The Medical Notes
Various conditions can cause the distended abdomen. It is also described as ‘bloating’ among people. This is commonly caused by gas in the stomach and intestines. Conditions that cause Abdominal distension Ascites Intestinal parasite infection (coccidiosis, fasciolosis, giardiasis, hookworm: ancylostomiasis and necatoriasis, Strongyloidiasis) Bowel obstruction () Toxic megacolon Abdominal or Pelvic mass Inflammatory bowel disease Organomegaly Whipple’s disease Coeliac disease Cystic fibrosis Diverticulitis Kwashiorkor Pregnancy
Ranulas are that can be seen in the floor of the mouth results from an injury to the duct of salivary glands, usually the major salivary glands. Ranulas present as a swelling of connective tissue consisting of collected mucin. Ranulas may be asymptomatic. Treatment Incision and drainage Ranula excision Complete excision of the ranula with the sublingual gland Read More at: https://emedicine.medscape.com/article/1076717-overview https://en.wikipedia.org/wiki/Ranula http://www.exodontia.info/Ranulas.html
Gram-negative bacteria are a group of bacteria that do not retain the crystal violet stain used in the Gram staining method of bacterial differentiation
Granulomatosis with Polyangiitis (GPA) is a rare multisystem autoimmune disease. Typically, the upper and lower respiratory tract and the kidneys are affected, but it may affect any organs. Small vessel vasculitis granulomatous inflammation of vessels Signs and symptoms VASCULITIS: FEVER – MALAISE – WEIGHT LOSS – ARTHRALGIA/MYALGIA Recurrent respiratory infection in adults Sinusitis Epistaxis Otitis media Mastoiditis Rhinitis Nasal ulcers Pulmonary nodules Pulmonary infiltrates Hemoptysis Hematuria Glomerulonephritis Renal failure Other: Joint, eye, skin lesions Saddle nose deformity Goodpasture syndrome is similar to GPA, however nasal lesions and sinusitis could not be found in Goodpasture syndrome. Dx The best initial test: C-ANCA (+ve) Cytoplasmic antineutrophil cytoplasmic antibody (c-ANCA) Accurate test: Biopsy CXR: pneumonitis, pulmonary nodules ( “coin lesions”) and infiltrations Tx Prednisolone Cyclophosphamide ——————————— Read more at: http://www.merckmanuals.com/en-ca/professional/musculoskeletal-and-connective-tissue-disorders/vasculitis/granulomatosis-with-polyangiitis-gpa https://en.wikipedia.org/wiki/Goodpasture_syndrome http://emedicine.medscape.com/article/332622-overview
Chronic seronegative inflammatory arthritis primarily affects axial skeleton (sacroiliac joints and vertebrae) and peripheral joints. Morning stifness > 1 hour; imporves with exercise. HLA-B27 M > F Signs and symptoms Axial lower back pain stiffness of back Pain radiates to the buttock – persistant buttock pain painful sacroiliac joint Flattening of lumbar curvature Decreased cheast expansion – respiratory difficulty Peripheral enthesitis (heel-Achilles tendon) Extraarticular Cardiac – aortic insufficiency –> CHF anterior uveitis AV block (III degree) GIT – IBD Dx + FABER TEST (Flexion, ABduction and External Rotation): painful sacroiliac joint + SCHOBER TEST: measures spine flexion —-> decrease spine mobility Postural changes: increase thoracic kyphosis and decrease lumbar lordosis X-ray: Fusion of the sacroiliac spine; Bamboo spine; squaring of the vertebral bodies, calcification Accurate test is MRI Elevated CRP, ESR Tx Excercise (swimming), deep breathing exercise, no smoking NSAID Anti-TNF (infliximab, adalimumab, etanercept) DMARD (Sulfasalazine, MTX)
Reactive arthritis (ReA), formerly known as Reiter syndrome, is inflammation of the joints and tendon, often accompanied by inflammation of the eye’s conjunctiva or iris and the mucous membranes, such as those of the mouth and genitourinary tract. It is an auto immune Sero-negative arthritis which develops in response to an infection of the GI or GU tracts. The classic triad of symptoms: conjunctivitis, urethritis, and arthritis Enthesitis: tenderness at the insertion of the (Achilles) tendon Case: A 23-year-old man has a 2 week history of intermittent diarrhea, urethral discharge, and pain in the left knee. He is sexually active with multiple partners. He has several oral ulcers, iritis, a scaly papular rash on palms and soles. Genito urinary examination shows multiple superficial ulcers on the glans penis. The results of gram-stain and culture of urethral discharge are negative. Rheumatoid factor is not present. Antibiotic against Chlamydia: Doxycycline and azithramycine
Differential Diagnosis of Anemia.
