chapter 11 gastrointestinal pathologies mosby’s pathology for massage therapists copyright ©...

Chapter 11Chapter 11

Gastrointestinal Gastrointestinal PathologiesPathologies

Mosby’s PATHOLOGYfor Massage Therapists

Copyright © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.

2Copyright © 2010, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.

Lesson 11.1 ObjectivesLesson 11.1 Objectives

Discuss anatomic structures and physiologic Discuss anatomic structures and physiologic processes related to the gastrointestinal processes related to the gastrointestinal system.system.

Define general dysfunctions of the Define general dysfunctions of the gastrointestinal tract and list appropriate gastrointestinal tract and list appropriate massage considerations for each.massage considerations for each.


Classes of NutrientsClasses of Nutrients

CarbohydratesCarbohydrates ProteinsProteins Lipids (fats)Lipids (fats) VitaminsVitamins MineralsMinerals WaterWater


Building Blocks of Nutrients Building Blocks of Nutrients

Carbohydrates – Deconstruct to Carbohydrates – Deconstruct to monosaccharides or simple sugarsmonosaccharides or simple sugars

Proteins – Deconstruct to amino acidsProteins – Deconstruct to amino acids Fats – Deconstruct to glycerol and fatty acidsFats – Deconstruct to glycerol and fatty acids


Gastrointestinal Structures Gastrointestinal Structures

From Thibodeau GA, Patton KT: From Thibodeau GA, Patton KT: The human body in health and disease,The human body in health and disease, ed 4, St. Louis, 2005, Mosby. ed 4, St. Louis, 2005, Mosby.


PeritoneumPeritoneum

From Thibodeau GA, Patton KT: From Thibodeau GA, Patton KT: Anatomy & physiology,Anatomy & physiology, ed 6, St. Louis, 2007, Mosby. ed 6, St. Louis, 2007, Mosby.


Abdominal AreaAbdominal Area

Abdominal quadrants Abdominal quadrants and regionsand regions

From Lewis SL et al: From Lewis SL et al: Medical–surgical nursing,Medical–surgical nursing, ed 7, St. Louis, 2007, Mosby. ed 7, St. Louis, 2007, Mosby.


Digestive FunctionsDigestive Functions

IngestionIngestion SecretionSecretion Mixing and propulsion (peristalsis)Mixing and propulsion (peristalsis) DigestionDigestion AbsorptionAbsorption DefecationDefecation


Digestive ProcessDigestive Process

Begins in the mouthBegins in the mouth Food, now a bolus, moves to the stomachFood, now a bolus, moves to the stomach Stomach grinds and mixes bolus with gastric Stomach grinds and mixes bolus with gastric

juicesjuices Bolus, now chyme, moves to the small Bolus, now chyme, moves to the small

intestineintestine Chyme moves through to the colon for final Chyme moves through to the colon for final

absorption and defecationabsorption and defecation


Digestive Process Digestive Process (cont’d.)(cont’d.)

Liver produces bileLiver produces bile Pancreas produces enzymesPancreas produces enzymes Gallbladder stores excess bileGallbladder stores excess bile

These products enter the small intestine via ductsThese products enter the small intestine via ducts Absorption into blood and lymphAbsorption into blood and lymph Blood circulates nutrients to cells of bodyBlood circulates nutrients to cells of body


General Dysfunctions of GI TractGeneral Dysfunctions of GI Tract

NauseaNausea VomitingVomiting ConstipationConstipation DiarrheaDiarrhea


NauseaNausea

Unpleasant subjective experience often Unpleasant subjective experience often leading to an urge to vomit; often called sick leading to an urge to vomit; often called sick to the stomach, upset stomach, or to the stomach, upset stomach, or queasinessqueasiness

Modify massage according to cause Modify massage according to cause (pregnancy, GI infection); in most cases, use (pregnancy, GI infection); in most cases, use a semireclining position and avoid pressure a semireclining position and avoid pressure and speed that causes rockingand speed that causes rocking


VomitingVomiting

Reflexive, forceful emptying of stomach and Reflexive, forceful emptying of stomach and intestinal contents through the mouthintestinal contents through the mouth

Massage is contraindicated; if vomiting Massage is contraindicated; if vomiting occurs during session, treat vomitus as occurs during session, treat vomitus as infectiousinfectious


ConstipationConstipation

Infrequent or difficult passing of stoolsInfrequent or difficult passing of stools Modify massage according to cause (IBS, Modify massage according to cause (IBS,

diverticulitis); in most cases, apply circular diverticulitis); in most cases, apply circular gliding strokes, kneading and vibration in a gliding strokes, kneading and vibration in a clockwise direction on abdomenclockwise direction on abdomen


Constipation Constipation (cont’d.)(cont’d.)


