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Also bacteria helpful to humans buy cefpodoxime 200 mg on line, there may be loosening of teeth at the site of the fistula and spontaneous hemorrhage from the mouth Radiographically: Peripheral nothing unless radiopaque material injected antibiotic stewardship buy cefpodoxime 100mg with mastercard. An aneurysmal bone cyst may result from an overzealous attempt at repair in bone marrow Clinically: Progressive swelling of the jaw that may be associated with pain or tenderness antibiotic for skin infection cefpodoxime 200mg with visa. As the lesion increases in size antibiotic with steroid discount 100mg cefpodoxime free shipping, there is marked expansion and thinning of the cortex bacteria water test order generic cefpodoxime on line, resulting in a ballooning that distends the jaw Differential diagnosis: central myxoma, giant-cell lesion, odontogenic cysts or tumors. They are benign, congenital tumors that may occur in the region near the pituitary gland, in the submaxillary region and in the sex glands, particularly the ovary. Many contain teeth, which permits a fairly reliable diagnosis to be made from the radiographic examination alone. Primary as well as permanent teeth may be present but are smaller than normal and jawbones may be seen as small rudimentary fragments. In rare instances the tumor may arise with in the jaws from cell rests remaining from the enamel organ and sheath of Hertwig Radiographically: Early stage often N. Any ulcerated growth of the soft tissue beneath which there is radiographic evidence of destruction of bone should be suspected of being malignant. Differential diagnosis: simulates severe infection osteomyelitis Carcinomas that occur in the jaws as a result of metastases from lesions elsewhere most often arise in the central portion of the jaws, because red bone marrow appears to be the most frequent site of metastases to bone. The first evidence of metastasis may be radiographic signs of an osteolytic lesion in a jaw that, appears clinically to be normal. The lesions in the mandible may cause parasthesia of the lip; when this symptom is present, one should suspect that the lesion is malignant 2. Either the maxilla or the mandible may be involved; the molar-premolar area is the usual site. Central lesions appear twice as frequently in women as in men, and the average age at diagnosis is 46 years Radiographically: A multilocular radiolucency similar to ameloblastoma; however, wide variations occur. Nothing will be seen where the lesion is limited to the soft tissue Clinically a slowly enlarging mass with or without pain 3. May originate in fibrous tissue, cartilage, bone, muscle, fat, or endothelial tissue. Irregular and diffuse destruction of bone and a patchy appearance at an early stage and there may be no line of demarcation from the normal surrounding bone. In contrast to osteosarcoma, they are found uniformly in both young and older age groups. Divided into osteoblastic, osteoclastic, chondroblastic, and fibroblastic tumors, depending on the dominating element the mean age at the time of the first-noted symptom related to the tumor is significantly greater (about a decade) than for osteosarcoma of other bones. Haemotagenous metastasis less frequently observed Clinically: Swelling of the involved area, with or without associated pain. Nasal obstruction may be noted with maxillary lesions Radiographically: Destructive lesion with indistinct borders, may appear sclerotic or lytic, or there may be a combination of these findings. There may be a symmetrically widened periodontal membrane space associated with a few teeth. Predilection for adulthood and older age groups Radiographically: Suggestive of malignancy, but no characteristic features that allow differentiation. The malignant lymphomas are a group of neoplasms that are derived from lymphocytes and reticulum cells in any of their developmental stages Clinically: Present with swelling and pain of the involved area. Myeloma is a tumor of bone that arises from bone marrow constituents resembling plasma cells. These neoplasms are almost always multiple and may be widely distributed throughout the skeleton. There may be spotty distribution of lesions throughout the maxilla and the mandible. The eosinophilic granuloma may appear as a poorly demarcated periapical lucency or a localized severe periodontal problem in young persons. Radiographically large marrow spaces Metasteses from prostate, ovaries, kidneys, stomach, breast etc. Commonly seen in the posterior region of the mandible in the region of the mandibular canal as a poorly demarcated lucency. The liver also produces cholesterol, acids, and bile salts that get stored in the gallbladder until required to help break down ingested fats. More advanced liver damage leads to a feeling of fullness or pain in the upper right abdomen, itching, jaundice (yellowing of the skin and whites of the eyes), easy bruising, fatigue, and fluid retention. This is a condition whereby extra fat gets deposited in the liver, squeezing