Rheumatoid Arthritis is a chronic inflammatory disease that affects mainly the joints, especially small joints – synovium, but can affect systemically. The disease is caused by an autoimmune response against an unknown self antigen(s). RA is more common in women Unknown etiology Chronic poly arthritis symmetric, erosive synovitis PIP MCP Wrists Knees Ankles MTP C Spine Pathogenesis Genetic predisposition along with environmental factors may trigger the development of rheumatoid arthritis (RA), with subsequent synovial T cell activation. CD4+ T cells become activated by antigenpresenting cells (APCs) through interactions between the T cell receptor and class II major histocompatibility complex (MHC)-peptide antigen. (see the diagram in Robins Pathology) Clinical Presentation Morning stiffness – more than 1 hour – improves with activity, increases with rest Fatigue, depression, myalgia, weight loss (before the onset of arthritis) Ocular: episcleritis Lung: pleural effusions and nodules of parenchyma vasculitis Cervical vertebra: C1 – C2 subluxation Pericarditis Carpal tunnel syndrome Ruptured Baker cyst Ligaments and tendons damage: Radial deviation of the wrist and ulnar deviation of the digits (MCP) Boutonniere deformity: ((PIP flexion with DIP hyperextension) PIP permanently bent toward the palm DIP bent back away Swan neck deformity: (DIP flexion with PIP hyperextension) Hammer toe, mallet toe, claw toe Remember only […]
Lab Test and investigations normal CBC, ESR, CRP ANA and RF (-)ve Radiology Joint space narrowing Osteophytes Dense subchondral bones subchondral cyst Treatment The goal of treatment is minimize pain and increase the quality of life. Presently no treatment completely cure the disease. non-pharmacotherapy Avoiding activities that overload the joints moderate exercise: improve the strength of the muscle that connected to the joints (physiotherapy) weight loss pharmacotherapy Acetaminophen, NSAID, COX-2 inhibitor (celexicob) *not for long term treatment Intra articular injections: corticosteroid, hyaluronic acid (Hyaluronan) Topical: NSAID (Diclofenac), Capasaicin cream surgical treatment Joint replacement osteotomy Herbeden nodes in Osteo arthritis Mnemonic L: loss of joint space O: osteophytes S: subchondral cysts S: subchondral sclerosis Download as Word document Download [1.53 MB]
High anion gap metabolic acidosis is a form of metabolic acidosis characterized by a high anion gap (a medical value based on the concentrations of ions in a patient’s serum). An anion gap is usually considered to be high if it is over 11 mEq/L. G — glycols (ethylene glycol & propylene glycol) O — oxoproline, a metabolite of paracetamol L — L-lactate, the chemical responsible for lactic acidosis D — D-lactate M — methanol A — aspirin R — renal failure K — ketoacidosis, ketones generated from starvation, alcohol, and diabetic ketoacidosis M — Methanol U — Uremia (chronic kidney failure) D — Diabetic ketoacidosis P — Paraldehyde I — Infection, Iron, Isoniazid, Inborn errors of metabolism L — Lactic acidosis E — Ethylene glycol S — Salicylates Ingestion of ethylene glycol (commonly used in antifreeze) leads to a metabolic acidosis and severe damage to the central nervous system, heart, lungs, and kidneys. The increased anion gap and osmolar gap are attributable to ethylene glycol and its metabolites, oxalic acid, glycolic acid, and other organic acids.
A-a Gradient or Alveolar-arterial PO2 difference – measure of the difference between the alveolar concentration (A) of oxygen and the arterial (a) concentration of oxygen. The A-a Gradient can help determine the cause of hypoxia. Assesment of oxygenation valid only on room air increase with age Causes of increased (A-a) difference: COPD Atelectasis Pneumonia Pulmonary edema Asthma Pneumothorax ARDS Interstitial Lung disease Increase in all cases of hypoxemia, except hypoventilation and high altitude.
