Lewy body dementia when compared to Alzheimer's dementia

Which of the following is more commonly seen in patients with Lewy body dementia when compared to Alzheimer's dementia?

• A) Hallucinations
• B) Lip smacking
• C) Tremor
• D) Emotional lability
• E) Repetitive behavior

The answer is A.

Although difficult to know for sure, Lewy body dementia may be the second most common dementia after Alzheimer's disease.

Lewy bodies are hallmark lesions of degenerating neurons in Parkinson's disease "deposits of the protein alpha-synuclein inside nerve cells in the brain"  and occur in dementia with or without features of Parkinson's disease. In Lewy body dementia, Lewy bodies may predominate markedly or be intermixed with classic pathologic changes of Alzheimer's disease. Symptoms, signs, and course of Lewy body dementia resemble those of Alzheimer's disease, except hallucinations (mainly visual) are more common and patients appear to have an exquisite sensitivity to antipsychotic-induced extrapyramidal adverse effects.

Essentials of Neuroimaging for Clinical Practice

The use of neuroimaging studies in psychiatry is explodingAand offers tremendous potential for practicing clinicians. Yet if you’re like many psychiatrists, you’re sometimes uncertain about which studies to use in specific situations. Until now, you’ve had to sort through the only information availableAtechnical reviews in the literatureAfor guidance. But no more. Essentials of Neuroimaging for Clinical Practice is an all-in-one resource that explains how to use these powerful techniques to improve outcomes. It demystifies neuroimaging with clear, concise, and practical advice on using today’s most advanced applications in the diagnostic workup of patients. This practical clinical guide will help you achieve a solid understanding of the full range of neuroimaging modalities: -Structural techniques such as computed tomography (CT) and magnetic resonance imaging (MRI) -Functional techniques such as positron emission tomography (PET), single photon emission computed tomography (SPECT), functional magnetic resonance imaging (fMRI), and magnetic resonance spectroscopy (MRS) -Other techniques such as electroencephalography (EEG)Aincluding quantitative EEG and event-related potentialsAand magnetoencephalography. For each modality, you’ll find: -A basic review of the techniqueAtrace the development of each modality, and become familiar with its underlying technology. -Guidance on when to use itAlearn which techniques are best to use in specific clinical situations. -Tips for ordering studiesAdiscover how to write up orders to obtain the most accurate and detailed information from each study, including when to use contrast and how to determine the best acquisition parameters. -A look at its future potential in practice and researchAexplore the current capabilities of each modality and the most promising strategies for improving diagnostic results. Filled with examples of real-life imaging studies, Essentials of Neuroimaging for Clinical Practice is a must-have tool for all practicing psychiatrists and psychologists. In addition, it will serve as an excellent clinical guide for residentsAand an outstanding text for courses in clinical neuroimaging for psychiatrists.

HERE

Tongue`s surface in Prolonged antibiotic use

Which of the following conditions is the skin finding shown in the picture associated with?

• A) Prolonged antibiotic use
• B) Sjögren's syndrome
• C) Addison's disease
• D) Chronic gastroesophageal reflux
• E) Malignant melanoma

The answer is A. 

(Black tongue) Black hairy tongue results from hyperplasia of the filiform papillae with deposition of keratin on the surface. The condition causes the tongue to have ..............

READ MORE...................>>

The Barber's Itch

Barber's itch is a type of Folliculitis "an inflammation of one or more hair follicles".
It is an infectious skin disease which arises on bearded area of the face and upper lip. The condition takes place when the hair follicles get damaged by constant friction with clothing and it may even take place due to blockage and shaving

The disease develops and the first signs of the condition are the appearance of painful pimples that develop at the hair follicles along the beard, these pimples can grow either superficial or may occur in the deeper layers of the skin associated with some common symptoms as rash, itching, and pimples or pustules near a hair follicle in the neck, groin, or genital zone.

The cause that responsible for Barber`s folliculitis may be either a bacterial or a fungal infection :
- Mustache hair is usually affected by the bacteria; staphylococci.
- Bearded hair on the cheeks and the chin is commonly affected by the fungus.

#The condition is aggravated by shaving ,On the other hand the sharing of towels and razors passes on the highly contagious fungal infection

Menstrual Cycle explanation

This animation video explains the biological processes of Menstruation and the physiology of Menstrual Cycle

malignant external otitis

 A 72-year-old patient withlong-standing Type 2 diabetes mellitus presents with complaints of pain in his right ear with purulent drainage. On physical exam, the patient is afebrile. The pinna of the left ear is tender, and the external auditory canal is swollen and edematous. The peripheral white blood cell count is normal. The organism most likely to grow from the purulent drainage is :

• a. Pseudomonas aeruginosa
• b. Staphylococcus aureus
• c. Candida albicans
• d. Haemophilus influenzae
• e. Moraxella catarrhalis

 The answer is a.

Ear pain and drainage in an elderly diabetic patient must raise concern about malignant external otitis. Presence of swelling and inflammation of the external auditory meatus strongly suggests this diagnosis. This infection usually occurs in older diabetics and is almost always caused by organism Pseudomonas aeruginosa.