out normal liver cells. This can happen in other conditions as well, like diabetes, pregnancy, and obesity. No specific treatment is necessary as it does not cause any symptoms, but weight loss along with control of blood cholesterol levels will usually rid the liver of the extra fat and should be encouraged in any patient that has fat deposits. It is treated with the same kinds of medicine that ulcerative colitis and Crohn’s disease are treated with, to decrease the inflammation. Autoimmune hepatitis can lead to liver scarring (cirrhosis) and permanent liver damage if not treated. If gallstones try to leave the gallbladder and block the ducts, pain, nausea, and vomiting occurs. Scarring of the bile ducts and eventually the liver is caused by the inflammation. Bile buildup leads to itching and jaundice, and if there is enough damage, fatigue can occur. To control the bile build-up, stents are usually placed within the bile ducts to keep the bile flowing. If the liver is damaged too much, cirrhosis can occur and liver transplantation can be considered. Disclaimer: the Crohn’s & Colitis Foundation provides information for educational purposes only. We encourage you to review this educational material with your health care professional. The Foundation does not provide medical or other health care opinions or services. The inclusion of another organization’s resources or referral to another organization does not represent an endorsement of a particular individual, group, company or product. The skin lesion spontaneously resolved over the following years leaving the residual skin changes. The An otherwise healthy 14-year-old white girl presented to skin lesion had remained unchanged for the last 4 years our dermatologic laser clinic with a protruding tumor without further improvement in appearance. The patient’s parents rePhysical examination revealed a protruding subcutaported that the patient had a fast-growing red tumor durneous tumor, abnormally lax overlying skin with several ing the first months after birth in the same area. The lelinear indentations, and a soft atrophic scarlike surface texsion at that time was diagnosed as infantile hemangioma ture (Figure 1A and Figure 2A). Several telangiectaby the pediatrician, and no further intervention was carsias were discernable within the skin lesion and in its immediate surrounding skin. Findings of the genA B eral skin examination were unremarkable: no other similarly protruding skin lesions were found. Of special concern for the patient was the irregular surface structure of the skin lesion rendering the application of make-up in an attempt to mask the lesion impossible. Close-up photographs taken at a 45° angled view to emphasize the rough surface structure before (A) and 4 weeks after (B) 5 fractional surfacing were also deemed to be too aggressive and risky photothermolysis treatment sessions. Less invasive procedures to imwas used for the before and after pictures, assuring constant light and prove the cosmetic appearance of the skin lesion were photography angles. Close-up photographs taken at 90° angled view (profile) to emphasize be needed and that additional liposuction might be necthe herniation of the skin lesion before (A) and 4 weeks after (B) 5 fractional essary to reduce the residual fibro-fatty mass. The first It has been clearly established that corticosteroids 3 treatments were done with the Fraxel 750 device at a and/or pulsed-dye laser treatments can cause early invomicrobeam energy of 16 mJ per microthermal treatment lution of infantile hemangiomas. Ninety-two percent of these paFurthermore, a forced-air cooling device (Zimmer Cooltients underwent preauricular excision of redundant skin ing Device; Medizin Systems, Irvine, California) was used and/or fibrofatty tissue, and 37% of patients needed auon a setting of 3 during the laser exposure to reduce disricular revision. Surgical excision of excess tissue and/or comfort and the potential risk of bulk heating. Treatmentintervalsvariedbetween4weeks been improved by Mulliken et al20 and Vlahovic et al,21 who and 4 months. With this technique, the residual scar size is A cold compress was applied to the area immediately after approximately 70% the size of the scar resulting from staneach laser treatment to reduce edema and patient discomdard lenticular excisions. Another advantage of the pursefort, and the patient was instructed to continue to cool the string closure technique is minimal distortion of surroundtreatmentareatoreduceposttreatmentedemaanderythema. The patient herself was especially pleased with the tion, tissue necrosis, and nerve damage. Traditional ablative laser resurfacing or dermabrasion Infantile hemangioma is a benign vascular proliferation can be used,22,23 but these techniques cause wounds with showing some similarities to placental vasculature. The potential for these adverse effects was strictly remon neoplasia in childhood. Hence, important disfigurement tion for these 3-dimensional changes is an increase in derpersists in approximately 25% of the cases even