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Techniques For Holding Surgical Instruments
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Bullous Pemphigoid - A Blistering Skin Disease
Introduction: Bullous pemphigoid is an autoimmune condition causing sub epidermal blistering of the skin. If untreated, it can persist for months or years, with periods of spontaneous remissions and exacerbation. The disease can be fatal, particularly in patients who are debilitated.
Bullous pemphigoid is most common in people older than age 60.
Pathophysiology: The bullae are formed by an immune reaction, initiated by the formation of IgG autoantibodies targeting Dystonin, also called Bullous Pemphigoid Antigen. It can also occur secondary to the development of antibodies against hemidesmosomal proteins BP180 and BP230.
Clinical features: The primary feature of bullous pemphigoid is the appearance of large blisters that don't easily rupture when touched. The fluid inside the blisters is usually clear but may contain some blood. The skin around the blisters may appear normal, reddish or darker than usual. Some people with bullous pemphigoid develop an eczema or hive-like rash rather than blisters.
In most cases, the blisters appear on the lower abdomen, groin, upper thighs and arms. Blisters are often located along creases or folds in the skin, such as the skin on the inner side of a joint.
This condition requires prompt diagnosis and treatment.
Generalized bullous form: The most common presentation; tense bullae arise on any part of the skin surface, with a predilection for the flexural areas of the skin
Vesicular form: Less common than the generalized bullous type; manifests as groups of small, tense blisters, often on an urticarial or erythematous base
Vegetative form: Very uncommon, with vegetating plaques in intertriginous areas of the skin, such as the axillae, neck, groin, and inframammary areas
Generalized erythroderma form: This rare presentation can resemble psoriasis, generalized atopic dermatitis, or other skin conditions characterized by an exfoliative erythroderma
Urticarial form: Some patients with bullous pemphigoid initially present with persistent urticarial lesions that subsequently convert to bullous eruptions; in some patients, urticarial lesions are the sole manifestations of the disease
Nodular form: This rare form, termed pemphigoid nodularis, has clinical features that resemble prurigo nodularis, with blisters arising on normal-appearing or nodular lesional skin
Acral form: In childhood-onset bullous pemphigoid associated with vaccination, the bullous lesions predominantly affect the palms, soles, and face
Infant form: In infants affected by bullous pemphigoid, the blisters tend to occur frequently on the palms, soles, and face, affecting the genital areas rarely; 60% of these infant patients have generalized blisters.
Diagnosis: is by skin biopsy in which immunofluorescence shows IgG and C3 at the dermoepidermal junction.
Management:
- Referral to dermatologist for biopsy and confirmation of diagnosis
- Oral corticosteroids are the mainstay of treatment
- Topical corticosteroids, immunosuppressants and antibiotics are also used
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Simplified Approach To Reading Chest X- Rays.
A good understanding of normal anatomy and variations is essential for the interpretation of chest
radiographs.Here is given a simplified approach to reading chest x -rays.
Most commonly the chest x rays are in a PA (posterio anterior) view in which the X-ray beam first
enters the patient from the back and then passes through the patient to the film that is placed anterior to the patient‘s chest. It uses 80–120 kV and focus film distance of 6 feet.
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A Normal Chest X-Ray (PA view)
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A Chest X-Ray (PA view) showing Mediastinal Borders
On a PA film, lung is divided radiologically into three zones:
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X- ray chest (PA view) showing lung zones
1. Upper zone extends from apices to lower border of 2nd rib anteriorly.
2. Middle zone extends from the lower border of 2nd rib anteriorly to lower border of 4th rib anteriorly.
3. Lower zone extends from the lower border of 4th rib anteriorly to lung bases.
Radiological division does not depict anatomical lobes of the lung.
In a well-centered chest X-ray, medial ends of clavicles are equidistant from vertebral spinous process. Lung fields are of equal transradiance.