DiarrheaDiarrhea

Frequent passing of unformed, loose, watery Frequent passing of unformed, loose, watery stoolsstools

Massage is contraindicated in acute cases; Massage is contraindicated in acute cases; chronic cases might entail suggested use of chronic cases might entail suggested use of toilet before massage and avoidance of lower toilet before massage and avoidance of lower abdomenabdomen


Lesson 11.2 ObjectivesLesson 11.2 Objectives

Name various diseases of the upper Name various diseases of the upper gastrointestinal tract and state appropriate gastrointestinal tract and state appropriate massage considerations. massage considerations.

Discuss diseases of the lower gastrointestinal Discuss diseases of the lower gastrointestinal and appropriate massage considerations. and appropriate massage considerations.

Contrast and compare ulcerative colitis with Contrast and compare ulcerative colitis with Crohn disease.Crohn disease.

Explain how to accommodate clients who have Explain how to accommodate clients who have had a colostomy or ileostomy.had a colostomy or ileostomy.


Diseases of the Upper GI TractDiseases of the Upper GI Tract

MumpsMumps ThrushThrush TonsillitisTonsillitis Gastroesophageal reflux diseaseGastroesophageal reflux disease Peptic ulcer diseasePeptic ulcer disease GastritisGastritis GastroenteritisGastroenteritis


MumpsMumps

Viral infection leading to Viral infection leading to enlargement of one or enlargement of one or both parotid glandsboth parotid glands

Massage isMassage is contraindicatedcontraindicated

Courtesy Dr. GDW McKendrik. In Zitelli BJ, Davis HW: Atlas of pediatric physical diagnosis, ed 3, St. Louis, 1997, Mosby.


ThrushThrush

Fungal infection of the Fungal infection of the oral mucosaoral mucosa

Avoid prone position if Avoid prone position if it produces facial pain; it produces facial pain; avoid lower portion of avoid lower portion of face face

From Zitelli BJ, Davis HW: From Zitelli BJ, Davis HW: Atlas of pediatric physical diagnosis,Atlas of pediatric physical diagnosis, ed 4, St. Louis, 2002, Mosby. ed 4, St. Louis, 2002, Mosby.


Tonsillitis, AcuteTonsillitis, Acute

Inflammation of the Inflammation of the tonsilstonsils

Massage isMassage is contraindicatedcontraindicated

From Forbes CD, Jackson WF: From Forbes CD, Jackson WF: A color atlas and text of clinical medicine,A color atlas and text of clinical medicine, London, 1993, Mosby Europe.London, 1993, Mosby Europe.


Gastroesophageal Reflux Gastroesophageal Reflux DiseaseDisease

Periodic regurgitation of gastric contents into Periodic regurgitation of gastric contents into the esophagus; causes heartburnthe esophagus; causes heartburn

Use semireclining position; avoid chest and Use semireclining position; avoid chest and upper abdomen if sensitiveupper abdomen if sensitive


Peptic Ulcer DiseasePeptic Ulcer Disease

Ulcerations of the Ulcerations of the mucosal lining in GI mucosal lining in GI tract exposed to tract exposed to acidic gastric juice acidic gastric juice

Use semireclining Use semireclining position; avoid position; avoid abdomen if sensitiveabdomen if sensitive

From Fletcher CDM, Mckee PH: From Fletcher CDM, Mckee PH: An atlas of gross pathology,An atlas of gross pathology, London, 1987, Gower Medical Publishing.London, 1987, Gower Medical Publishing.


GastritisGastritis

Inflammation of Inflammation of gastric mucosagastric mucosa

Massage is Massage is contraindicated in contraindicated in acute cases; acute cases; otherwise, use otherwise, use semireclining semireclining position and avoid position and avoid abdomenabdomen

From Damjanov I, Linder J: From Damjanov I, Linder J: Pathology: a color atlas,Pathology: a color atlas, St. Louis, 2000, Mosby. St. Louis, 2000, Mosby.