after the mal strength and elasticity due to the laser treatment. This natural involution process of the infantile hemangiomas dermal “tissue tightening” then could decrease the apparis completed. Hemangiomas and vascular malformations of infancy Accepted for Publication: June 21, 2008. Managementofparotidhemangiomain100 chusetts General Hospital, Wellman Center for Photochildren. Significant hemangiomas and vascular malformations of the head and neck: clinical management and treatment (hlaubach@partners. Place of the precocious surgical treatof the data in the study and takes responsibility for the inment in facial hemangioma [in French]. Circular excision of hemangioma and pursestring closure: the smallest possible scar. Clinical trial of penses and research funding from Reliant Technologies alaserdevicecalledfractionalphotothermolysissystemforacnescars. Fractionalresurfacingforthe ing, and royalties from Reliant Technologies Inc; Dr Luger treatment of hypopigmented scars: a pilot study. Manuscripts should be prepared double-spaced with tothermolysis for the treatment of surgical scars: a case report. Fractional laser treatment for pigmentation and graphs, and illustrations must be sharply focused and subtexture improvement. Fractional photorequired copyright transfer statement (see authorship thermolysis for treatment of poikiloderma of Civatte. Miembro de la Sociedad de Pediatria de Andama capilar es la facial, y en particular periocular. Hemangioma capilar; Inmunohistoquimica; Corticoides inHospital Universitari Bellvitge.

But extra kindness and consideration will most likely help take the edge off her emotions antimicrobial yahoo purchase cefpodoxime 100 mg amex, and this approach is the right and responsible thing to antibiotics for acne for 6 months buy cefpodoxime visa do virus 68 florida order generic cefpodoxime. Listen closely to antibiotic eye drops over the counter trusted cefpodoxime 200 mg the things she says and try to antibiotics in breast milk cefpodoxime 200mg generic help accommodate those special needs, which may vary or change from month to month. Remember you are building your relationship for a lifetime, so invest wisely with kind acts, wisdom, and patience. Conception and Pregnancy Fertilization takes place in the shelter of a mother’s oviduct, which is the tube that leads from the ovary to the womb. This is the meeting ground for the successful union of the female egg and the male sperm cell. Egg and Sperm the round egg of the female is the largest single human cell, yet it is smaller than a dot (. It is much smaller than the egg, so much smaller that twenty-five hundred would be needed to cover a comma—and all the sperm needed to repopulate the world could be fitted into an aspirin tablet! The egg is so much larger because it is laden with food to sustain a growing embryo in its first few days. With the lashing of its hair-fine tail, a sperm cell can propel itself ahead about one inch in eight minutes, which, for its size, is a much better speed than an athlete can match. By way of comparison, an athlete would have to run 70 miles per hour for 250 miles to approximate the speed and distance traveled by a sperm. At ovulation the immobile egg is thrust out of the ovary in a gently rising spring of fluids and is swept up by the fingerlike fringes (fimbriae) into the oviduct opening. They may arrive some hours before it, or after it, providing an approximate total of three to four days in each monthly cycle during which intercourse could result in conception (see figure 6). In sexual intercourse, the sperm are ejected in a somewhat forceful fine stream that normally aims at the narrow entrance of the cervix and finds entry most readily at the time of ovulation, when the normally dense mucus at the entrance to the cervix is thinner and more fluid. Fertilization of the Egg Millions of sperm begin the journey, but a comparative few (200) reach the tiny egg in the oviduct. Some sperm attach to the membrane that covers the egg and activate it, so that finally one sperm may enter and fertilize. The one sperm that enters the egg loses its tail, which is absorbed, and its head proceeds on through the food-rich substance of the egg. This one tiny sperm carries the father’s threads of inheritance to the egg’s center, where the mother’s threads of inheritance lie. These chromosomes contain thousands of smaller units called genes that specify the inherited characteristics of the child. In a few hours, the threads of inheritance of the two parents become knitted together. In a few hours, the fertilized egg begins to divide and goes on to become a cluster of bubble like cells. The Nine Months of Pregnancy By the end of the first week, the cell cluster comes to rest in the upper part of the uterus, where it clings and takes root. The nesting cluster finds nourishment in the lining of the uterus, prepared during the menstrual cycle. Production by the woman’s body of pituitary hormones is inhibited, so that ovulation is now suppressed, the lining of the uterus is maintained, and menstruation is