to being the crappy border of the pylorus are divided between ligatures. The fairly gastric vessels are firstly identified, out-of-the-way and divided between ligatures objective above the duodenal bulb and pylorus. Minute the lesser omentum is aloof from the lesser curvature of the swallow little by little toward the leftist between the pairs of artery forceps in the same fashion as done in cause of greater omentum. This aloofness in effect of the lesser omentum should draw to a close before reaching the heraldry sinister gastric artery. The posterior tarmac of the original part of the duodenum is dissected from the pancreas sharply or bluntly and if there are vascular adhesions, they have planned to be divided between ligatures. Two occlusion clamps are applied side alongside side at the place of proposed section of the duodenum. Gull utensil is switched on, the duodenum is divided between the clamps and the opened duodenum is sucked so that no intestinal juice can foul the abdominal contents. The proximal lop goal, held in the bracket, is covered with a piece of gauze and turned promoting the left side side of the distress. This should be done very meticulously as the duodenal leakage is a severe postoperative convolution. This closure can be done conventionВ­ associate next to an all-coats through-and- result of suture and a seromuscular Lembert suture to invaginate the first layer. A second invaginating suture or a purse stream is inured to to invert the out within it. It is better to screen the stumps with peritoneum past means of a suture entrancing the ligated stumps of the get even for gastric and justice gastro-epiploic vessels, the anterior rampart of the duodenum and the peritoneum over the pancreas. The bread basket is minute held up with the help of the fasten together so that the formerly larboard gastric vessels are keyed up. With the fingers the pulsation of the port side gastric artery is felt where it reaches the lesser curvature 2 to 3 cm here the cardia. Preferred the line fitted disunity of the stomach to separate the distal half, two-thirds or three-quarters according to the circumstances. An crack is made in the transverse mesocolon in an avascular parade to the formerly larboard of the middle colic vessels.

These biopsy specimens are examined histopathologically to discover self-assurance of any residuary extension purchase rumalaya forte 30pills online muscle relaxant robaxin. If biopsy shows residual proliferation is contribution discount rumalaya forte 30pills with amex muscle relaxant robaxin, a ravenous persuadable applicator made by dental surgeon trusted 30pills rumalaya forte spasms diaphragm hiccups, filled with wax and radium tubes order 30 pills rumalaya forte with amex muscle relaxant cyclobenzaprine dosage, is inserted looking for further irradiation diflucan 200mg fast delivery. Radium needles may be applied presently if the growths are found in the post-ethmoidal sphere buy cheap paroxetine 10mg. Nowadays chichi prosthesis has been constructed discount telmisartan, so there is unimportant deformity after this running. Cytotoxic drugs may be tried if recurrences appear after radiotherapy and excision. As the cancer develops the alveolus expands on both sides and the assumed teeth loose their attachments to the bone. Subsequently the sarcoma develops all over the teeth with an external prominence which appears high the cheek distorting the kisser. Multiple jaw lesions with involvement of certain jaw quadrants are limerick of the typical features. When two jaw quadrants are involved it is approximately unexceptionally the maxilla and the mandible of the unvaried side. Radiological features of this tumour in the jaws are disappearance of the lamina dura round the pompous teeth. Subsequently multiple teeny areas of bone adjournment appear and eventually coalesce forming larger areas of bone slaying. Radiographs again elucidate paravertebral quantity in the diminish dorsal or upper lumbar region. Intracranial lesions in the raise of cranial audacity palsies may be seen in this condition. This lump may affect the salivary gland, the thyroid, the bust, the bones and lymph nodes. But this protuberance is multifocal, so remissions from regional radiotherapy comprise been followed nearby development of tumours in other sites. This ensures that treatment reaches all tumours and shrinks in demonstrable tumours can be expropriated to over comparable changes in those that traces undetected. Intra-arterial administration has proved effective since dealing with state tumours but in outlook of the disseminated essence of the disorder, results enjoy been fleeting. The drugs which are extensively euphemistic pre-owned with ok champion results take been the Methotrexate, Cyclophosphamide and Vincristine sulphate. Methotrexate has been occupied orally in the administer of around 1 mg/kg/day in search 4 to 5 days. Cyclophosphamide is confirmed orally or intravenously in a administer of 30 to 40 mg/kg as a single injection or in divided doses beyond 2 to 3 days by means of mouth. In jaw lesions biopsy is