GastroenteritisGastroenteritis

Inflammation of the lining of the gastric and Inflammation of the lining of the gastric and intestinal mucosa; also known as stomach fluintestinal mucosa; also known as stomach flu

Massage is contraindicatedMassage is contraindicated


Diseases of the Lower GI TractDiseases of the Lower GI Tract

PolypsPolyps DiverticulosisDiverticulosis Diverticulitis Diverticulitis Irritable bowel Irritable bowel

syndromesyndrome Ulcerative colitisUlcerative colitis

Crohn diseaseCrohn disease Intestinal obstructionIntestinal obstruction AppendicitisAppendicitis HemorrhoidsHemorrhoids


Polyps, ColorectalPolyps, Colorectal

Benign growths on Benign growths on mucous membranes; mucous membranes; commonly found in coloncommonly found in colon

Avoid abdomen if Avoid abdomen if sensitivesensitive

Courtesy David Bjorkman, M.D., University of Utah School of Courtesy David Bjorkman, M.D., University of Utah School of Medicine, Department of Gastroenterology. In McCance KL, Medicine, Department of Gastroenterology. In McCance KL,

Heuther SE: Heuther SE: Pathophysiology: the biologic basis for disease in Pathophysiology: the biologic basis for disease in adults and children, adults and children, ed 5, St. Louis, 2006, Mosby.ed 5, St. Louis, 2006, Mosby.


DiverticulosisDiverticulosis

Presence of Presence of diverticula diverticula (herniations) in the (herniations) in the colon wall colon wall


From Damjanov I, Linder J: From Damjanov I, Linder J: Pathology: a color atlas,Pathology: a color atlas, St. Louis, 2000, Mosby; St. Louis, 2000, Mosby; and Modified from Stevens A, Lowe J: and Modified from Stevens A, Lowe J: Pathology,Pathology, ed 2, London, 2000, Mosby. ed 2, London, 2000, Mosby.


DiverticulitisDiverticulitis

Infection in the Infection in the diverticuladiverticula

Massage is Massage is contraindicatedcontraindicated

From Frazier MS, Drzymkowski J: From Frazier MS, Drzymkowski J: Essentials of human diseases Essentials of human diseases and conditions,and conditions, ed 3, Philadelphia, 2004, WB Saunders. ed 3, Philadelphia, 2004, WB Saunders.


Irritable Bowel SyndromeIrritable Bowel Syndrome

Abnormal muscular contraction of large Abnormal muscular contraction of large intestine and excessive mucus in stoolsintestine and excessive mucus in stools

Focus on relaxation during massage while Focus on relaxation during massage while avoiding the abdomen if sensitive avoiding the abdomen if sensitive


Ulcerative ColitisUlcerative Colitis Inflammation of the colon; usually begins in the Inflammation of the colon; usually begins in the

rectum and then spread proximally, eventually rectum and then spread proximally, eventually involving the entire coloninvolving the entire colon Periods of remission and exacerbation Periods of remission and exacerbation

Avoid the abdomenAvoid the abdomen

From Cooke RA, Stewart B: From Cooke RA, Stewart B: Colour atlas of anatomical pathology,Colour atlas of anatomical pathology, ed 3, Sydney, 2004, Churchill Livingstone. ed 3, Sydney, 2004, Churchill Livingstone.


Crohn DiseaseCrohn Disease Chronic irritable bowel disease that affects any Chronic irritable bowel disease that affects any

part of GI tractpart of GI tract Characterized by skip lesionsCharacterized by skip lesions Periods of remission and exacerbation Periods of remission and exacerbation

Avoid the abdomenAvoid the abdomen

From Damjanov I: From Damjanov I: Pathology for the health-related professions,Pathology for the health-related professions, ed 2, Philadelphia, 2000, WB Saunders. ed 2, Philadelphia, 2000, WB Saunders.


Ulcerative Colitis vs.Ulcerative Colitis vs.Crohn DiseaseCrohn Disease


Ulcerative Colitis vs.Ulcerative Colitis vs.Crohn Disease Crohn Disease (cont’d.)(cont’d.)