postponed for the duration of the pregnancy. During the first two months of pregnancy, the mother’s breasts will enlarge and begin to be tender as a result of the change in the hormone level in her body. After about the twenty-seventh day, the placenta, the so-called afterbirth, which is attached to the lining of the uterus and is linked to the embryo by the umbilical cord, starts a variety of functions necessary to maintain the pregnancy. Since chorionic gonadotropin rises to a high level for a short period of time, its detection in urine serves as a test for pregnancy. This hormone from the placenta is vitally important in maintaining the pregnant uterus and equally important in preventing the ovaries from developing another mature egg. The heart begins to beat on about the twenty-second day, but it is still so small that it cannot be heard easily for another four to five months. It can move the arms and legs, turn the head, open and close the mouth, and swallow. In the last three months of pregnancy, the reproductive system becomes stretched to its limits in size and in capacity for supplying nourishment. The baby gains about five to six additional pounds, some of it as a padding of fat. From the maternal bloodstream the baby also accumulates essential immunities to diseases. In the ninth month a little understood chemical reaction occurs, which causes profound changes in the great muscles of the uterus. In the first stage of labor, the muscles of the uterus exert a force of about fifty pounds per square inch to push the baby out through the cervix. The narrow opening of the cervix gradually expands to let the baby’s head and body pass through. Next, the baby’s body stretches the walls of the vagina and reaches the light of day. Birth Birth is remarkable—all the more so because the reproductive organs, having performed an enormous task, very soon return to their former size and functions. Although nursing may hasten the return of the reproductive organs to their original size and may delay menstruation, it will not always prevent ovulation, as many people believe. This is about the time the new mother should return to her physician for her six weeks examination. Immediately after the birth of a baby, the mother has a great drop in her estrogen level, for there is almost no estrogen produced by her ovaries. During pregnancy most of the estrogen was being produced by the placenta, which is no longer present. Some new mothers may feel very depressed (postpartum depression) after the birth of their babies because of this lowered estrogen level. Nursing also suppresses the production of estrogen, and if the baby continues to nurse for several months, thinning of the vaginal lining may result. This thin vaginal lining is like senile vaginitis older women develop in the menopausal years. During this time if there is any discomfort, do not neglect to use ample artificial lubrication before every sexual union. The Male Reproductive System To aid in understanding the anatomy of the male sex organs, please refer to the accompanying drawings (figures 7 and 8). The most obvious fact about the penis is that it can be distended with blood under mental or physical stimulus, so that it becomes stiff or erect. The penis is made up of three columns of spongy erectile tissue—the middle one containing the urethra. The glans contains many nerve endings, which help build orgasmic tensions during sexual contact. The foreskin requires special care to keep it clean and prevent accumulation of a greasy secretion called smegma. For these reasons, the practice of circumcision shortly after birth has grown in popularity as a hygienic measure. It is interesting to note that this is the only surgical operation mentioned in the Bible. About four thousand years ago, God commanded that the operation be done on the eighth day after birth. It is only in the last few decades that it has been found that the eighth day is when blood-clotting and infection-preventing factors are the most favorable in a baby’s life. Today, however, the timing of this operation is not as critical, because we have vitamin K injected at birth to prevent bleeding problems and drugs with which to avoid and control infection. The urethra is a small tube that carries the urine from the bladder through the prostate gland and the penis. The length of the unstimulated or flaccid penis varies greatly, but the erect penis is usually from five to seven inches long. Practically all the sexually stimulating sensations take place in the glans of the penis for the male and in the clitoris for the female. So, length of the penis has little to do with stimulation of the wife or with satisfaction for the husband. Contrary to popular belief, there is more chance for a wife to feel discomfort and a lack of satisfaction from too large a penis than from one which is too small. During erection the rim of the glans becomes a little harder than the tip and may increase female excitement. Recent research proves there is no difference in sexual sensation for the male, whether he is