Haemophilus influenzae and Moraxella catarrhalis frequently cause otitis media but not external otitis.

Acute otitis externa with the canal somewhat narrowed from edema and obstructed by desquamating epithelium, soft cerumen, and purulent discharge; this must be removed to visualize the tympanic membrane and to allow ototopical therapy to penetrate to all the superficially infected areas of the canal skin.

Types of Hypospadias

Hypospadias is one of the most frequent male congenital malformations and may be part of the testicular dysgenesis syndrome, It occures 1-2 of 100 boys. Hypospadias is a birth defect found in boys in which the urinary tract opening is not at the tip of the penis. Bending of the penis on erection may be associated and is as chordee.

This picture shows Proximal shaft hypospadias . Note the deficient ventral foreskin, blind urethral pit at the glanular level, and lighter pigmented urethral plate extending to the true meatus at the proximal shaft level.

The location of the urethral meatus was described if visible, and hypospadias was graded as glandular, coronal, penile, penoscrotal, scrotal, or perineal according to the anatomical position

Types of hypospadias classified by the anatomical position of the urethral meatus. 1, Glandular; 2, coronal; 3, penile; 4, penoscrotal; 5, scrotal; 6, perineal.

On examination :A dorsal hood of foreskin and glanular groove are evident, but, upon closer inspection, the prepuce is incomplete ventrally and the urethral meatus is noted in a proximally ectopic position. Rarely, the foreskin may be complete, and the hypospadias is revealed at the time of circumcision. If hypospadias is encountered during neonatal circumcision, after the dorsal slit has been performed, the procedure should be halted, and the patient should be referred for urologic evaluation.
 The most simple classification of Hypospadias is mild, moderate and severe, which can also be called first, second and third degrees of severity. This classification system is based on the location of the external opening for urine and semen (the urethral meatus). In mild or first degree hypospadias, the opening is on the underside of the head of the penis or where the head and the shaft meet. This accounts for about 80% of the cases of hypospadias.

Moderate or second degree hypospadias (15%) occurs when the hole is actually on the shaft of the penis, somewhere between the junction of head and shaft, and the lower part of the shaft. Severe or third degree hypospadias occurs when the hole is located on the lower part of the shaft just in front of the testicles or is located behind the testicles, between them and the anus.

About Visual fields

 A patient presents with a bilateral homonymous quadranopsia involving the right upper visual field. Which of the following represents the MOST likely anatomic location of the abnormality?

• (A) Prechiasmal, right side
• (B) Optic chiasm
• (C) Postchiasmal, prethalamic, left side
• (D) Occipital lobe, right side
• (E) Occipital lobe, left side

The answer is E.

Homonymous visual field cuts imply a postchiasmal location of the abnormality because this is the first point where fibers from the same visual field of both eyes join. Fibers further divide between the thalamus and occipital lobe into upper and lower quadrant visual fields. The most common location for quadranopsia defects is the occiptal lobe. Stroke, tumor, and atypical migraine may present with quadranopsia.
Visual fields are named from the perspective of the patient, i.e., the right visual field corresponds to the left side of the retina. Therefore, a right-sided visual field cut involves the left-sided neurologic tracks.

Preoperative dose of antibiotic

When vancomycin is used as a preoperative prophylactic antibiotic, it should be administered within ______ minutes of the start of surgery.

A) 15
B) 30
C) 60
D) 120
E) At the time of incision

Answer and Discussion

The answer is D.
Ideally, a preoperative dose of antibiotic should provide a sufficient antibiotic serum level throughout the surgery to combat organisms most likely to cause a site infection. It is recommended that the first dose be timed to occur within 60 minutes before the surgical incision is made. If a fluoroquinolone or vancomycin is chosen for prophylaxis, the first dose should be administered within 120 minutes of the start of surgery. If the surgery involves the use of a tourniquet (e.g., hip or knee arthroplasty), the antibiotic infusion should be completed before inflation of the tourniquet. For most surgeries, it is recommended that use of prophylactic antibiotics end within 24 hours after surgery.

Mindmap for Appendicitis

Revise appendicitis faster with this mindmap!

Click here for enlargment

Acanthosis nigricans in diabetes mellitus

You note the shown skin disorder during a general medical evaluation. You explain to the patient they are at risk for the development of:

A) Alzheimer's disease

B) tuberculosis

C) diabetes mellitus

D) Grave's disease

E) melanoma



 The answer is C. (Diabetes mellitus) 
Although the majority of cases of acanthosis nigricans are benign and associated with obesity, the disease can represent the onset of malignancy as well as a variety of conditions related to insulin resistance.
Acanthosis nigricans has been reported in association with a number of malignancies, particular gastrointestinal cancers (e.g., gastric, hepatocellular) and lung cancer. The suspicion for malignancy increases in patients with extensive or rapidly progressive lesions, when there is mucous membrane involvement, or when there is prominent sole and palm disease.

The common finding in all non-malignancy associated cases of acanthosis nigricans is insulin resistance. This explains the relationship between this skin disorder and diseases such as diabetes mellitus, Cushing's syndrome, and hypothyroidism (most likely due to weight gain and subsequent insulin resistance), and with obesity.