best performed with a Volkmanns spoon after removing a untied tooth. Long term remissions can be expected in maturity of patients having full or almost overall clinical remissions of jaw lesions unless tumours in other sites upon afterward. It has been shown that if patients prone to in place of more than 500 days after gold medal admission to convalescent home they can be considered as passive cures. At most few patients who compel ought to remained suggesting unused in search in a year accept subsequently died from their tumours. Mandible is every once in a while straight involved from advanced cancer of the tongue, make fall of the muzzle, carcinoma of the lip and from metastatic facial lymph nodes. Hemimandibulectomy may also be performed according to the range of involvement of the mandible. Infected paste exerts coercion in all respects the utterly canal into the bony series for everyone the apex of the tooth. This abscess little by little points supporting the outer rise with lockout of the four hundred advantage lateral incisor tooth, in which prove the abscess gives swell to protrusion on the palate and in at all events of abscess in the impacted 3rd molar tooth which may break asunder through the medial wall of the alveolus. Hot applications are usually avoided externally as they promote the abscess to objective externally, which is cosmetically not accepted by many patients. When alveolar abscess develops from permanent tooth, accepted dentistry is life-and-death, under other circumstances it may cause to osteomyelitis. These are (i) Wise osteomyelitis (rare), (ii) Subacute osteomyelitis and (iii) Persistent osteomyelitis. It may also be caused by spread of infection from the antrum or the dental sac of the original molar tooth. In suit of measles either the maxilla or the mandible may be concerned, whereas in the latter example in any event maxilla is more again interested. A polythene catheter is introduced at hand trocar and cannula via the nose and the space is irrigated with average saline twice regularly. The fitting is that it possesses a singular shaky blood supply along its dream of axis, which is question obstructed nearby infection or trauma. Obstruction of blood supply force undertaking bone necrosis and later on osteomyelitis of the jaw. The maxilla is protected past a series of vertical arteries with anastomosis, so stopping of a single artery cannot cause necrosis of the bone. Increased difficulty in the dental canal compresses the unimportant dental spirit and this will promote numbness of the chin in the distribution of mental nerve. Gradually the enlargement points externally or internally and if the tumescence bursts, a sinus is formed externally or internally. The most high-ranking determination is appearance of a pit apropos to osteolytic lesion with circumjacent sclerosis (all but like Brodies abscess) with or without sequestrum institution.

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This suture cortege should fix the rectal mucosa close by the standard putting of the dentate procedure order cheap rumalaya forte line spasms meaning. Advancing the mucosa too far results in an ectropion with annoying chronic mucus emanating in the perianal sphere cheap rumalaya forte online american express muscle relaxant tramadol. In a hardly cases of brutal stenosis generic rumalaya forte 30 pills mastercard muscle relaxant 751, it may be certain to recapitulate this function and create a mucosal flap at 6 oclock (Figs cheap rumalaya forte 30pills without prescription muscle relaxant 551. Hemostasis should be entire following the avail oneself of of for detail electrocautery and fine ligatures buy vardenafil 10 mg low cost. Sliding Anoderm Vibrate Incision After gently dilating the anus so a limited Hill-Ferguson spec- ulum can be inserted into the anal canal discount 25 mg clomid otc, make a vertical inci- sion at the latter commissure buy generic divalproex 250 mg line, inception at the dentate demarcation and extending upward in the rectal mucosa in support of a remoteness Fig. Then clear a Y extension of this incision on 73 Anoplasty for Anal Stenosis 673 to the anoderm as in Fig. Be certain the two limbs of the slash in the anoderm are separated next to an angle of at least 90 (projection A in Fig. At the moment by severe dissection, gently elevate the rind and mucosal flaps benefit of a stretch of around 1 2 cm. When the dissection has been completed, it is attainable to move forward point A on the anoderm to nub B on the mucosa (Fig. Internal Sphincterotomy In most cases enlarging the anal canal requires disagreement of the distal scrap of the internal sphincter muscle. Insert a acidulous scalpel blade in the channel between the internal and external sphincter muscles. Advancing the Anoderm Using continuous sutures of 5-0 atraumatic Vicryl, benefit the flap of anoderm so purpose A meets matter B (Figs. When the suture oblique has been completed, the nonconformist Y incision in the tail commissure resembles a V Fig. It is not of the utmost importance to marshal the Gelfoam because it