uncircumcised or circumcised. The two testicles are normally carried in the scrotum—a double sac divided by a membrane. Its main structure is a mass of tiny, coiled tubes in which the male reproductive cells, called sperm cells, are produced. The new sperm move off into other small tubes that cover one side of the testicle in a bundle. Then the sperm are carried to the prostate gland in a larger and longer tube— the vas deferens—which takes a roundabout course through the inside of the pelvis—about eighteen inches in all. In performing a vasectomy for sterilization of the husband, a one-to two-inch section of each vas deferens is removed (see figure 9). The vas from each testicle broadens out into a seed reservoir, or ampulla, just before it enters the prostate. Opening off these reservoirs are the seminal vesicles—large pouches on each side and behind the prostate. These fill with sperm and act both as storerooms and as a physical reminder of the need for sexual relief. While in the storeroom, the sperm cells are joined by a lubricating prostatic secretion that helps them do their next job —swimming. Other similar secretions are added to make up the final seminal fluid, as the seed take the next step in their journey. During the sexual climax—the ejaculation—the fluid is forced from the storerooms through small tubes that meet in the ejaculatory duct, just before entering the base of the penis. The muscular contractions that take place in the prostate gland force the seminal fluid past the base of the penis, then through the urethral canal, and out the meatus (the outside opening of the urethra). This fluid, called semen, usually is projected forcefully enough to travel twelve to twenty-four inches after it leaves the penis. The contraction of the prostate gland provides much of the pleasant sensation of sexual climax. The prostate gland, approximately the size of a walnut, is located at the base of the urinary bladder. This gland literally encircles the urethra, the tube emptying the bladder, which is the only exit for urine from the bladder. Because of the intimate anatomic relationship between the prostate, the bladder neck, and the urethra, a benign enlargement of the prostate poses a concern regarding various degrees of bladder outflow obstruction. As we age, the prostate enlarges so that a man in his sixties and seventies will generally have a prostate two to three times the size of a man in his twenties and thirties.

Diseases

Bruising of the mouth and lips can be caused when an assailant places a hand over the face to antibiotics make me sick order cefpodoxime 100 mg otc keep the victim quiet infection game plague inc buy cefpodoxime us. Love bites (“hickeys”) may be present often in the form of discrete areas of ovoid petechial bruising on the neck and breasts antibiotics for uti and chlamydia order cefpodoxime 200 mg fast delivery. However bacterial diseases cefpodoxime 100 mg free shipping, it is important to virus going around 2014 order 100 mg cefpodoxime mastercard recognize that the latter may be the sequelae of consensual sexual encounters. Abrasions An abrasion (or a graze) is a superficial injury involving only the outer layers of the skin and not penetrating the full thickness of the epidermis. Abrasions exude serum, which progressively hardens to form a scab, but they may also bleed because occasionally they are deep enough to breach the vascular papillae that corrugate the undersurface of the epidermis in which case frank bleeding may be present at an early stage. More superficial abrasions that barely damage the skin with little or no exudation of serum (and thus little or no scab formation) may be termed brush or scuff abrasions. Scratches are linear abrasions typically caused by fingernails across the surface of the skin. Pointed but noncutting objects may also cause linear abrasions and to differentiate them from fingernail scratches may be termed “point abrasions. Thus they may have a linear appearance, and close examination may show ruffling of the superficial epidermis to one end, indicating the direction of travel of the opposing surface. Thus, a tangential blow could be horizontal or vertical, or it may be possible to infer that the victim had been dragged over a rough surface. The patterning of abrasions is clearer than that of bruises because abrasions frequently take a fairly detailed impression of the shape of the object causing them and, once inflicted, do not extend or gravitate; therefore, they indicate precisely the area of application of force. In manual strangulation, small, crescent-shaped abrasions caused by the fingernails of the victim or assailant may be the only signs visible on the neck. A victim resisting a sexual or other attack may claw at her assailant and leave linear parallel abrasions on the assailant’s face. Some abrasions may be contaminated with foreign material, such as dirt or glass, which may have important medicolegal significance. In such cases, consultation with a forensic scientist can ensure the best means of evidence collection and