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A 35 Year Old Patient With Progressive Hearing Loss

February 2, 2017, 1:41 pm
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A 35-year-old presents with unilateral hearing loss that has been gradual but progressive over the last 6 months. Otoscopy reveals a Cholesteatoma.



Appropriate treatment of the above condition consists of
A) Prolonged antibiotics for up to 4 weeks
B) Decongestant and antihistamine administration
C) Corticosteroid treatment for 2 weeks
D) Hearing aid amplification
E) Tympanomastoidectomy

Answer:
The answer is E. (Tympanomastoidectomy)

Discussion: Cholesteatoma is a growth of desquamated, stratified, squamous epithelium within the middle ear space. The condition occurs when keratin desquamates from the epithelial lining of the sac and gradually enlarges with eventual erosion of the ossicular chain, mastoid bowl, and external auditory canal. The development of a cholesteatoma typically occurs after a retraction pocket has formed in the posterior/superior quadrant of the ear, often as a result of chronic eustachian tube dysfunction. It may also occur after tympanic membrane (TM) trauma, such as a traumatic, inflammatory, or iatrogenic perforation. Without treatment, cholesteatomas may erode the tegmen
tympani (the bony covering of the middle fossa), the sigmoid sinus, or even the inner ear. As a result, untreated cholesteatomas can result in lateral sinus thrombosis, sepsis, brain abscess, sensorineural hearing loss, vertigo, disequilibrium, facial paralysis, and even death.
Treatment is surgical, usually involving a tympanomastoidectomy.
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Shoulder Dislocation - A Brief DIscussion

February 4, 2017, 8:51 am
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Anterior shoulder dislocations are the most common and frequently caused by falling with the arm externally rotated and abducted.

Clinical Presentation: Patients present with the affected extremity held in adduction and internal rotation. Often, they complain of shoulder pain, refuse to move the affected arm, and may support the dislocated shoulder with the other arm. The acromion becomes prominent with loss of the rounded contour of the deltoid. A neurovascular examination of the upper extremity should be
performed to rule out associated injury, most commonly of the axillary nerve (sensation over the deltoid) and of the musculocutaneous nerve (sensation on the anterolateral forearm). Vascular injuries have rarely been reported to occur.

Diagnosis: Standard radiographic examination to evaluate for associated fracture should include AP and either axillary lateral or scapular views.

Anterior Shoulder Dislocation. Radiographic evaluation demonstrates that the humeral head is not in the glenoid fossa but is located anterior and inferior to it.


Posterior shoulder dislocations are commonly missed because of subtle radiographic findings.


Clinical Presentation: The arm is held internally rotated and slightly abducted. Patients are unable to externally rotate their shoulder. On examination, a posterior prominence exists. Posterior dislocations can occur with a posterior-directed force as seen during grand mal seizures or electric shock.

Posterior Shoulder Dislocation. AP radiograph of this rare type of shoulder dislocation. Because of internal rotation of the greater tuberosity, the humeral head appears like a dip of ice cream on a cone, thus called the “ice cream cone sign.”

Management: Closed reduction is the treatment for all types of shoulder dislocations and should be completed as soon as possible to avoid avascular necrosis to the humeral head. Due to shoulder girdle spasm, conscious sedation is often required. There are many methods to reduce anterior shoulder dislocations, including Stimson, Rockwood traction and counter traction, and Milch. The basic premise is to apply axial traction, externally rotate, and abduct. Scapular manipulation and the Stimson method are successful techniques, especially in the thin patient.

Neurovascular and radiographic examination should occur before and after reduction.

The patient should be placed in a sling after reduction and follow-up with a musculoskeletal specialist should be recommended.
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Brachial Plexus - Anatomy

February 4, 2017, 1:36 pm
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Introduction To Erythema multiforme

February 4, 2017, 2:00 pm
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Definition: Erythema multiforme (EM) is an acute, self-limited, and sometimes recurring skin condition that is considered to be a type IV hypersensitivity reaction.
Etiology: It occurs in response to medicines, infections, or illness

  • Herpes simplex virus (HSV; frequently labialis) is strongly associated but may not be clinically apparent. Other viruses, bacteria (M pneumoniae, Chlamydia, Salmonella, Mycobacterium), and fungi (Histoplasma capsulatum, dermatophytes)
  • are also associated. 
  • Medications account for <10%; NSAIDs, sulfonamides, antiepileptics, allopurinol, and antibiotics are
  • responsible for the majority. 
  • Physical factors such as trauma, ultraviolet light exposure, and cold have been reported to elicit EM.