Klinefelter syndrome also known as 47,XXY or XXY, is the set of symptoms that result from two or more X chromosomes in males. Apart from 47,XXY there also 48,XXXY and 49,XXXXY types exist. This is called as variants of Klinefelter syndrome. Klinefelter syndrome is a form of primary testicular failure, with elevated gonadotropin levels due to lack of feedback inhibition by the pituitary gland. Findings tall, slim, underweight long limb gynecomastia lack of facial hair (Androgen Deficiency) antisocial and aggressive behavior infertility due to hypogonadism (Small atrophic testes) Dx Laboratory → Increase FSH, increase LH, increase estradiol, decrease testosterone Tx Androgen therapy Speech and behavioral therapy Treatment for infertility: microsurgical testicular sperm extraction (TESE) and the use of freshly retrieved sperm for in-vitro fertilization (IVF) Men with Klinefelter syndrome are at a higher risk of autoimmune diseases, diabetes mellitus, leg ulcers, osteopenia and osteoporosis, tumors (breast and germ cells), systemic lupus erythematosus, rheumatoid arthritis, and Sjögren syndrome
Fragile X syndrome an X-linked disorder caused by expansion of the CGG trinucleotide repeat affecting the Fragile X mental retardation 1 (FMR1) gene on the X chromosome. X-linked dominant – males are more severely affected by this disorder than females. It is the most common inherited form of mental retardation and second only to Down’s syndrome as a cause of mental impairment. Mothers of affected patients are obligate gene carriers. – Findings Learning disabilities (mental retardation) and cognitive impairment Language delay, echolalia Large, protruding ears Long face Large Jaw Large testes (Macroorchidism) at puberty Hyperextensible finger joints Hyperextensible (‘Double-jointed’) thumbs Diagnosis DNA probe to pinpoint the defective gene Other Names fra(X) syndrome FRAXA syndrome FXS marker X syndrome Martin-Bell syndrome X-linked mental retardation and macroorchidism MCQ Point Fragile X syndrome is associated with the following characteristics a) More common in boys b) Most common form of inherited mental retardation c) Involves the long arm of the X chromosome d) Can be diagnosed with a blood test e) Treatment is limited to symptomatic management
Turner syndrome (gonadal dysgenesis – 45,X) is a condition in which a female is partly or completely missing an X chromosome. Signs and symptoms Short stature Lymphedema of the hands and feet of a newborn Broad chest and widely spaced nipples Protruding ears (low set ears) Low Posterior hairline Reproductive sterility Rudimentary ovaries gonadal streak (underdeveloped gonadal structures that later become fibrotic) Amenorrhoea Increased weight, obesity Shortened metacarpal IV Small fingernails Characteristic facial features Webbed neck Aortic valve stenosis Coarctation of the aorta Bicuspid aortic valve Horseshoe kidney Nonverbal learning disability (problems with math, social skills, and spatial relations) Points Turner’s syndrome is not typically associated with central nervous system malformations or intellectual disability, although they may have some mild learning disabilities. Intellectual disability (Mental retardation) is seen in 6% of affected children. Cystic hygroma is very common Dx Echocardiogram (Congenital heart disease) Renal ultrasonography (Renal anomalies – Horshoe Kidney) Chromosome analysis – A karyotype test will reveal chromosome profile to be 45,XO Tx Growth hormone therapy – for short stature Estrogen – induce secondary sexual characteristics
Vesicoureteral reflux (VUR) – Abnormal backflow of urine from the bladder into the ureters/kidneys. Bacteria in the lower urinary tract can easily be spread by reflux to the upper tract, leading to recurrent infection with potential scarring and renal dysfunction. Grading Grade I – reflux into non-dilated ureter (results in urine reflux into the ureter only) Grade II – reflux into the renal pelvis and calyces without dilatation Grade III – mild/moderate dilatation of the ureter, renal pelvis and calyces with minimal blunting of the fornices Grade IV – dilation of the renal pelvis and calyces with moderate ureteral tortuosity Grade V – gross dilatation of the ureter, pelvis and calyces; ureteral tortuosity (twisting); loss of papillary impressions (severe hydronephrosis) VCUG – Voiding cystourethrogram
Gastroesophageal reflux Disease(GERD) occurs when stomach contents reflux, or back up, into the esophagus during or after a meal. The lower esophageal sphincter (LES) normally opens to release gas after meals. When the LES opens, stomach contents often reflux into the esophagus and out the mouth, resulting in regurgitation, or spitting up, and vomiting. GERD is common in healthy infants. More than half of all babies experience reflux in the first 3 months of life, but most stop spitting up between the ages of 12 to 24 months. Only a small number of infants have severe symptoms.
Heart Murmurs Differentiation
A collection of Classic findings in diseases
DiGeorge syndrome is also known as 22q11.2 deletion syndrome, DiGeorge anomaly, velocardiofacial syndrome (VCFS), Shprintzen syndrome, conotruncal anomaly face syndrome or Takao syndrome,Sedlackova syndrome, Cayler cardiofacial syndrome,Strong syndrome, congenital thymic aplasia, and thymic hypoplasia.
Reye’s syndrome is encephalopathy combined with hepatic fatty infiltration which usually begins shortly after recovery from an acute viral illness, especially influenza and varicella (chickenpox) in a child who has recently had aspirin or salicylates.
Differential Diagnosis of Anemia.
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