Photos of Melanosis coli "Pseudomelanosis coli"

Melanosis coli, also pseudomelanosis coli, is a disorder of pigmentation of the wall of the colon, often identified at the time of colonoscopy.
The most common cause of melanosis coli is the extended use of laxatives, this darkening of the colonic mucosa caused by the accumulation of lipofuscin particles within the macrophages of the lamina propria of the colonic mucosa as a result of long term exposure to anthraquinone-containing laxatives as Senna and other plant glycosides. However, other causes are identified, including an increase in colonic epithelial apoptosis.

This is the photograph of the colon, and there is an extremely dark appearance to the wall of the colon. This is seen in patients who have taken laxatives over many years and the pigment from the laxative gets deposited in the wall of the bowel giving an extremely dark appearance to it. This is a benign condition, not cancerous, and does not become cancerous, but often it is quite obvious.

- Melanosis coli is a misnomer, as the pigmentation is due to lipofuscin-laden macrophages - not melanin pigment. Pseudomelanosis coli is a more appropriate descriptor, but not in common usage.

The differential diagnosis of brown pigmentation of the colon is:

* Pseudomelanosis coli.
* Hemosiderin-laden macrophages (old haemorrhage).
* Melanin (rare).

Vacuum Assisted Delivery: A Brief Summary of Key Principles

Decompression sickness "divers' disease"

A 55-year-old male diver begins complaining of back pain and urinary retention 1 h after a dive. What is the MOST likely diagnosis?

• (A)Barotrauma to the bladder


• (B)Lumbar strain


• (C)Neurotoxin from a marine envenomation


• (D)Nitrogen narcosis


• (E)Decompression sickness

The answer is E.

Barotrauma is the most common affliction of divers and usually affects the ears, sinuses, lungs, and, rarely, the gastrointestinal tract. The bladder is not involved.

Decompression sickness (DCS),also known as divers' disease, the bends or caisson disease, is caused by formation of gas bubbles in tissues after ascent from a dive and results in vascular occlusion, usually in the venous circulation. DCS may have cutaneous manifestations including rash and pruritus. It classically causes joint and back pain and may be associated with neurologic symptoms secondary to spinal cord involvement.

Patients with neurologic or other severe forms of DCS should be referred for hyperbaric oxygen therapy. Nitrogen narcosis is due to the anesthetic effects of breathing nitrogen at high partial pressures and causes divers to become altered on deep dives.

Superior vena cava syndrome

A 72-year-old man who was overweight and had a history of hypertension and heavy smoking presented with a swollen neck. He had no dysphagia. He reported that he had experienced increased snoring and daytime sleepiness during the previous 3 weeks.
An otolaryngologic examination was unremarkable except for an unusually narrow upper airway. On inspection, the patient's hands were swollen and showed signs of pitting edema (Figure 1A). Inflammatory parameters and complete blood count were normal.

Contrast-enhanced computed tomography scans of the neck and chest revealed an enlarged retropharyngeal space (Figure 1B) and a mass compressing the superior vena cava (Figure 1C). A transthoracic needle biopsy showed a non–small-cell carcinoma. Radiotherapy resulted in clinical improvement and a rapid reduction in compression of the superior vena cava.

The exact incidence of superior vena cava syndrome remains unknown, It has mainly malignant causes.
Nonmalignant causes can include aneurysm of the aorta, thromboses after implanted intravascular catheters or fibrosing mediastinitis.

Classically, compression of the superior vena cava leads to visible swelling and venous distension in the face, neck, chest and upper limbs. Other symptoms of varying severity can occur, from cough, hoarseness and dyspnea to headache, confusion and visual symptoms. In patients who are overweight, swelling of the neck may go unnoticed, and signs such as obstructive sleep apnea or edema of the upper limb may point to the diagnosis.

Characteristic shape of Molluscum contagiosum infection

A 4-year-old preschooler presents with the skin lesions shown here. The area affected is just below the chin on the child's right side. The lesions have been present over the last month, and the child has reported no symptoms associated with them. The most likely diagnosis is

• A) varicella


• B) herpes zoster


• C) Rhus dermatitis


• D) molluscum contagiosum


• E) scabies

 The answer is D. (Molluscum contagiosum) 

Molluscum contagiosum is a common, superficial viral infection of the skin that typically occurs in infants and preschoolers. The incidence decreases after the age of 6 to 7 years. The condition can be spread via sexual contact in young adults.
The lesions are dome-shaped, waxy, or pearly-white papules with a central white core and are 1 to 3 mm in diameter. Frequently, groups of lesions are found. The lesions may resolve spontaneously. Treatment involves removal with a sharp needle or curette, application of liquid nitrogen, antiwart preparations, electrodessication and curettage, or trichloroacetic peels for extensive areas. Typically, infants or young preschool-age children should not be treated aggressively.

Typical flesh-colored, dome-shaped and pearly lesions

Illustration of Vaginal Delivery on a model

Synthesis and metabolism of vitamin D in the regulation of calcium, phosphorus, and bone metabolism.