Clinical Features: 

Erythema Multiforme. Symmetric distribution of targetoid macules and plaques. The dusky central zone is more obvious on the left waistline lesions.

  • Erythema multiforme (EM) begins with symmetric, erythematous, sharply defined extremity or trunk macules, and evolves into a “targetoid” or “bull’s eye” morphology (a flat, dusky, central area with two concentric, erythematous rings).
  • Bullae may appear in the central dusky area (bullous EM).
  • The mucous membranes, typically oral, may become involved and raise concern for Steven Johnson Syndrome. 
  • The typical targetoid lesions allow a diagnosis to be made clinically (bullae, purpura, and mucosal involvement should prompt a dermatology consultation).
  • The rash usually persists for 1 to 4 weeks.
Erythema Multiforme. Wrist, hand, and fingers with typical central dusky centers surrounded by the concentric “bull’s eye” rings.


Classification: The condition varies from a mild, self-limited rash to a severe, life-threatening disease.
  • Erythema multiforme minor—typical targets or raised, edematous papules distributed acrally
  • Erythema multiforme major—typical targets or raised, edematous papules distributed acrally with involvement of one or more mucous membranes; epidermal detachment involves less than 10% of total body surface area (TBSA)
  • SJS/TEN—widespread blisters predominant on the trunk and face, presenting with erythematous or pruritic macules and one or more mucous membrane erosions; epidermal detachment is less than 10% TBSA for Stevens-Johnson syndrome and 30% or more for toxic epidermal necrolysis.
Management: 
  • Prevention of HSV recurrences is essential. Antivirals administered after lesions present have minimal clinical impact, but patients should be referred for future prophylaxis consideration.
  • Use of facial sunscreens and lip balms may help prevent UVB-induced recurrences. 
  • Systemic steroids are discouraged but can be considered in atypical presentations. 
  • With the distinctive clinical findings and no systemic symptoms, patients may be discharged home. Systemic symptoms and atypical presentations require admission and dermatologic consultation.
Treatment of mild symptoms may include:
  • Medicines such as antihistamines to control itching
  • Moist compresses applied to the skin
  • Oral antiviral medicine if the reaction is caused by herpes simplex
  • Pain medication recommended by your doctor to reduce fever and discomfort
  • Topical anesthetics (especially for mouth sores) to ease discomfort that interferes with eating and drinking
Treatment of severe symptoms may include:
  • Antibiotics for skin infections
  • Corticosteroids to control inflammation
  • Treatment in an intensive care or burn care unit for severe cases, Stevens-Johnson syndrome, and toxic epidermal necrolysis (top layer of skin separates from the lower layers)
  • Intravenous immunoglobulins (IVIG, an injection of healthy cells from donors into a vein) to stop the disease process
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Metastasis - Detected On Radiology

February 5, 2017, 9:39 am
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A 58 years old male came to his physician complaining of chest pain  for about 6 months. The pain was initially mild but now has gradually increased in severity. The patient mentions feeling tired all the time with no energy and unintentional weight loss.
He was sent for a chest X ray which is shown below:

X-ray chest shows a large (8 × 6 cm) well-defined mass lesion abutting the left lower chest wall with broad base towards the chest wall with partial destruction of lateral aspect of 4th rib on the left.

It was suspected to be a malignant lesion. CT chest was advised which is shown below:

Contrast CT chest (Figs A to D) was done which shows moderately enhancing metastatic bone lesion which is rounded and well-defined having a large soft tissue component from the left 4th rib, and right 10th rib (Figs B and C) laterally, the ribs are partially destroyed, few small scattered calcific densities are seen in the lesions. There is a single iso to hypodense lesion seen in liver measuring 5 × 4 cm. The lesion shows moderate heterogeneous post-contrast enhancement (Fig. D).

Diagnosis: Metastasis to ribs and liver

Case Discussion: Primary tumors which originate in other organs and involve the skeletal structures of the body either by hematogenous, lymphatic route or by direct invasion are called metastasis.
Metastases are generally multiple commonly found in the axial skeleton and sites of residual red marrow.
The common sites are vertebrae, pelvic bones, proximal femur and humerus, skull and ribs. It is unusual for metastasis to involve bones distal to the elbows or knees.
Osteolysis within the thoracic skeleton is frequent and is usually as a result of metastases. Other causes of osteolysis are enchondroma, eosinophilic granuloma or multiple myeloma.
In addition to destructive processes, degenerative processes involving sclerosis and osteophyte formation of bone must be differentiated from osteosclerotic metastases, which are usually from carcinoma prostate.
The common primary neoplasm which spread to bones is from breast, lungs, prostate, kidney and thyroid.
Occult primary is a primary malignancy in which there are no localizing signs suggestive of the site of primary tumor and has not been detected by any of the available investigative protocols. However, the metastatic lesions have been detected on clinical, radiological and biomedical parameters. Histopathology may suggest the likely site of primary.