Colostomy and Ileostomy Colostomy and Ileostomy

Colostomy – Incision Colostomy – Incision in colonin colon

Ileostomy – Incision Ileostomy – Incision in small intestine in small intestine (usually the ileum)(usually the ileum)

Both procedures are Both procedures are used to create an used to create an opening that is opening that is affixed to exterior affixed to exterior abdominal wallabdominal wall

From Salvo S: From Salvo S: Massage therapy: principles and practice,Massage therapy: principles and practice, ed 2, Philadelphia, 2003, WB Saunders. ed 2, Philadelphia, 2003, WB Saunders.


Colostomy and Colostomy and IleostomyIleostomy (cont’d.)(cont’d.)

Ask client not eat 2-3 hrs Ask client not eat 2-3 hrs before session before session

Do not apply lubricant on or Do not apply lubricant on or near bag openingnear bag opening

Include use of a side lying Include use of a side lying positionposition

From Salvo S: From Salvo S: Massage therapy: principles and practice,Massage therapy: principles and practice, ed 2, Philadelphia, 2003, WB Saunders. ed 2, Philadelphia, 2003, WB Saunders.


Intestinal ObstructionIntestinal Obstruction

Any blockage of the Any blockage of the intestines; Small intestines; Small intestine most often intestine most often involvedinvolved



Appendicitis, AcuteAppendicitis, Acute

Inflammation of the Inflammation of the vermiform appendixvermiform appendix

Massage isMassage is contraindicated contraindicated

From Gould BE: From Gould BE: Pathophysiology for the health professionsPathophysiology for the health professions, ed 3, St. Louis, 2006, Saunders., ed 3, St. Louis, 2006, Saunders.


HemorrhoidsHemorrhoids

Dilated and inflamed Dilated and inflamed anal or rectal veinsanal or rectal veins

Position client for Position client for comfort; this usually comfort; this usually involves avoiding involves avoiding semireclining and semireclining and seated positions seated positions

From Lewis SM, Heitkemper MM, Dirksen SR: From Lewis SM, Heitkemper MM, Dirksen SR: Medical-surgical nursing: Medical-surgical nursing: assessment and management of clinical problems,assessment and management of clinical problems, ed 7, St. Louis, 2007, Mosby. ed 7, St. Louis, 2007, Mosby.


Lesson 11.3 ObjectivesLesson 11.3 Objectives Identify diseases of the liver, gallbladder, and Identify diseases of the liver, gallbladder, and

pancreas and list appropriate massage pancreas and list appropriate massage considerations.considerations.

Delineate types of viral hepatitis.Delineate types of viral hepatitis. Discuss disorders of nutrient and absorption and Discuss disorders of nutrient and absorption and

include appropriate massage considerations.include appropriate massage considerations. Discuss other gastrointestinal disorders and list Discuss other gastrointestinal disorders and list

appropriate massage considerations.appropriate massage considerations.


Diseases of the Liver, Gallbladder, Diseases of the Liver, Gallbladder, and Pancreasand Pancreas

JaundiceJaundice Viral hepatitisViral hepatitis CirrhosisCirrhosis CholelithiasisCholelithiasis CholecystitisCholecystitis PancreatitisPancreatitis


JaundiceJaundice

Yellowish color of skin Yellowish color of skin and mucosa caused by and mucosa caused by elevated blood bilirubin elevated blood bilirubin levelslevels


From Damjanov I: From Damjanov I: Pathology for the health professionsPathology for the health professions ed 3, ed 3, St. Louis, 2006, Saunders.St. Louis, 2006, Saunders.


Viral HepatitisViral Hepatitis Inflammation of the liverInflammation of the liver Modify massage according to symptoms; avoid Modify massage according to symptoms; avoid

abdomen and deep pressure as client may abdomen and deep pressure as client may bruise easily bruise easily


Types of HepatitisTypes of Hepatitis Modes of transmission:Modes of transmission:

Type A (HAV): oral-fecal contact, contaminated food or Type A (HAV): oral-fecal contact, contaminated food or waterwater

Type B (HBV): sexual contact, blood contact, mother to Type B (HBV): sexual contact, blood contact, mother to baby during birthbaby during birth

Type C (HCV): blood contact, mother to baby during Type C (HCV): blood contact, mother to baby during birthbirth

Type D (HDV): sexual contact, blood contact, mother to Type D (HDV): sexual contact, blood contact, mother to baby during birthbaby during birth


CirrhosisCirrhosis

Progressive disease that Progressive disease that destroys liver cellsdestroys liver cells

Massage is contraindicated in Massage is contraindicated in later stages (indicated by later stages (indicated by jaundice); avoid deep jaundice); avoid deep pressure over abdomen and pressure over abdomen and areas of pitting edema areas of pitting edema

Modified from Fazier MS, Drzymkowski JW: Modified from Fazier MS, Drzymkowski JW: Essentials of human diseases and conditions,Essentials of human diseases and conditions, ed 2, ed 2,

Philadelphia, 2000, WB Saunders.Philadelphia, 2000, WB Saunders.