preservation. Lacerations Lacerations are caused by blunt force splitting the full thickness of the skin (see Fig. Boxers classically develop lacerations when a boxing glove presses on the orbital rim. When inflicted deliberately, the force may cause the assailant and weapon to be contaminated with blood. Lacerations have characteristic features but often mimic incised wounds (or vice-versa), particularly where the skin is closely applied to underlying bone, for example, the scalp. Close examination of the margins of the wound, which are usually slightly inverted, normally resolves the issue. Blood vessels, nerves, and delicate tissue bridges may be exposed in the depth of the wound, which may be soiled by grit, paint fragments, or glass. The shape of the laceration may give some indication regarding to the agent responsible. For example, blows to the scalp with the circular head of a hammer or the spherical knob of a poker tend to cause crescent-shaped lacerations. A weapon with a square or rectangular face, such as the butt of an axe, may cause a laceration with a Y-shaped split at its corners. Incisions these wounds are caused by sharp cutting implements, usually bladed weapons, such as knives and razors, but sharp slivers of glass, the sharp edges of tin cans, and sharp tools, such as chisels, may also cause clean-cut incised injuries. Axes, choppers, and other similar instruments, although capable of cutting, usually cause lacerations because the injury caused by the size of the instrument. Mixed wounds are common, with some incised element, some laceration, bruising, and swelling and abrasion also present. Machetes and other large-blade implements are being used, producing large deep cuts known as slash or chop injuries. They Injury Assessment 141 gape, and the deeper tissues are all cut cleanly in the same plane. If the blade of the weapon is drawn across the skin while it is lax, it may cause a notched wound if the skin creases. The direction of travel of the blade of the weapon is not always easy to decide, but usually the deeper part of the wound is near the end that was inflicted first, the weapon tending to be drawn away toward the end of the wound. In an attempt to ward off the assailant, the arms are often raised in a protective gesture and incisions are then often seen on the ulnar borders of the forearms. If the blade of the weapon is grasped, then incised wounds are apparent on the palmar surfaces of the fingers. Incised wounds may be a feature of suicide or attempted suicide (see Subheading 3. They are usually located on the wrists, forearms, or neck, although other accessible areas on the front of the body may be chosen. The incisions usually take the form of multiple parallel wounds, most of them being tentative and superficial; some may be little more than simple linear abrasions. Stab Wounds Stab wounds are caused by sharp or pointed implements and wounds with a depth greater than their width or length. They are usually caused by knives but can also be inflicted with screwdrivers, pokers, scissors, etc. Although the external injury may not appear to be particularly serious, damage to vital structures, such as the heart, liver, or major blood vessels, can lead to considerable morbidity and death, usually from hemorrhage. In those individuals who survive, it is common for little information to be present about the forensic description of the wound because the priority of resuscitation may mean that no record is made. If operative intervention is undertaken, the forensic significance of a wound may be obliterated by suturing it or using the wound as the entry for an exploratory operation. In such cases, it is appropriate to attempt to get a forensic physician to assess the wound in theatre or subsequently. Stab wounds are rarely accidental and occasionally suicidal, but usually their infliction is a result of criminal intent. In the case of suicide, the wounds are usually located on the front of the chest or upper abdomen and, as with selfinflicted incisions, may be associated with several superficial tentative puncture wounds (see Subheading 3. When deliberately inflicted by an assailant, stab wounds may be associated with defense injuries to the arms and hands. The appearance of the skin wound will vary depending on the weapon used and can easily be distorted by movement of the surrounding skin. If the blade is doubleedged, such as that of a dagger, the extremities of the wound tend to be equally pointed. A stab wound from a single-edged blade, such as a kitchen knife, will usually have one extremity rounded, squared-off, or fish-tailed (caused by the noncutting back of the blade). When blunt weapons are used—a pair of scissors, for example—the wound tends to be more rounded or oval, with bruising of its margins (see Fig. Scissor wounds can sometimes have a cross-shape caused by the blade screws or rivets. Notched wounds are often caused by the blade of the weapon being partially withdrawn and then reintroduced into the wound or twisted during penetration. It is rarely possible from