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COPD ( Emphysema And Chronic Bronchitis) Mnemonic

February 5, 2017, 1:36 pm
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Depressed Skull Fracture

February 5, 2017, 1:55 pm
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Depressed skull fractures typically occur when a large force is applied over a small area. They are classified as open if the skin above them is lacerated. Abrasions, contusions, and hematomas may also be present over the fracture site.
The patient’s mental status is dependent upon the degree of underlying brain injury. Direct trauma can cause abrasions, contusions, hematomas, and lacerations without an underlying depressed skull fracture.  Evidence of other injuries such as a basilar fracture, facial fractures, or cervical spinal injuries may also be present.

                                            CT demonstrating depressed skull fracture. 

Management: Explore all scalp lacerations to exclude a depressed fracture. CT should be performed in all suspected depressed skull fractures to determine the extent of underlying brain injury.

  • Depressed skull fractures require immediate neurosurgical consultation. 
  • Treat open fractures with antibiotics and tetanus prophylaxis as indicated. 
  • The decision to observe or operate immediately is made by the neurosurgeon. 


Children below 2 years of age with skull fractures can develop leptomeningeal cysts, which are extrusion of CSF or brain through dural defects. For this reason, children below age 2 with skull fractures require close follow-up or admission.

Ping pong ball skull fractures can occur in new borns from a forceps delivery or from compression by mother’s sacral promontory during delivery.

Ping Pong Ball Skull Fracture. Akin to the greenstick fracture, a ping pong ball fracture occurs when a newborn or infant’s relatively soft skull is indented by the corner of a table or similar object without causing a frank break in the bone.

                                                CT demonstrates the ping pong ball effect.
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Introduction To Chilblains (Pernio)

February 5, 2017, 2:16 pm
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Chilblains (sometimes referred to as pernio) describes a number of symptoms which occur in the peripheries (e.g. toes, fingers, earlobes) in response to the cold. It is thought to be caused by an abnormal vascular response to cold exposure.

Clinical Signs And Symptoms: 
  • The areas most affected are the toes, fingers, earlobes, nose.
  • Blistering of affected area
  • Burning and itching sensation in extremities
  • Dermatitis in extremities
  • Digital ulceration (severe cases only)
  • Erythema (blanchable redness of the skin)
  • Pain in affected area
  • Skin discoloration, red to dark blue
  • Chilblains usually heal within 7–14 days.
Risk factors: Factors that may increase risk of  developing chilblains include:
  • Clothing that is tight or exposes skin to the cold. 
  • Women are more likely to get chilblains than are children and males. 
  • People who weigh about 20 percent less than is expected for their height have an increased risk of chilblains.
  • Chilblains are less likely in colder and drier areas because the living conditions and clothing used in these areas are more protective against cold. The risk of chilblains is higher if you live in an area with high humidity and cold, but not freezing, temperatures. They are more common from November to April.
  • Having poor circulation. 
  • Having been diagnosed with Raynaud's disease. 
Complications: Chilblains may cause complications if the  skin blisters. If that happens, it may develop ulcers and infections. Besides being painful, infections are potentially life-threatening if left untreated.

Management: Although chilblains are uncomfortable, they do not usually cause any permanent damage. They will usually heal on their own if further exposure to the cold is avoided.
  • Keep the affected areas warm. This means staying out of the cold, or wearing warm gloves, socks, etc, when outdoors.
  • No other treatment is normally needed, as they usually go away by themselves.
  • A range of creams and lotions can be bought from a pharmacy. However, there is no evidence that any of these are of benefit so they are therefore not recommended.
  • Steroid creams are no longer recommended for the treatment (or prevention) of chilblains.
  • If you smoke then you should try to stop, as smoking can make chilblains worse.
  • Medicines are not usually needed. A medicine called nifedipine can open wide (dilate) the small blood vessels and may help to treat chilblains which are not settling within the normal time. Occasionally it may also be used to prevent chilblains in the winter months in people who have recurring symptoms.
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Acute Anterior Myocardial Infarction - ECG

February 6, 2017, 11:00 am
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ECG Findings
• ST segment elevation in the anterior precordial leads.
• V1-V4: Anteroseptal injury.
• V3-V4: Anterior injury.
• V3-V6: Anterolateral injury. Leads I and aVL may also be involved, especially if the circumflex artery is affected (high lateral injury).
• Reciprocal ST segment depressions are often present in the inferior leads (II, III, aVF).