Apices are visualized free of ribs and clavicles on apicogram shown below:
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X- Ray Chest - Apicogram
The normal length of trachea is 10 cm, it is central in position and bifurcates at T4–T5 vertebral level. Left atrial enlargement increases the tracheal bifurcation angle (normal is 60°). An inhaled foreign body is likely to lodge in the right lung due to the fact that the right main bronchus is shorter, straighter and wider than left main bronchus
Normal heart shadow is uniformly white with maximum transverse diameter less than half of the maximum transthoracic diameter.
Cardiothoracic ratio is estimated from the PA view of chest. It is the ratio between the maximum transverse diameter of the heart and the maximum width of thorax above the costophrenic angles:
a = right heart border tomidline,
b = left heart border to midline,
C = maximum thoracic diameter above costophrenic angles from inner borders of ribs. Cardiothoracic ratio = a + b: c. Normal cardiothoracic ratio is 1:2
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Chest x-ray (Pa view) showing Measurement of Cardiothoracic ratio
To detect any pulmonary pathology, it is important to remember the normal thoracic architecture, both lungs are compared for areas of abnormal opacities, translucency or uneven bronchovascular distribution in the lungs.
An abnormal opacity should be closely studied to ensure that it is not amalgamated opacity formed by superimposed normal structures such as bones, costal cartilages, vessels, muscles or nipple. Any opacity is evaluated by its extent, margins and location with presence or absence of calcification or cavitation. A general assessment survey is made to look for any other lesion or displacement of adjacent structures.
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Chest X ray Lateral view
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X-ray chest Pa view (negative) to help visualize bony thorax
radiographs.Here is given a simplified approach to reading chest x -rays.
Most commonly the chest x rays are in a PA (posterio anterior) view in which the X-ray beam first
enters the patient from the back and then passes through the patient to the film that is placed anterior to the patient‘s chest. It uses 80–120 kV and focus film distance of 6 feet.
On a PA film, lung is divided radiologically into three zones:
1. Upper zone extends from apices to lower border of 2nd rib anteriorly.
2. Middle zone extends from the lower border of 2nd rib anteriorly to lower border of 4th rib anteriorly.
3. Lower zone extends from the lower border of 4th rib anteriorly to lung bases.
Radiological division does not depict anatomical lobes of the lung.
In a well-centered chest X-ray, medial ends of clavicles are equidistant from vertebral spinous process. Lung fields are of equal transradiance.
Apices are visualized free of ribs and clavicles on apicogram shown below:
The normal length of trachea is 10 cm, it is central in position and bifurcates at T4–T5 vertebral level. Left atrial enlargement increases the tracheal bifurcation angle (normal is 60°). An inhaled foreign body is likely to lodge in the right lung due to the fact that the right main bronchus is shorter, straighter and wider than left main bronchus
Normal heart shadow is uniformly white with maximum transverse diameter less than half of the maximum transthoracic diameter.
Cardiothoracic ratio is estimated from the PA view of chest. It is the ratio between the maximum transverse diameter of the heart and the maximum width of thorax above the costophrenic angles:
a = right heart border tomidline,
b = left heart border to midline,
C = maximum thoracic diameter above costophrenic angles from inner borders of ribs. Cardiothoracic ratio = a + b: c. Normal cardiothoracic ratio is 1:2
To detect any pulmonary pathology, it is important to remember the normal thoracic architecture, both lungs are compared for areas of abnormal opacities, translucency or uneven bronchovascular distribution in the lungs.
An abnormal opacity should be closely studied to ensure that it is not amalgamated opacity formed by superimposed normal structures such as bones, costal cartilages, vessels, muscles or nipple. Any opacity is evaluated by its extent, margins and location with presence or absence of calcification or cavitation. A general assessment survey is made to look for any other lesion or displacement of adjacent structures.
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A 16-year-old girl who just returned from a camping trip reports an intensely pruritic vesicular rash.