Click for photo enlargement

During exposure to solar UVB radiation, 7-dehydrocholesterol in the skin is converted to previtamin D3, which is immediately converted to vitamin D3 in a heat-dependent process. Excessive exposure to sunlight degrades previtamin D3 and vitamin D3 into inactive photoproducts. Vitamin D2 and vitamin D3 from dietary sources are incorporated into chylomicrons and transported by the lymphatic system into the venous circulation. Vitamin D (hereafter, “D” represents D2 or D3) made in the skin or ingested in the diet can be stored in and then released from fat cells.
Vitamin D in the circulation is bound to the vitamin D–binding protein, which transports it to the liver, where vitamin D is converted by vitamin D-25-hydroxylase to 25(OH)D. This is the major circulating form of vitamin D that is used by clinicians to determine vitamin D status. (Although most laboratories report the normal range to be 20 to 100 ng/mL [50 to 250 nmol/L], the preferred range is 30 to 60 ng/mL [75 to 150 nmol/L].) This form of vitamin D is biologically inactive and must be converted in the kidneys by 25-hydroxyvitamin D-1α-hydroxylase (1-OHase) to the biologically active form 1,25(OH)2D.
 Serum phosphorus, calcium, fibroblast growth factor 23 (FGF-23), and other factors can either increase (+) or decrease (−) the renal production of 1,25(OH)2D. 1,25(OH)2D decreases its own synthesis through negative feedback and decreases the synthesis and secretion of PTH by the parathyroid glands. 1,25(OH)2D increases the expression of 25-hydroxyvitamin D-24-hydroxylase (24-OHase) to catabolize 1,25(OH)2D to the water-solubl biologically inactive calcitroic acid, which is excreted in the bile.

1,25(OH)2D enhances intestinal calcium absorption in the small intestine by interacting with the vitamin D receptor–retinoic acid x-receptor complex (VDR-RXR) to enhance the expression of the epithelial calcium channel (transient receptor potential cation channel, subfamily V, member 6 [TRPV6]) and calbindin 9K, a calcium-binding protein (CaBP). 1,25(OH)2D is recognized by its receptor in osteoblasts, causing an increase in the expression of the receptor activator of RANKL.
RANK, the receptor for RANKL on preosteoclasts, binds RANKL, which induces preosteoclasts to become mature osteoclasts. Mature osteoclasts remove calcium and phosphorus from the bone, maintaining calcium and phosphorus levels in the blood. Adequate Ca2+ and phosphorus (HPO42−) levels promote the mineralization of the skeleton.

8 clinical criteria predict management in an ICU

Which of the following would indicate the patient must be monitored in an intensive care unit setting following an overdose?

• A) PaCO2 >45 mmHg


• B) Seizures


• C) QRS duration ≥ 0.12 seconds


• D) Second- or third-degree atrioventricular block


• E) All of the above

Answer and Discussion
The answer is E.
The presence of any of eight clinical criteria predict a complicated hospital course that could be best managed in an ICU:

1- PaCO2 >45 mmHg
2- A need for emergency intubation
3- The presence of postingestion seizures
4- Unresponsiveness to verbal stimuli
5- A non-sinus cardiac rhythm
6- Second- or third-degree atrioventricular block
7- Systolic blood pressure <80 mmHg
8- QRS duration ≥ 0.12 seconds

Heparin . . . The forgotten hero in myocardial infarction

Description of Hallux Malleus "hammer toe"

-Hallux for the big toe
-Malleus for a hammer

Hallux malleus is a deformity of the great toe. This deformity can be very stiff or flexible. The joint in the great toe becomes contracted in a flexed or downward position.
This deformity usually occurs due to an imbalance of the tendons that insert on the top and the bottom of the great toe. When the tendon on the bottom of the toe (the tendon that causes the toe to flex down) over powers the tendon that causes the toe to bend up, this deformity occurs.

Usually patients will develop a callus and even an ulcer on the tip of the great toe. This deformity is often seen in conjunction with hammer toes. High arched feet are typically the most affected by this deformity.

This deformity is treat initially with padding techniques to prevent sores from developing at the tip of the toe. Custom, soft, accommodative orthoses are sometimes prescribed for the patient to provide cushioning and also to prevent worsening of the deformity.

If conservative treatment fails, surgery is indicated. Surgery usually consists of performing a bone fusion of the 2 bones in the great toe. This can be done with screws, staples, or wire fixation.

About Retinal Detachments

Which of the following statements is TRUE regarding acute traumatic retinal detachments?

• (A) Most detachments can be visualized on standard fundoscopy
• (B) Eighty percent of detachments occur within 24 h of the traumatic event
• (C) Most detachments originate in the inferotemporal quadrant
• (D) Visual outcome depends on the extent of involvement of the optic disc
• (E) Sudden onset of pain is a prominent feature

The answer is C. 

The typical retinal detachment is heralded by painless flashes of light, floaters, and a shade across the visual field. Interestingly, most detachments follow a latent period, up to 8 months posttrauma in 50 percent of cases.