Important Points To Remember: 
1. The left anterior descending artery supplies blood to the anterior and lateral left ventricle and ventricular septum.
2. Normal R-wave progression (increasing upward amplitude with R wave > S wave at V3 or V4) may be interrupted.

3. The development of pathologic Q waves in any of the V leads other than V1 strongly suggests that the injury has progressed to an infarction, as seen in this example.

Pathologic ST-segment elevation beyond 1 mm (double arrow) with pathologic Q waves (arrow) in lead V3. The ST segment demonstrates a convex upward, or “tombstone,” morphology.
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Treatment Algorithm And A Brief Description Of Anaphylaxis

February 6, 2017, 11:22 am
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Anaphylaxis is a generalized immunological condition of sudden onset, which develops after exposure to a foreign substance.

Pathophysiology: The mechanism may:
• Involve an IgE-mediated reaction to a foreign protein (stings, foods, streptokinase), or to a protein–hapten conjugate (antibiotics) to which the patient has previously been exposed.
• Be complement mediated (human proteins eg G -globulin, blood products).
• Be unknown (aspirin, ‘idiopathic’).
Irrespective of the mechanism, mast cells and basophils release mediators (eg histamine, prostaglandins, thromboxanes, platelet activating factors, leukotrienes) producing clinical manifestations.
Angio-oedema caused by ACE inhibitors and hereditary angio-oedema may present in a similar way
to anaphylaxis. Hereditary angio-oedema is not usually accompanied by urticaria and is treated with C1 esterase inhibitor.

Common causes: include:

• Drugs and vaccines (e.g antibiotics, streptokinase, suxamethonium, aspirin, non-steroidal anti-inflammatory drugs (NSAIDs), intravenous (IV) contrast agents).
• Hymenoptera (bee/wasp) stings.
• Foods (nuts, shellfi sh, strawberries, wheat).
• Latex.

Clinical features: The speed of onset and severity vary with the nature and amount of the stimulus, but the onset is usually in minutes/hours. A prodromal aura or a feeling of impending death may be present. Patients on B -blockers or with a history of ischemic heart disease (IHD) or asthma may have especially severe features.
Usually two or more systems are involved:
Respiratory:  Swelling of lips, tongue, pharynx, and epiglottis may lead to complete upper airway occlusion. Lower airway involvement is similar to acute severe asthma — dyspnoea, wheeze, chest tightness, hypoxia, and hypercapnia.
Skin: Pruritus, erythema, urticarial, and angio-oedema.
Cardiovascular:  Peripheral vasodilation and increased vascular permeability cause plasma leakage from the circulation, with decreased intravascular volume, hypotension, and shock. Arrhythmias, ischaemic chest pain, and electrocardiogram (ECG) changes may be present.
GI tract:  Nausea, vomiting, diarrhoea, abdominal cramps.

Treatment
• Discontinue further administration of suspected factor (eg drug). Remove stings by scraping them carefully away from skin.
• Give 100 % oxygen (O 2 ).
• Open and maintain airway. If upper airway oedema is present, get specialist senior help immediately. Emergency intubation or a surgical airway and ventilation may be required.
• In patients with shock, airway swelling, or respiratory difficulty give 0.5mg (0.5mL of 1:1000 solution) adrenaline intramuscular (IM). Repeat after 5 min if there is no improvement. In adults treated with an adrenaline autoinjector (eg EpiPen ® ) the 300mcg dose is usually sufficient, but additional doses may be required. Give only 50 % of the usual dose of adrenaline to patients taking tricyclic antidepressants, MAOIs, or B –blockers.
• In profound shock or immediately life-threatening situations, give CPR/ ALS as necessary, and consider slow IV adrenaline 1:10,000 or 1:100,000 solution. This is recommended only for experienced clinicians who can also obtain immediate IV access. Note the different strength of adrenaline required for IV use. If there is no response to adrenaline, consider glucagon 1–2mg IM/IV every 5min (especially in patients taking B -blockers).
• Give a B 2 -agonist (eg salbutamol 5mg) nebulized with O 2 for bronchospasm, possibly with the addition of nebulized ipratropium bromide 500 mcg.
• Give IV fluid if hypotension does not rapidly respond to adrenaline. Rapid infusion of 1–2 L IV 0.9% saline may be required, with further infusion according to the clinical state.
• Antihistamine H 1 blockers (e.g chlorphenamine 10–20 mg slow IV) and H 2 blockers (e.g ranitidine 50 mg IV) are commonly given. They are second line drugs that, with hydrocortisone 100–200 mg slow IV, may reduce the severity/duration of symptoms.
• Admit/observe after initial treatment: prolonged reactions and biphasic responses may occur.
•  Where identified, the patient and GP must be informed and the hospital records appropriately labelled. Medic-Alert bracelets are useful.

