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.

Minimally Invasive Anterior Hip Replacement

The anterior approach is an approach to the front of the hip joint as opposed to a lateral (side) approach to the hip or posterior (back) approach. It is a true anterior approach to the hip and should not be confused with the Harding approach which is often referred to as an anterior approach.

Between Tinea capitis and Psoriasis of the scalp

 A 6-year-old child presents complaining of patchy hair loss on the back of the scalp. Examination reveals well-demarcated areas of erythema and scaling, and although there are still some hairs in the area, they are extremely short and broken in appearance. Which of the following is the most likely diagnosis?

• a.Androgenic hair loss
• b.Psoriasis of the scalp
• c.Seborrheic dermatitis
• d.Tinea capitis
• e.Carbuncle

 The answer is d. 

The history is most consistent with tinea capitis due to either Trichophyton tonsurans or Microsporum canis. It is usually seen in school-age children and may be transmitted from person to person.

 A mild but widespread infection by Tinea capitis (Scalp ringworm). Inflamed areas are seen on the front, behind the ear and on the back of the neck.Black dots are from broken hair

Psoriasisis a hereditary disorder characterized by scaling patches and plaques appearing in specific areas of the body, such as the scalp, elbows, lumbosacral region, and knees. The lesions are “salmon pink” with a silver-colored scale that on removal produces blood (Auspitz sign). The Koebner phenomenon (with trauma, the lesion jumps to a new location) is also elicited in patients with psoriasis.
Seborrheic dermatitisis a common chronic dermatosis occurring in areas with active sebaceous glands (face, scalp, and body folds) and may occur either in infancy or in people over the age of 20. The eczematous plaques of seborrheic dermatitis are yellowish red and are often greasy with a sticky crust. Androgenic hair loss is a progressive hereditary bitemporal, frontal, or vertex balding that may begin any time after puberty. A carbuncle is a deep infectious collection of interconnecting abscesses (furuncles) arising from several hair follicles.

Uvular Necrosis after Endoscopy

This 28-year-old man presented with a sore throat 72 hours after undergoing upper endoscopy. The patient had a 6-month history of intermittent solid-food dysphagia; upper endoscopy revealed a Schatzki ring. A wire was placed endoscopically, and a 20-mm Savary dilator was passed over the wire uneventfully.
The patient felt well after the procedure and was discharged home. He noted a mild sore throat, starting 24 hours after the procedure. When it persisted, he presented for evaluation.
Physical examination revealed necrosis of the distal uvula. No specific therapy was given, and acetaminophen was recommended for discomfort. The patient reported that the tip of the uvula spontaneously sloughed off the next day, and the discomfort resolved completely. He has had no further solid-food dysphagia.

Uvular necrosis is a rare event that can occur after upper endoscopy or direct laryngoscopy. The symptoms are generally mild, and the recovery is usually complete. The mechanism of injury is thought to be impingement of the uvula by the instrument against the hard palate or posterior pharynx, leading to ischemia. Uvular injury has also been reported as a result of aggressive oropharyngeal suctioning.

Penile Prosthesis Surgery for Erectile Dysfunction