A 16-year-old girl who just returned from a camping trip reports an intensely pruritic vesicular rash. The most likely diagnosis is
A) Rhus dermatitis
B) Lyme disease
C) Chigger bite
D) Brown recluse spider bite
E) Black widow spider bite
The answer is A. (Rhus dermatitis)
Discussion:
Poison ivy or poison oak is also referred to as Rhus dermatitis. The condition is associated with intensely pruritic linear streaks of vesicles, papules, and blisters. The plants contain a resinous oil that gives rise to an allergic response approximately 2 days after exposure. Contrary to common belief, the fluid in the blisters can neither transfer the rash to others nor cause it to spread.
Treatment involves topical steroid creams, Burow’s solution, calamine lotion, antihistamines, cool baths with colloidal oatmeal, and oral steroids (for 2 to 3 weeks to prevent rebound dermatitis) for more widespread cases.
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Congestive Heart Failure - Signs And Symptoms (Mnemonic)
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Costochondral Calcification Seen On Chest X-Ray
A 64 years old male came to radiology department for X-ray chest with history of cough and cold.
The X- Ray is shown below:
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1. Describe the radiological signs in the above given X ray?
Answer: X-ray chest shows normal lung fields with normal cardiac configuration. Calcification of upper and lower margins of costal cartilages is seen.
2. Comment and Explain the calcification of the costal cartilages?
Answer: Calcification of upper and lower margins of costal cartilages is seen in male (picture comparion given below) However, in females the calcification of costal cartilages is seen as solid tongue like protrusion with beak towards the sternum.
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3. Give your opinion on the X ray?
Answer: X-ray chest is normal in appearance. The pattern of calcification of costal
cartilages seen is specific for males.
Clinical Discussion: Costochondral calcifications may be seen above the age of 20 years in
male and 16 years in female. They are marginal in males and central in females. The configuration of costal cartilage calcification helps to determine the sex. This information can be of use in medical jurisprudence.
The X- Ray is shown below:
1. Describe the radiological signs in the above given X ray?
Answer: X-ray chest shows normal lung fields with normal cardiac configuration. Calcification of upper and lower margins of costal cartilages is seen.
2. Comment and Explain the calcification of the costal cartilages?
Answer: Calcification of upper and lower margins of costal cartilages is seen in male (picture comparion given below) However, in females the calcification of costal cartilages is seen as solid tongue like protrusion with beak towards the sternum.
3. Give your opinion on the X ray?
Answer: X-ray chest is normal in appearance. The pattern of calcification of costal
cartilages seen is specific for males.
Clinical Discussion: Costochondral calcifications may be seen above the age of 20 years in
male and 16 years in female. They are marginal in males and central in females. The configuration of costal cartilage calcification helps to determine the sex. This information can be of use in medical jurisprudence.
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Calcium Antagonist - Mnemonic
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Seborrheic Keratoses- Management
An 82-year-old nursing home resident is seen on monthly rounds. The floor nurse points out the skin lesions shown here. The patient is asymptomatic. Appropriate management includes
A) Punch biopsy
B) Topical 5-fluorouracil cream
C) Cryotherapy
D) Hydrocortisone cream
E) Observation
Answer: The answer is E. (Observation)
Discussion: Seborrheic keratoses are common skin lesions that affect the elderly. They tend to run in families. The average diameter is 1 cm, but they can grow to 3 cm in diameter. The lesions are brown or black, oval in shape, raised, and have a “stuck on” appearance.
They most commonly occur on the face, back, neck, and scalp. They may appear suddenly and become pruritic and crusted. Numerous lesions that appear rapidly may signal the development of an underlying malignancy.
Treatment is cosmetic and usually reserved for those that are inflamed or causing symptoms.
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Common Drug Antidotes - Chart
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Chest X Ray Showing Depressed Sternum (Pectus Excavatum)
A 48 years old male came to radiology department for X-ray chest with history of cough over several days. His chest X ray is shown below:
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X-ray chest PA and lateral view show depressed sternum or pectus excavatum (arrow), otherwise lung fields are clear.
Discussion: Pectus excavatum or depressed sternum is a congenital condition in which the sternum is caved-in along with the ribs and on X-ray chest the heart may be a little more on right side because of rotation. It can be present at birth. It is also known as cobbler’s chest, sunken chest or funnel chest.