Detachments begin as small tears in the ora serrata (called dialysis), most frequently affecting the inferotemporal quadrant, followed by the superonasal quadrant. Because most detachments are very peripherally situated on the retina, standard fundoscopy is typically inadequate for visualization. Although a number of techniques have been developed to correct the detachment, visual outcome remains largely determined by the degree of macular involvement.

Prostate diseases in relation to Prostate zones

Most cancer lesions occur in the peripheral zone of the gland, fewer occur in the transition zone and almost none arise in the central zone. Most benign prostate hyperplasia (BPH) lesions develop in the transition zone, which might enlarge considerably beyond what is shown.

The inflammation found in the transition zone is associated with BPH nodules and atrophy, and the latter is often present in and around the BPH nodules. Acute inflammation can be prominent in both the peripheral and transition zones, but is quite variable.
The inflammation in the peripheral zone occurs in association with atrophy in most cases.

Although carcinoma might involve the central zone, small carcinoma lesions are virtually never found here in isolation, strongly suggesting that prostatic intraepithelial neoplasia (PIN) lesions do not readily progress to carcinoma in this zone. Both small and large carcinomas in the peripheral zone are often found in association with high-grade PIN, whereas carcinoma in the transition zone tends to be of lower grade and is more often associated with atypical adenomatous hyperplasia or adenosis, and less often associated with high-grade PIN. The various patterns of prostate atrophy, some of which frequently merge directly with PIN and at times with small carcinoma lesions, are also much more prevalent in the peripheral zone, with fewer occurring in the transition zone and very few occurring in the central zone.

Local anesthesia for a complex lower lip laceration (Mental nerve block)

A 20-year-old male kick boxer sustains a lower lip laceration during a practice match. The wound is complex and crosses the vermilion border. Which is the best way to achieve anesthesia?

• (A) Local infiltration with 1 percent lidocaine
• (B) Local infiltration with 1 percent lidocaine with epinephrine
• (C) Inferior alveolar nerve block
• (D) Lingular nerve block
• (E) Mental nerve block

answer is E. 

A regional block is preferred for a complex lower lip laceration because it preserves tissue planes and landmarks, facilitating anatomically correct repair. 
The mental nerve supplies the skin and mucus membranes of the lower lip. The mental foramen is located inside the lower lip at its junction with the lower gum, just posterior to the first premolar tooth.

To avoid nerve injury, 1 percent lidocaine with epinephrine is injected close to, but not into, the mental foramen. The inferior alveolar and lingular nerves do not supply the lower lip and thus would not be effective in this patient.

Photo illustration of Actinic Keratosis

Actinic keratoses generally appear as rough, red/brown, scaly macules or papules on the skin. They start to appear usually about age 30 or older.

Actinic keratoses (AKs) are A premalignant neoplasm of the epidermis caused by excessive exposure to sunlight and manifesting as an ill-marginated, erythematous, scaling, rough papule or patch that form on sun exposed areas of the skin, including the scalp, face, forearms, and back of the hands.

Actinic keratoses are usually scaly, feel like sandpaper to the touch, and range in color from skin-toned to reddish-brown " AK are more easily felt than seen, as their overlying scale is thick and firmly adherent".  Actinic keratoses may be as small as the head of a pin or as large as a quarter (or bigger, if left untreated).

Actinic keratoses on the scalp

Actinic keratoses are most common in individuals over 40 years old with fair skin and years of excessive sun exposure. However, even younger people (including those with dark skin) can develop actinic keratoses if they live in very sunny climates.

Lesions are occasionally tender to palpation. Fair-skinned persons, who burn easily and tan poorly, are most commonly affected. A small percentage of AK on non-mucosal skin can progress to skin cancer squamous cell carcinoma. Ultraviolet light exposure induces formation of the lesions.

Arterial catheter placement

This video shows Indications, Allen`s test and Preparation for Arterial catheter placement.

Papillary muscle Rupture

Rupture of a papillary muscle is usually associated with an infarction of which area of myocardium?

• (A) Inferior
• (B) Inferior–posterior
• (C) Lateral
• (D) Anterior
• (E) Anteroseptal

The answer is B.

Papillary muscle rupture is usually associated with an inferior–posterior infarction and involves the posterior papillary muscle. Outcome depends on whether the entire muscle body or only the head is ruptured. Rupture of an entire muscle body is associated with a high mortality rate (up to 50 percent within 24 h).

Diagnosis of papillary muscle dysfunction or rupture may be made on echocardiography or by measuring large V waves in the pulmonary artery wedge pressure with a Swan-Ganz catheter.

Papillary Muscle Infarct with Rupture: Gross, an excellent example of ruptured papillary muscle.

How to remember Carpal bones !!

"She Looks Too Pretty; Try To Catch Her":

· Proximal row then distal row, both lateral-to-medial:

• Scaphoid
• Lunate
• Triquetrium
• Pisiform
• Trapezium
• Trapezoid
• Capate
• Hamate

· Alternatively: "She Likes To Play; Try To Catch Her".

Note :The scaphoid bone is a small carpal bone on the thumb side (radial side) of the wrist. It is the most commonly fractured carpal bone.