CholelithiasisCholelithiasis

Formation and Formation and presence of presence of gallstonesgallstones

Massage is Massage is contraindicated if contraindicated if symptoms are symptoms are severe; severe; otherwise, avoid otherwise, avoid abdomen abdomen

A, from Stevens A, Lowe J: A, from Stevens A, Lowe J: Pathology,Pathology, ed 2, London, 2000, Mosby. ed 2, London, 2000, Mosby.


CholecystitisCholecystitis Inflammation of the gallbladder and cystic ductInflammation of the gallbladder and cystic duct Massage is contraindicated in acute cases or if Massage is contraindicated in acute cases or if

fever is present; otherwise, avoid abdomenfever is present; otherwise, avoid abdomen

From Fletcher CDM, Mckee PH: From Fletcher CDM, Mckee PH: An atlas of gross An atlas of gross pathology,pathology, London, 1987, Gower Medical Publishing. London, 1987, Gower Medical Publishing.


PancreatitisPancreatitis

Inflammation of the Inflammation of the pancreaspancreas

Massage is Massage is contraindicated in acute contraindicated in acute cases; otherwise, avoid cases; otherwise, avoid abdomenabdomen

From Damjanov I: From Damjanov I: Pathology for the health-related professions,Pathology for the health-related professions, ed 2, Philadelphia, 2000, WB Saunders. ed 2, Philadelphia, 2000, WB Saunders.


Diseases of Nutrient Intake and Diseases of Nutrient Intake and MalabsorptionMalabsorption

Anorexia nervosaAnorexia nervosa BulimiaBulimia ObesityObesity Celiac diseaseCeliac disease Food poisoningFood poisoning


Anorexia NervosaAnorexia Nervosa

Refusal to maintain normal Refusal to maintain normal body weight for person’s age body weight for person’s age and height; both an eating and and height; both an eating and emotional disorderemotional disorder

Reduce treatment time and Reduce treatment time and pressure if client is fatigued; pressure if client is fatigued; use a warm blanketuse a warm blanket

From Forbes CD, Jackson WF: From Forbes CD, Jackson WF: A color atlas and text of A color atlas and text of clinical medicine,clinical medicine, London,1993, Mosby Europe. London,1993, Mosby Europe.


BulimiaBulimia Continuous eating (bingeing) followed by Continuous eating (bingeing) followed by

recurrent inappropriate compensatory behaviors recurrent inappropriate compensatory behaviors to prevent weight gainto prevent weight gain Primary method is self- induced vomiting called Primary method is self- induced vomiting called

purgingpurging Reduce treatment time and pressure if client is Reduce treatment time and pressure if client is

overly fatigued overly fatigued


ObesityObesity

Increase in the proportion of fat Increase in the proportion of fat cellscells

Body weight is 30% above Body weight is 30% above normal for age, height, frame normal for age, height, frame size, and gendersize, and gender

Associated with leading causes Associated with leading causes of death in U.S.: cardiovascular of death in U.S.: cardiovascular disease, type II diabetes, and disease, type II diabetes, and cancer cancer

From Lemmi FO, Lemmi CAE: Physical assessment findings CD-ROM, Philadelphia, 2000, WB Saunders.From Lemmi FO, Lemmi CAE: Physical assessment findings CD-ROM, Philadelphia, 2000, WB Saunders.


Massaging the Larger ClientMassaging the Larger Client

Lower table or use floor matLower table or use floor mat Use sheet drapingUse sheet draping Avoid deep pressure over Avoid deep pressure over

adipose tissue or over loose adipose tissue or over loose skinskin

From Salvo S: From Salvo S: Massage therapy: principles and practice,Massage therapy: principles and practice, ed 3, St. Louis, 2007, Saunders. ed 3, St. Louis, 2007, Saunders.