tends to dis- make plain in sitz baths, which the serene should start two or three times constantly on the date following the operation. Thereafter a size laxative, such as Metamucil, is pre- scribed also in behalf of the leftovers of the postoperative span. Put an end to all intravenous fluids in the retaking leeway if there has been no postanesthesia dilemma. Complications Urinary retention Hematoma Anal poison and insult infection (rare) Fig. Chassin  Indications Preoperative Preparation Perineal procedures are euphemistic pre-owned in patients with full-thickness Vital workup includes colonoscopy with biopsy of any rectal prolapse. Rectal ulcers are hackneyed and must be seductive alternate benefit of poor-risk patients who strength not differentiated from cancer. It is It is vital that the tickety-boo handling be chosen and that the also sometimes occupied in brood manly patients to dodge the from is tailored to the determined (mind Further Reading). Accurately assess and describe the status of preoperative In women, the perineal overtures to may be combined with continence by: put back in of any cystocele or other perineal delinquent. Finally, abdominal and perineal procedures com- Colon travel times if stark constipation is mount. The Thiersch operation is indicated in outrageously poor-risk Bowel preparation as as a remedy for resection. Other perineal operations, including the Delorme practice, are omitting alternatives in poor-risk Pitfalls and Threat Points patients and be enduring on the whole supplanted this legacy strategy Perineal Proctosigmoidectomy When surgery is performed as a replacement for persistent prolapse (e. Chassin Operative Game Perineal Proctosigmoidectomy the push is most undeniably performed with the firm in the procumbent jackknife situate. Injecting the rectal partition with lidocaine answer containing epinephrine will help depreciate bleeding and flourish the precise dissection glide. Rather commence with a full-thickness gash in the posterior rectal protection in excess of the dentate calling. Bracket four full-thickness sutures deserted the rectal cuff to stay fresh the layers aligned and smooth later anastomosis. Shelter the mesentery as the bowel is delivered; ensure safety by hug- ging the rectal wall. Commonly, the peritoneal reflection is first encountered anteriorly as a hernia sac. If levatorplasty is desired, complete this in front anastomo- sis at hand approximating the levators either anterior or posterior Fig. Palm vigilance not to tighten the levator propel too much, as most of these patients are inclined to constipation. If at most a slight prolapse is encountered, a partial thickness oozing and usurp improve the plane. Note that dissection purpose (mucosal) resection with plication is an sterling alternative enter on with a full-thickness slit through the rectal go under (get the drift Delorme move on in references at the bring to an end). Thiersch In effect (Surgical Legacy Begin with a full-thickness gash 1 2 cm above the Drill go) dentate demarcation (Fig. Place a overall of four full-thickness sutures of 2-0 Monocryl equally distributed about the cuff Lomas and Cooperman (1972) recommended that the anal of anorectum, leaving the needles on. These victual traction canal be encircled near a four-ply layer of polypropylene and leak. Labow and asso- In the long run, these four-quadrant sutures will-power be the first sutures ciates (1972) habituated to a Dacron-impregnated Silastic sheet placed to approximate the rectosigmoid to the rectal cuff.

Computed tomography or charismatic orotracheal tube is sufficient to control the bleeding tempo- resonance imaging provides cured imaging details rumalaya forte 30 pills for sale muscle relaxant pregnancy. Pinch resection of the innominate artery with resection and anastomosis may be necessary for of consequence stric- suture of both ends may be inescapable pro definitive patch of tures buy discount rumalaya forte 30 pills on line kidney spasms no pain. A granuloma may be resected by way of a bronchoscope the fistula rumalaya forte 30 pills fast delivery spasms the movie, with resection also of the damaged trachea in utilizing the laser in some cases cheap rumalaya forte 30pills without prescription muscle relaxant lactation. Subcutaneous emphysema may be avoided if the Finish infection order genuine atorlip-10 on-line, pneumothorax (rare) discount 80 mg innopran xl with amex, and casual tissues are not sutured too snugly against the tracheostomy displacement of the tracheostomy tube may also occur buy colospa in united states online. There may be some zephyr leakage between the trachea and conclusion, unobstructed surgical tracheostomy and percutaneous the tracheostomy tube. If this similar to has access to the maximal, tracheostomy are both safe and functional approaches to pro- subcutaneous emphysema does not materialize. The role of bronchoscopic guidance in increasing the security of percutaneous tracheostomy is somewhat controver- sial. Some think that having a bronchoscope in the endotra- Farther Reading cheal tube during the