This is probably because it actually crosses two rows of carpal bones, forming a hinge.

Laparoscopic Harvested Omental Flap for Sternal Wound Dehiscence

Evaluation of groin pain

A 70-year-old female with mild dementia complains of unilateral groin pain. There is some limitation of motion in the right hip. Which of the following is the most appropriate first step in evaluation?

• a.CBC and erythrocyte sedimentation rate
• b.Rheumatoid factor
• c.X-ray of right hip
• d.Bone scan

The answer is c.

Hip pain may result from fracture, bursitis, arthritis, tumor, or pain referred from the lumbosacral spine. A film of the right hip is mandatory in this patient. Fracture of the hip must be ruled out, particularly in a woman with mental status abnormalities, who may be prone to falls. Elderly women with osteoporosis are most prone to hip fracture.

Pain from the hip joint is most often felt in the groin radiating down the anterior thigh. It is important to realize that patients will often complain of “hip” pain when they mean pain in the buttocks or low back. Pain in the buttocks is most often referred pain from the spine.

Surface anatomy of both kidneys on the back

Viewed posteriorly the right kidney has its upper edge opposite the 11th dorsal spine and the lower edge of the 11th rib. Its lower edge is opposite the upper edges of L3 spine and vertebral body and about 4 cm. (1 1/2 in.) above the highest point of the crest of the ileum, which is opposite the fourth spine.The left kidney is usually 1.25 cm. (1/2 in.) higher, but being a little longer than the right, its lower limit may not be quite that much higher. The kidney is slightly lower in women and children than in men. The inner border reaches 10 cm. (4 in. ) and the hilum 4 to 5 cm. (1 1/2 to 2 in.)

Notice that the left kidney is higher (highest border T11 lowest border L2) whereas the right kidney is lower (highest border T12 lowest border L3). The right kidney is less enclosed by the rib cage, because of the presence of right lobe of liver above it, therefore pushing it down. So, the right kidney is palpable during inspiration (moves down by 1 inch).

The renal angle as seen in the image, is located between the

-lower border of the 12th rib
-& lateral border of the erector spinae muscle

Left kidney related to 11th & 12th rib. Right kidney related to only 12th rib.

 Also to indicate the position of the kidney from the back, the parallellogram of Morris is used; two vertical lines are drawn, the first 2.5 cm., the second 9.5 cm. from the middle line; the parallelogram is completed by two horizontal lines drawn respectively at the levels of the tips of the spinous process of the eleventh thoracic and the lower border of the spinous process of the third lumbar vertebra. The hilum is 5 cm. from the middle line at the level of the spinous process of the first lumbar vertebra.

  Back of lumbar region, showing surface markings for kidneys, ureters, and spleen. The lower portions of the lung and pleura are shown on the right side.

Antinucleolar antibody in diagnosis of Scleroderma

A 45-year-old woman has pain in her fingers on exposure to cold, arthralgias, and difficulty swallowing solid food. Of the following tests,which, if positive, would be most supportive of a definitive diagnosis?

• a.Rheumatoid factor
• b.Antinucleolar antibody
• c.ECG
• d.BUN and creatinine
• e.Reproduction of symptoms and findings by immersion of hands in cold water

The answer is b.

The symptoms of Raynaud’s phenomenon, arthralgia, and dysphagia point toward the diagnosis of scleroderma. Scleroderma, or systemic sclerosis, is characterized by a systemic vasculopathy of small and medium-sized vessels, excessive collagen deposition in tissues, and an abnormal immune system. It is an uncommon multisystem disease affecting women more often than men. There are two variants of scleroderma ;a relatively benign type called the CREST syndrome "C-calcinosis.R- raynaud phen. E- esophagal dysmotility.S-sclerodactyly.T-talangiectasia" and a more severe, diffuse disease.

Antinucleolar antibody occurs in only 20 to 30% of patients with the disease, but a positive test is highly specific. Cardiac involvement may occur, and an ECG could show heart block or pericardial involvement but is not at all specific. Renal failure can develop insidiously. Rheumatoid factor is nonspecific and present in 20%
of patients with scleroderma. Reproduction of Raynaud’s phenomena is nonspecific and is not recommended as an office test.

The clinical spectrum of scleroderma

The spectrum of sclerodermatous diseases comprises a wide variety of clinical entities such as morphea (patchy, linear, generalized), pseudo-scleroderma and the overlap-syndromes with similar cutaneous and histopathologic manifestations.

Ultrasound Guided Femoral Nerve Block for Large Thigh Laceration

Here is a quick case study on ultrasound guided regional anesthesia from the Emergency Ultrasound Nerve Block Project.

Evaluation of a case pseudogout with diabetes and cardiomegaly

A 43-year-old man with diabetes and cardiomegaly has had an attack of pseudogout. He should be evaluated for which of the following?

• a.Renal disease
• b.Hemochromatosis
• c.Peptic ulcer disease
• d.Lyme disease
• e.Inflammatory bowel disease

The answer is b.