Notes: For the treatment algorithm given above , some details are as follows:

1. Life-threatening problems: include

  • Airway: Swelling, hoarseness, stridor
  • Breathing: Rapid breathing, wheeze, fatigue, cyanosis, SpO2 < 92%, confusion
  • Circulation: Pale, clammy, low blood pressure, faintness, drowsy/coma

2. Adrenaline (give IM unless experienced with IV adrenaline)
IM doses of 1:1000 adrenaline (repeat after 5 min if no better)
• Adult: 500 micrograms IM (0.5 mL)
• Child more than 12 years: 500 micrograms IM (0.5 mL)
• Child 6–12 years: 300 micrograms IM (0.3 mL)
• Child less than 6 years: 150 micrograms IM (0.15 mL)
Adrenaline IV to be given only by experienced specialists 
Titrate: Adults 50 micrograms; Children 1 microgram/kg

3. IV fluid challenge:
  • Adult - 500–1000 mL
  • Child - crystalloid 20 mL/kg
Stop IV colloid if this might be the cause of anaphylaxis.

4. An inhaled B 2 -agonist such as salbutamol may be used as an adjunctive measure if bronchospasm is severe and does not respond rapidly to other treatment.

5. If adults are treated with an EpiPen ® the 300mcg will usually be sufficient. A second dose may be required.


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Nevus Simplex Or A Salmon Patch - A Vascular Lesion Of Infancy

February 7, 2017, 5:13 pm
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Nevus simplex (salmon patch) is the most common vascular lesion in infancy, present in about 40% to 60% of newborns. It appears as a blanching, slightly pink-red macule or patch most commonly on the nape of the neck, the glabella, mid-forehead, or upper eyelids. Lesions generally fade over the first 2 years of life but may become more prominent with crying or straining.

                                Newborn with characteristic salmon patches over his face.

Important Points:
1. Salmon patches are composed of ectatic dermal capillaries.
2. Salmon patches appear symmetrically and cross the midline in contrast to the unilateral distribution of a port-wine stain.
3. When seen on the nape of the neck, this lesion is referred to as a stork bite  (see picture below) or as an angel’s kiss when appearing on the forehead.

4. About 5% of those appearing at the nape of the neck will remain permanently or recur.

                Characteristic lesion on the nape of the neck is commonly called a stork bite

5. Obtain imaging to evaluate for spinal dysraphism in patients with a lumbosacral nevus simplex and another lumbosacral abnormality (dermal sinus or pit, patch of hypertrichosis, or deviated gluteal cleft).

Management: Parental education and reassurance can be helpful, but no immediate treatment is indicated. Pulsed dye laser may be considered for persistent lesions that are cosmetically undesirable.
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Different Types Of Tremors - Chart

February 8, 2017, 12:54 pm
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Acute Inferior-Posterior Myocardial Infarction - ECG

February 8, 2017, 1:06 pm
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Acute Inferior-Posterior Myocardial Infarction: 


ECG Findings: 
• ST segment elevation in inferior leads (II, III, aVF)
• ST segment depressions in the anterior leads (V1-V3) and possibly high lateral leads (I, aVL)

Important Points: 
1. The right coronary artery supplies blood to the right ventricle, the sinoatrial (SA) node, the inferior portions of the left ventricle, and usually to the posterior portion of the left ventricle and the atrioventricular (AV) node.
2. Infarctions involving the SA node may produce sinus dysrhythmias including tachycardias, bradycardias, and sinus arrest.

3. Infarctions involving the AV node may produce AV blocks.
4. In the presence of acute inferior injury, a right-sided ECG should be obtained to look for right ventricular involvement. The administration of nitroglycerin in the presence of acute right ventricular infarction can precipitate profound hypotension, as these patients are preload-dependent.
5. Since the right coronary artery so often supplies the posterior left ventricle, look for evidence of a posterior infarction (as present in the example) and consider obtaining an ECG with posterior leads.