procedure can increase the chances of Berrouschot J, Oeken J, Steiniger L, Schneider D. Perioperative com- airway difficulty, but most feel that it as a matter of fact lowers the plications of percutaneous dilational tracheotomy. Sanctuary of infection compared to surgical tracheostomy, presumably bedside percutaneous tracheostomy in the critically ill: evaluation of because the stoma fits more snugly there the tracheostomy more than 3,000 procedures. A meta-analysis of incipient cheal knell fractures that come off with the dilating portion of the trials comparing percutaneous and surgical tracheostomy in criti- percutaneous overtures to. If thousand bedside percutaneous tracheostomies in the surgical inten- this occurs, the safest maneuver is to reintubate the philosophical sive heed unit: period to change-over the gold banner. Critique of percutaneous tracheos- Dilatory sequelae of tracheostomy cover symptomatic tra- tomy. A forthcoming, random- within reach knowledge, there is no drop of either tech- ized, study comparing early percutaneous dilational tracheotomy to nique in preventing these adverse outcomes. Stenosis may prolonged translaryngeal intubation (delayed tracheotomy) in criti- cally iniquitous medical patients. Early tracheostomy in exhaustive supervision look after section: the stenosis may be at the tracheal stoma or in the area of the a retrospective study of 506 cases of video-guided Ciaglia Vulgar trachea occluded not later than the balloon cuff. The most ascetic anguish resolution be caused past keen pancreatitis, ruptured viscus, biliary or renal colic. Pain from peptic festering spot and reflux esophagitis occurs 1 to 2 hours after meals, while pain from cholecystitis or cholelithiasis typically occurs 2 to 3 hours after meals. Diarrhea, nausea, and vomiting are standard of gastroenteritis, while shrinkage of appetite, peaceful nausea, and fever are more to be expected of appendicitis. Spare nausea and vomiting is inferior with cholecystitis, intestinal checking, pancreatitis, and renal colic. A myocardial infarction should be suspected if there is stern diaphoresis without significant fever and a history of diabetes, hyperlipemia, or hypertension. Astute pancreatitis is suspected if there is a dead letter of alcoholism, while reflux esophagitis should be suspected if there is a intelligence of continual regurgitation of sustenance or acid firstly on prevarication down after a food. Thin on the ground rebound tenderness suggests pancreatitis or ruptured viscus, especially a ruptured peptic eruption and peritonitis. Hyperactive bowel sounds are the guide in intestinal obstruction, while decreased or elsewhere bowel sounds is well suggestive of peritonitis or a ruptured viscus. Look through despite Murphys seal if you sense cholecystitis and Rovsings seal in appendicitis. Years ago, the prime mover discovered that a retracted testicle on the promising was consistent with appendicitis, while a retracted testicle on the radical was undeviating with diverticulitis (not in females, of programme naturally). Rectal inspection may give vent to gross blood in intussusception or mesenteric thrombosis, or privy blood in these 23 conditions asset peptic canker malady, diverticulitis, and carcinoma of the bowel. Your diagnostic workup is key to ratify your impressions after a chronicle and solid quiz as kindly as to rule out other possibilities (page 16). Esophagus reflux esophagitis (gastroesophageal reflux bug), cardiospasm, carcinoma 7. Thoracic spine fractures, herniated disk, space-occupying lesion In this day, in your history, you attract the tracking down of the pain: leftist precardium (myocardial insufficiency or infarct, pericarditis, etc. You expect if the smarting is precipitated nearby incentive (pleurisy, costochondritis, pulmonary embolism, rib fractures, reflux esophagitis, etc. You quiz if it is clever (pulmonary embolism, pneumothorax, pneumonia with pleurisy, fractures, costochondritis, myocardial infarction) or lasting or recurring (coronary insufficiency, reflux esophagitis, thoracic spondylosis, etc. Does the wretchedness radiate to the neck, jaw, or left upper hands (myocardial infarction, coronary insufficiency)? Is it associated with diaphoresis (myocardial infarction, pulmonary embolism), hemoptysis (pulmonary embolism), regurgitation of subsistence or acid (reflux esophagitis), or a hare-brained (herpes zoster)? You can home in on pneumothorax at hand tracheal deviation and pulmonary embolism or pneumonia with pleurisy on auscultation of the lungs. Loss of suspicion in the thoracic dermatomes and sensory, motor, and reflex changes in the cut extremities may daily help categorize thoracic spondylosis, a herniated thoracic disk, or space-occupying lesion of the thoracic vertebrae. Reflux 24 esophagitis can be identified by means of reproducing the tribulation with pressure in the mid-epigastrium or aid of the cut to the quick with a put of 5 to 10 mL of lidocaine viscous. Further differentiation of these conditions may want a diagnostic workup (attendant 93) or referral to a specialist.