Calcium Pyrophosphate Crystals

Pseudogout is part of the spectrum of calcium pyrophosphate deposition disease. It is usually an acute monoarthritis or oligoarthritis caused by calcium pyrophosphate crystals in the joint. Pseudogout may be associated with hemochromatosis. Since the patient has a history of diabetes mellitus and cardiomyopathy, hemochromatosis must be considered. Serum iron saturation should be measured. Ferritin may also be a useful measure of iron stores. Pseudogout has also been associated with hyperparathyroidism. A familial form of the disease has been localized to chromosomes 8q and 5p. Inflammatory bowel disease, Lyme disease, and peptic ulcer disease do not predispose to pseudogout.

Ortho Instruments & Function

About Opioids In a multi-trauma patient with a head injury

 In a multi-trauma patient with a head injury, opioids ;

• a)can be used to treat severe pain
• b)cannot be given to a ventilated patient
• c)can be given intramuscularly (IM) in the general ward
• d)will cause a change to ICP in a ventilated patient whose blood pressure remains constant
• e)will require the use of supplemental oxygen

 T F F F T

A multi-trauma patient with a head injury is likely to be in severe pain. Pain can increase ICP, therefore it is not only humane to treat the patient it is intracranially beneficial. However if opioids can be avoided by the use of nerve blocks this should be done. If not suitable, then small intravenous doses of an opioid can be used with the patient’s neurological status closely monitored in an intensive care or high dependency environment.

In patients who are being ventilated, it is quite safe to use opioids. Provided blood pressure does not fall, there is no change in ICP. If BP falls, autoregulation induces cerebral arterial vasodilatation, which, in a decompensated state, will raise ICP. A patient who is breathing spontaneously, may also have a fall in arterial saturation. This would exacerbate the effects of a rising CO.
Supplemental O2 should be given whenever possible to reduce the risk of hypoxia, known to occur when a patient is under the effect of an opioid falls asleep.

Proposed decision tree for the management of epiglottitis

The main consideration in management is airway maintenance. Patients without signs and symptoms of airway obstruction can be treated medically in a hospital unit with equipments and personnel available for airway management if required.
A second or third generation cephalosporin is the most effective antibiotic against beta lactamase producing organisms and should be considered as initial antibiotic therapy. Simultaneous treatment of the underlying condition is mandatory. Corticisteroids have not proven in a prospective randomized trial to reduce the need for airway intervention or hasten recovery in adult acute epiglottitis.
This algorithm shows the proposed decision tree for the management of epiglottitis.

 Click her for enlargement

Types of respiratory pattern of breathing

A 55-year-old man with emphysema will have which kind of respiratory pattern of breathing?

• a.Biot respiration
• b.Apneustic breathing
• c.Cheyne-Stokes respiration
• d.Rapid and shallow breathing
• e.Kussmaul breathing

The answer is d.

In emphysema, there is destruction of alveolar septa and reduced elastic recoil. This causes collapse of the small airways and prolongs the expiratory phase of respiration.
During the prolonged expiration, patients will “purse” their lips to avoid collapse of the small airways. The respiratory rate is increased by having a markedly shortened inspiratory interval.

Kussmaul respirations are slow and deep respirations to increase the tidal volume in patients with diabetic ketoacidosis. Biot respirations are seen in patients with increased intracranial pressure. These are irregular, unpredictable periods of apnea alternating with periods of noisy hyperventilation. Cheynes-Stokes respirationis a rhythmic, gradually changing pattern of apnea and hyperpnea that is cardiac or neurologic in origin. Apneustic breathing is characterized by a long period of inspiration or gasping with almost no expiratory phase.

A case of Necrolytic migratory erythema due to glucagonoma.

This 63-year-old woman with a 4 1/2-year history of diabetes mellitus presented with an ulcerating rash, primarily on the shins, groin, and face (Panel A); cheilitis (Panel B); and glossitis.
Her symptoms had been worsening for 4 years despite specialized wound care. In addition, she noted concurrent weight loss, depression, abdominal pain, and intractable nausea. She was taking 500 mg of metformin daily. Given her history of diabetes mellitus and the skin findings, abdominal computed tomography was performed, and glucagon levels were measured.

An enhancing, lobulated mass measuring 7 cm in diameter was found in the tail of the pancreas, and the patient's fasting glucagon level was elevated, at 890 pg per milliliter (normal range, 0 to 80). The mass was resected, and pathological examination of the specimen confirmed a diagnosis of glucagonoma.

Glucagonomas are rare neuroendocrine tumors that can cause diabetes and a rash known as necrolytic migratory erythema, which has a characteristic annular pattern of erythema with central crusting and bullae. The prognosis correlates with the stage of tumor development and the potential for resection. In this patient, 1 day after resection, the rash had faded significantly. Four weeks after discharge, the patient had normal glucose levels (while taking no medication), and the necrolytic migratory erythema had completely resolved.

Video demonstrates Actions of the ocular muscles

This short video demonstrates how the eye muscles work together to move the eye illustrated by simple animation

Management of a case of scrotal pain and swelling testis

A 5 year old presents to your office complaining of scrotal pain and you note swelling of the left testis. Appropriate management at this time includes

• A) continued observation
• B) elevation of the scrotum and ice therapy
• C) ultrasound evaluation
• D) doppler stethoscope evaluation
• E) CT scan of the pelvis

The answer is C. 