In this, the anterior ribs being more vertical and the posterior ribs being horizontal than normal.
Pectus excavatum is sometimes considered to be cosmetic; but may develop cardiac and respiratory symptoms. The heart may be displaced or rotated and base lung capacity may be decreased.
Clinical Point Of View: Pectus excavatum, also known as sunken or funnel chest is a congenital chest wall deformity in which several ribs and the sternum grow abnormally, producing a concave, or caved-in, appearance in the anterior chest wall.
It is a common type of congenital chest wall abnormality (90%), followed by pectus carinatum (5 7%), cleft sternum, pentalogy of Cantrell, asphyxiating thoracic dystrophy, and spondylothoracic dysplasia.
Pectus excavatum occurs in an estimated 1 in 400 births, with male predominance (male-to-female ratio of 3:1). The condition is typically noticed at birth, and more than 90% of cases are diagnosed within the first year of life.
Patients younger than 10 years do not typically experience symptoms associated with shortness of breath and tend to become symptomatic during their teenage years or in early adult life.
No effective nonoperative management strategies can correct of severe pectus excavatum.
The operative treatment of pectus excavatum had been fairly well standardized and is based on the open operation originally described by Ravitch in 1949. Surgery is indicated only if the patient develops cardiopulmonary impairment. The most common goal in operative repair of pectus excavatum is to correct the chest deformity. The desire to improve the appearance of the chest is also considered an appropriate medical indication for surgery, especially in young patients.
Discussion: Pectus excavatum or depressed sternum is a congenital condition in which the sternum is caved-in along with the ribs and on X-ray chest the heart may be a little more on right side because of rotation. It can be present at birth. It is also known as cobbler’s chest, sunken chest or funnel chest.
In this, the anterior ribs being more vertical and the posterior ribs being horizontal than normal.
Pectus excavatum is sometimes considered to be cosmetic; but may develop cardiac and respiratory symptoms. The heart may be displaced or rotated and base lung capacity may be decreased.
Clinical Point Of View: Pectus excavatum, also known as sunken or funnel chest is a congenital chest wall deformity in which several ribs and the sternum grow abnormally, producing a concave, or caved-in, appearance in the anterior chest wall.
It is a common type of congenital chest wall abnormality (90%), followed by pectus carinatum (5 7%), cleft sternum, pentalogy of Cantrell, asphyxiating thoracic dystrophy, and spondylothoracic dysplasia.
Pectus excavatum occurs in an estimated 1 in 400 births, with male predominance (male-to-female ratio of 3:1). The condition is typically noticed at birth, and more than 90% of cases are diagnosed within the first year of life.
Patients younger than 10 years do not typically experience symptoms associated with shortness of breath and tend to become symptomatic during their teenage years or in early adult life.
No effective nonoperative management strategies can correct of severe pectus excavatum.
The operative treatment of pectus excavatum had been fairly well standardized and is based on the open operation originally described by Ravitch in 1949. Surgery is indicated only if the patient develops cardiopulmonary impairment. The most common goal in operative repair of pectus excavatum is to correct the chest deformity. The desire to improve the appearance of the chest is also considered an appropriate medical indication for surgery, especially in young patients.
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Some Common ECG -- Charts
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Hypertensive Retinopathy. -- Charts
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Sprengel Deformity As Seen On Chest X Ray
A 25 years old male came to radiology department for X-ray chest with history of cough over few days. His X ray is shown below:
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Comments On the Above X ray: Chest X-ray shows Sprengel deformity on left side, 2nd dorsal vertebra is hemivertebra with bilateral 3rd and 4th bifid ribs on both sides.
Sprengel deformity is failure of descent of scapula secondary to fibrous or osseous omovertebral connection; it may be associated with Klippel- Feil syndrome, renal anomalies, and webbed neck. It results in elevation and medial rotation of scapula. It may be associated with Gorlin basal cell nevus syndrome.
Clinical Discussion:
Sprengel described 4 cases of upward displacement of the scapula in 1891
and named the entity as Sprengel deformity. It is also known as high scapula or congential high scapula. It is a rare cogenital skeletal abnormality where one shoulder blade sits higher on the back than the other.