Celiac DiseaseCeliac Disease Hypersensitivity to Hypersensitivity to

gluten in dietary grainsgluten in dietary grains Modify massage Modify massage

according to according to symptoms; avoid symptoms; avoid abdomen if sensitiveabdomen if sensitive


Food PoisoningFood Poisoning

Illness resulting from consuming contaminated Illness resulting from consuming contaminated food or beveragesfood or beverages Often due to bacteriaOften due to bacteria

Massage is contraindicatedMassage is contraindicated


Other GI DisordersOther GI Disorders

PeritonitisPeritonitis HerniasHernias

HiatalHiatal UmbilicalUmbilical InguinalInguinal FemoralFemoral


Other GI Disorders: PeritonitisOther GI Disorders: Peritonitis Inflammation of the Inflammation of the

peritoneum peritoneum Massage is contraindicatedMassage is contraindicated

From Frazier MS, Drzymkowski JW: From Frazier MS, Drzymkowski JW: Essentials of Essentials of human diseases and conditions, human diseases and conditions, ed 2, Philadelphia, ed 2, Philadelphia,

2000, WB Saunders.2000, WB Saunders.


HerniasHernias

Protrusion of tissues or organs through Protrusion of tissues or organs through weakness in a membranous or cavity wallweakness in a membranous or cavity wall

Four most common types: hiatal, inguinal, Four most common types: hiatal, inguinal, femoral, umbilicalfemoral, umbilical

From Leonard, PC: From Leonard, PC: Building a medical vocabulary,Building a medical vocabulary, ed 6, Philadelphia, 2005, WB Saunders. ed 6, Philadelphia, 2005, WB Saunders.


Hiatal HerniaHiatal Hernia

Protrusion of upper Protrusion of upper part of the stomach part of the stomach through diaphragmthrough diaphragm


From Redrawn from Price SA, Wilson LM: From Redrawn from Price SA, Wilson LM: Pathophysiology: clinical concepts of disease processes, Pathophysiology: clinical concepts of disease processes, ed 6, St. Louis, 2003, Mosby. In Lewis SL ed 6, St. Louis, 2003, Mosby. In Lewis SL et al: et al: Medical–surgical nursing, Medical–surgical nursing, ed 7, St. Louis, 2007, Mosby.ed 7, St. Louis, 2007, Mosby.


Umbilical HerniaUmbilical Hernia Protrusion of Protrusion of

intraabdominal contents intraabdominal contents through weakness around through weakness around umbilicusumbilicus


A, from Frazier MS, Drzymkowski JW: A, from Frazier MS, Drzymkowski JW: Essentials of human diseases and Essentials of human diseases and conditions, conditions, ed 2, Philadelphia, 2000, WB Saunders; B, from Zitelli BJ, Davis ed 2, Philadelphia, 2000, WB Saunders; B, from Zitelli BJ, Davis

HW: HW: Atlas of pediatric physical diagnosis,Atlas of pediatric physical diagnosis, ed 3, St. Louis, 1997, Mosby. ed 3, St. Louis, 1997, Mosby.


Inguinal HerniaInguinal Hernia

Protrusion of intestine Protrusion of intestine through the inguinal canalthrough the inguinal canal

Massage is Massage is contraindicated if severe contraindicated if severe pain is present; otherwise, pain is present; otherwise, position the client for position the client for comfort comfort

A, from A, Frazier MS, Drzymkowski JW: A, from A, Frazier MS, Drzymkowski JW: Essentials of human diseases and conditions, Essentials of human diseases and conditions, ed 2, Philadelphia, 2000, WB Saunders; ed 2, Philadelphia, 2000, WB Saunders; B, from Zitelli BJ, Davis HW: B, from Zitelli BJ, Davis HW: Atlas of pediatric physical diagnosis,Atlas of pediatric physical diagnosis, ed 3, St. Louis, 1997, Mosby. ed 3, St. Louis, 1997, Mosby.


Femoral HerniaFemoral Hernia

Protrusion of Protrusion of intestine through the intestine through the femoral canalfemoral canal

Massage is Massage is contraindicated if contraindicated if severe pain is severe pain is present; otherwise, present; otherwise, aavoid medial thigh if void medial thigh if sensitivesensitive

From Seidel H: From Seidel H: Mosby’s guide to physical examination,Mosby’s guide to physical examination, ed 5, ed 5, St. Louis, 2003, Mosby.St. Louis, 2003, Mosby.

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