Testicular torsion should be suspected in patients who complain of acute scrotal pain and swelling. Torsion of the testis is a surgical emergency because the likelihood of testicular damage increases as the duration of torsion increases.

Associated conditions that may resemble testicular torsion, such as torsion of a testicular appendage, epididymitis, trauma, hernia, hydrocele, varicocele, and Henoch-Sch?nlein purpura, in general do not require immediate surgical intervention. Testicular torsion is most common in neonates and postpubertal boys, although it can occur in males of any age. Henoch-Schonlein purpura and torsion of a testicular appendage typically occur in prepubertal boys, whereas epididymitis most often develops in postpubertal boys.

The cause of an acute scrotum can usually be made based on a careful history, a thorough physical examination and appropriate diagnostic tests. The onset, character, and severity of symptoms must be determined. The physical examination should include inspection and palpation of the abdomen, testis, epididymis, scrotum, and inguinal region. Urinalysis should always be performed. Scrotal imaging with Doppler color flow ultrasound is necessary when the diagnosis remains unclear. Once the correct diagnosis is established, prompt surgical evaluation should be performed.

A “spectacle” view of both testes with colour Doppler ultrasound

Significance of Carnett's sign

The idea of Carnett's sign is that (acute) abdominal pain remains unchanged or increases when the muscles of the abdominal wall are tensed.So, if Pain source is Intra-Abdominal (Negative Carnett's Sign),Abdominal Pain decreases with tensing abdomen.
And in Abdominal Muscle Wall Pain (Positive Carnett's Sign), Pain increases or remains unchanged

Technique

A- Patient lies supine
B- Patient tenses abdominal wall by
-asking the patient  to lift the head and shoulders from the examination table to tense the abdominal muscles
-An alternative is to ask the patient to raise both legs with straight knees.

Carnett's sign for patients with pelvic pain. The examiner places his or her finger on the tender area of the patient's abdomen and asks the patient to raise both legs off the table. An increase in the patient's pain during this maneuver is considered a positive test.

Picture and Imaging of Nasopharyngeal Cyst

This nasopharyngeal mass on the left side was discovered during a routine nasopharyngoscopy in a 38 year-old smoker who presented with hemoptysis and epistaxis.

The CT scan below showed a mass arising from the left lateral nasopharyngeal wall. The mass was surgically removed. It turned out to be a benign mucocele.

How to distinguish Athetosis from Chorea ?

Sometimes is difficult to distinguish athetosis from chorea (hence the term choreoathetosis). Typically, however, athetoid movements are slower than choreiform movements.

Athetosis is an extrapyramidal sign characterized by slow, continuous, twisting, involuntary movements. Typically, these movements involve the face, neck, and distal extremities, such as the forearm, wrist and hand.
Facial grimaces, jaw and tongue movements, and occasional phonation are associated with neck movements. Athetosis worsens during stress and voluntary activity, may subside during relaxation, and disappears during sleep. It is commonly a lifelong affliction.

A: With athetosis, movements are typically slow, twisting, and writhing. They're associated with spasticity and most commonly involve the face, neck, and distal extremities. 

B: With chorea, movements are brief, rapid, jerky, and unpredictable. They can occur at rest or during normal movement. Typically, they involve the hands, lower arm, face, and head.

Positions of fingers in movements of athetosis.

Athetosis usually begins during childhood, resulting from hypoxia at birth, kernicterus, or a genetic disorder. In adults, athetosis usually results from a vascular or neoplastic lesion, a degenerative disease, drug toxicity, or hypoxia.

Schatzki Ring as appeared by Endoscope and barium swallow

A Schatzki ring also called Schatzki-Gary ring is a narrowing of the lower part of the esophagus that can cause intermittent dysphagia. The narrowing is caused by a ring of mucosal tissue (which lines the esophagus) or muscular tissue.And This ring is congenital in origin.

Two rings have been identified in the distal esophagus.
1- Muscular ring, or A ring, is a thickened symmetric band of muscle that forms the upper border of the esophageal vestibule and is located approximately 2 cm above the gastroesophageal junction. The A ring is rare; furthermore, it is even more rarely associated with dysphagia.
2- Mucosal ring, or B ring, is quite common and is the subject of discussion in this topic. The B ring is a diaphragmlike thin mucosal ring usually located at the squamocolumnar junction; it may be symptomatic or asymptomatic, depending on the luminal diameter.

Endoscopic image of Schatzki ring.

Patients typically present with intermittent nonprogressive dysphagia for solids. Fortunately, most patients respond well to initial and repeat dilatation therapy. A small number of patients may have stubborn rings that require more aggressive endoscopic or surgical intervention.

This Prone, single-contrast barium esophagogram demonstrating Schatzki ring a thin, ringlike narrowing (arrows) in the lower esophagus just above a hiatal hernia. This view is most sensitive for detecting lower esophageal rings, provided adequate esophageal distention is achieved.