The deformity is due to a failure in early fetal development where the shoulder fails to descend properly from the neck to its final position.
Treatment includes surgery in early childhood and physiotherapy.
Comments On the Above X ray: Chest X-ray shows Sprengel deformity on left side, 2nd dorsal vertebra is hemivertebra with bilateral 3rd and 4th bifid ribs on both sides.
Sprengel deformity is failure of descent of scapula secondary to fibrous or osseous omovertebral connection; it may be associated with Klippel- Feil syndrome, renal anomalies, and webbed neck. It results in elevation and medial rotation of scapula. It may be associated with Gorlin basal cell nevus syndrome.
Clinical Discussion:
Sprengel described 4 cases of upward displacement of the scapula in 1891
and named the entity as Sprengel deformity. It is also known as high scapula or congential high scapula. It is a rare cogenital skeletal abnormality where one shoulder blade sits higher on the back than the other.
The deformity is due to a failure in early fetal development where the shoulder fails to descend properly from the neck to its final position.
Treatment includes surgery in early childhood and physiotherapy.
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Chicken Pox -- Charts
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Seroma Chest Wall.
A 17 years old male was operated for a left lateral chest wall lesion which on histopathology was a benign cystic lesion.
On 3rd postoperative day the patient developed a gradually increasing swelling under the sutures
on left chest wall without pain or discharge and there was no fever. The swelling is shown in picture below:
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He was sent for a chest X ray and it is shown below;
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Photograph of the large soft tissue lesion (the first picture), and X-ray chest show that lung fields are clear and a large soft tissue lesion over the chest wall under the suture which developed postoperatively and gradually increased in size without pain or discharge is suggestive of development of seroma.
Case Discussion:
Seroma is a pocket of clear serous fluid that sometimes develops following surgery, blood plasma seep out of ruptured small blood vessels and the dying injured cells resulting in fluid collection. It is different from hematoma which contains blood cells, and from abscess which contains
pus as a result of infection.
Seromas are sometimes seen after mastectomy, abdominal surgery and plastic surgery. It can also result following an injury.
The serous fluid in the seroma is gradually absorbed over a time (often taking many days or weeks); a knot of calcified tissue sometimes remains.
Management: In seroma depending on the volume of collection and duration of leakage, it may take a few weeks to resolve with aspiration of serum with pressure dressing. Conservative management is usually effective. If a serum or leak does not resolve, it may be necessary to place a suction drain into the wound.
On 3rd postoperative day the patient developed a gradually increasing swelling under the sutures
on left chest wall without pain or discharge and there was no fever. The swelling is shown in picture below:
He was sent for a chest X ray and it is shown below;
Photograph of the large soft tissue lesion (the first picture), and X-ray chest show that lung fields are clear and a large soft tissue lesion over the chest wall under the suture which developed postoperatively and gradually increased in size without pain or discharge is suggestive of development of seroma.
Case Discussion:
Seroma is a pocket of clear serous fluid that sometimes develops following surgery, blood plasma seep out of ruptured small blood vessels and the dying injured cells resulting in fluid collection. It is different from hematoma which contains blood cells, and from abscess which contains
pus as a result of infection.
Seromas are sometimes seen after mastectomy, abdominal surgery and plastic surgery. It can also result following an injury.
The serous fluid in the seroma is gradually absorbed over a time (often taking many days or weeks); a knot of calcified tissue sometimes remains.
Management: In seroma depending on the volume of collection and duration of leakage, it may take a few weeks to resolve with aspiration of serum with pressure dressing. Conservative management is usually effective. If a serum or leak does not resolve, it may be necessary to place a suction drain into the wound.