an inspection of the skin wound alone to comment usefully on the width of the blade because the skin retracts and the knife is unlikely to have been introduced and removed perfectly perpendicularly. Deliberate Self-Harm Deliberate self-harm refers to any attempt by an individual to harm himself or herself. When assessing injuries, it is important to understand which factors may indicate the possibility that an injury was caused by deliberate Injury Assessment 143 Table 4 Indicators of Possible Deliberate Self-Harm Injuries • Must be on an area of body accessible to the person to injure themselves. Individuals injure themselves for numerous reasons, including psychiatric illness and others, such as attempting to imply events took place that did not or for motives of gain. Self-inflicted injuries have several characteristics, which are not diagnostic but that together may give an indication of selfinfliction. Table 4 lists features that may assist in the recognition or suspicion that cuts or other injury, such as scratches, are self-inflicted—all or some may be present—their absence does not preclude self-infliction nor does their presence necessarily imply self-infliction (2). As with all injuries within the forensic setting it is essential in these nonfatal cases that the initial appearances of the injuries be accurately described and the wounds photographed. This is particularly important because subsequent surgical treatment may distort or completely obliterate the wound characteristics. Furthermore, any fragments, bullets, or pellets found within the wounds must be carefully removed and handed over to the appropriate authorities. Smooth-Bore Weapons Shotguns, which fire a large number of small projectiles, such as lead shot, are the most common type of smooth-bore weapons. They are commonly used in sporting and agricultural activities and may be either single or doublebarreled. The ammunition for these weapons consists of a plastic or cardboard cartridge case with a brass base containing a percussion cap. Inside the main part of the cartridge is a layer of propellant, plastic, felt, or cardboard wads and a mass of pellets (lead shot of variable size) (see Fig. In addition to the pellets, the wads and/or cards may contribute to the appearance of the wounds and may be important in estimating range and possible direction. Rifled Weapons Rifled weapons are characterized by having parallel spiral projecting ridges (or lands) extending down the interior of the barrel from the breach to the muzzle. The rifling also leaves characteristic scratches and rifling marks that are unique to that weapon on the bullet surface. There are three common types of rifled weapons: the revolver, the pistol, and the rifle. The Injury Assessment 145 revolver, which tends to have a low muzzle velocity of 150 m/s, is a shortbarreled weapon with its ammunition held in a metal drum, which rotates each time the trigger is released. Most military rifles are “automatic,” allowing the weapon to continue to fire while the trigger is depressed until the magazine is empty; thus, they are capable of discharging multiple rounds within seconds. The entrance wound is usually a fairly neat circular hole, the margins of which may be bruised or abraded resulting from impact with the muzzle. In the case of a double-barreled weapon, the circular abraded imprint of the nonfiring muzzle may be clearly seen adjacent to the contact wound. This is seen particularly where the muzzle contact against the skin is tight and the skin is closely applied to underlying bone, such as in the scalp. Carbon monoxide contained within the gases may cause the surrounding skin and soft Injury Assessment 145 revolver, which tends to have a low muzzle velocity of 150 m/s, is a shortbarreled weapon with its ammunition held in a metal drum, which rotates each time the trigger is released. In the self-loading pistol, often called “semi-automatic” or erroneously “automatic,” the ammunition is held in a metal clip-type magazine under the breach. Each time the trigger is pulled, the bullet in the breach is fired, the spent cartridge case is ejected from the weapon, and a spring mechanism pushes up the next live bullet into the breach ready to be fired. The rifle is a long-barreled shoulder weapon capable of firing bullets with velocities up to 1500 m/s. Shotgun Wounds When a shotgun is discharged, the lead shot emerges from the muzzle as a solid mass and then progressively diverges in a cone shape as the distance from the weapon increases. The pellets are often accompanied by particles of unburned powder, flame, smoke, gases, wads, and cards, which may all affect the appearance of the entrance wound and are dependent on the range of fire. Both the estimated range and the site of the wound are crucial factors in determining whether the wound could have been self-inflicted. If the wound has been sustained through clothing, then important residues may be found on the clothing if it is submitted for forensic examination.

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