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A Young Woman Presents With Painful Ulcers On Her Lower Lip
An 18-year-old sexually active woman presents with a two small ulcers located on the lower lip which are painful. She is a smoker and has noticed that the ulcers have been recurrent and correlate with the onset of menses. The most likely diagnosis is
A) Kawasaki disease
B) Aphthous stomatitis
C) Squamous cell carcinoma of the lip
D) Syphilis
E) Koplik’s spot
The answer is
B. (Aphthous stomatitis)
Discussion: Aphthous stomatitis, also known as canker sores, are painful eruptions that affect the mucosal surface of the mouth. The cause is unknown. Lesions typically develop at the same time and resolve in 5 to 10 days. A viral cause has not been proved. A streptococcal bacterium has been implicated. The lesions recur at regular intervals and may correlate with the onset of menses in some women.
Treatment consists of toothpaste swish therapy, triamcinolone acetonide (Kenalog in Orabase), or tetracycline solution swish and swallow. Severe cases may respond to systemic corticosteroids.
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Measles - A Quick Review -- Charts
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Guinea worm disease (Dracunculiasis) - A Rare Case
A 36 years old male came to radiology department for X-ray chest with history of cough since one week. His X ray shows a rare finding in which the lung fields are clear, however, there are a string
like linear high density calcified guinea worms in the right axillary soft tissues. The X ray is shown below:
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X-ray right knees (shown below) was done which shows calcified guinea worms in the soft tissues of the distal posterior aspect of thigh.
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Case Discussion: Transmission of dracunculiasis has been eradicated all over the world except only a few African countries. Man acquires infection by drinking water containing infected cyclops. In the stomach these cyclops are digested by gastric juice and the parasites are released.
They penetrate the duodenal wall; migrate through viscera to the subcutaneous tissues of the various parts of the body. They grow into adults into 9–12 months. The female grows to a length of 55–120 cm, and the male is very short 2–3 cm. After infestation many of these parasites (usually gravid female, as male dies)
emerge out through the skin, while few of them are lodged in the subcutaneous tissues, die, get encapsulated and get calcified as string like appearance. Upon contact with water, the female parasite releases up to one million, microscopic larvae which remain active in water for 3–6
days. They are picked up by small crustaceans called cyclops. The larvae require a period of about 15 days for development in cyclops, which is the intermediate host.
like linear high density calcified guinea worms in the right axillary soft tissues. The X ray is shown below:
X-ray right knees (shown below) was done which shows calcified guinea worms in the soft tissues of the distal posterior aspect of thigh.
Case Discussion: Transmission of dracunculiasis has been eradicated all over the world except only a few African countries. Man acquires infection by drinking water containing infected cyclops. In the stomach these cyclops are digested by gastric juice and the parasites are released.
They penetrate the duodenal wall; migrate through viscera to the subcutaneous tissues of the various parts of the body. They grow into adults into 9–12 months. The female grows to a length of 55–120 cm, and the male is very short 2–3 cm. After infestation many of these parasites (usually gravid female, as male dies)
emerge out through the skin, while few of them are lodged in the subcutaneous tissues, die, get encapsulated and get calcified as string like appearance. Upon contact with water, the female parasite releases up to one million, microscopic larvae which remain active in water for 3–6
days. They are picked up by small crustaceans called cyclops. The larvae require a period of about 15 days for development in cyclops, which is the intermediate host.
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A Patient With Black Discoloration of The Tongue
You are examining a a patient and discover the findings seen on the picture above. Which of the following conditions is this associated with?
A) Prolonged antibiotic use
B) Sjogren’s syndrome
C) Addison’s disease
D) Chronic gastroesophageal reflux
E) Malignant melanoma
The answer is
A. (Prolonged antibiotic use)
Discussion: Black hairy tongue results from hyperplasia of the filiform papillae with deposition of keratin on the surface. The condition causes the tongue to have a dark, velvety, hairlike appearance. Associated conditions include smoking, consumption of coffee, prolonged use of antibiotics, and possibly acquired immunodeficiency syndrome.
Treatment involves using a toothbrush to scrape off the excess keratin that forms on the tongue’s surface.
Read the related article in the link below:
http://studymedicalphotos.blogspot.com/2016/10/black-hairy-tongue.html
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Description Of Common Injection Sites
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