ST-segment elevation is present in the inferior leads (II, III, aVF) (arrow), with reciprocal ST depression in the anterior leads (V2-V4) (arrowhead) and high lateral leads (I, aVL).
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A 27 year Old Woman presents With Sudden Excessive Hair Loss

February 8, 2017, 1:13 pm
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A 27-year-old woman , a mother of 2 children and who is now 6 months postpartum complains of excessive hair loss.
The most likely diagnosis is
A) Alopecia areata
B) Telogen effluvium
C) Trichotillomania
D) Tinea capitis
E) Hypothyroidism

The answer is
B. (Telogen effluvium)

Discussion:
Telogen effluvium is sudden, diffuse hair loss that occurs 3 to 6 months after a stressful event.

The causes include:

  • medications (heparin, coumarin, propranolol, haloperidol, and lithium), 
  • neoplasms, 
  • infection, and 
  • crash diets. 

The stressful event triggers the hair follicles to go into a rest phase, and once the cycle returns a larger amount of hair is lost at one time. Typically, 30% to 50% of the scalp hair is affected.

No treatment is needed. Patients should be reassured that normal hair growth should resume.
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Acid Base Balance - Mnemonic Charts

February 8, 2017, 1:16 pm
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Bacterial Conjunctivitis - A Brief Introduction

February 8, 2017, 8:44 pm
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Bacterial conjunctivitis is characterized by the acute onset of conjunctival injection and a thick yellow, white, or green mucopurulent drainage. Lid edema, erythema, and chemosis may also be seen.

Bacterial Conjunctivitis. Mucopurulent discharge, conjunctival injection, and lid swelling in a 10 year-old with H influenzae conjunctivitis.

  • Staphylococcus aureus is the most common causative bacteria.
  • Streptococcus pneumoniae and Haemophilus influenzae occur more frequently in children.


Bacterial Conjunctivitis. Mucopurulent discharge and conjunctival injection in an adult with conjunctivitis.

Hyperacute bacterial conjunctivitis, the most severe form of acute purulent conjunctivitis, is associated with N gonorrhoeae.
Symptoms are hyperacute in onset, and findings include a purulent, thick, copious discharge, eyelid swelling and tenderness, marked conjunctival hyperemia, chemosis, and preauricular adenopathy. The condition is serious and threatens sight because Neisseria species are capable of invading an intact corneal epithelium. Corneal findings include epithelial defects, marginal infiltrates, and an ulcerative keratitis that can progress to perforation.


Management:

  • Encourage frequent hand washing and warm moist compresses.
  • Empiric antibiotic choices include polymyxin/trimethoprim drops and erythromycin ophthalmic ointment. 
  • Other options include bacitracin, sulfacetamide, or polymyxin-bacitracin ointments or fluoroquinolone or azithromycin drops. 
  • Improvement should be noted in 1 to 2 days. 
  • Patients who do not improve should be referred to an ophthalmologist.
  • Fluoroquinolones should be prescribed for contact lens wearers (and keratitis ruled out) due to concern for Pseudomonas infection. 
  • Hyperacute bacterial conjunctivitis requires immediate ophthalmologic consultation and hospitalization.
Points To Remember: 

1. Conjunctivitis is a common presentation of the red eye, and should be considered after more serious causes, such as acute angle-closure glaucoma (ACG), iritis, and infectious keratitis, have been ruled out.
2. Red flags include a significantly decreased visual acuity, ciliary flush, and corneal opacity.
3. Worsening symptoms during topical treatment with Neosporin or a sulfonamide suggest a contact allergic reaction.
4. N gonorrhoeae conjunctivitis must be considered in the sexually active adult with a prominent, thick, copious discharge. Urethritis is usually present.
5. Fluoroquinolones should be prescribed for contact lens wearers because of concern for Pseudomonas infection in these patients.
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Flail Chest In A Child Following An Accidental fall From The Rooftop.

February 10, 2017, 12:36 pm
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A 8 years old child was brought to radiology department for X-ray chest following an accidental fall from the roof top.
His X ray is shown below:


X- Ray Description: X-ray chest (AP view of chest) shows 3rd to 8th rib fractures (white arrows) on left side, each at two places with encysted hemothorax (black arrow) and lung contusion (extends between the asterisks) with mediastinal pushed to the right side.

Diagnosis: Flail chest.

Clinical Discussion:
 Flail chest is a critical condition following major blunt chest trauma in which two or more
contiguous ribs are fractured at two or more places. In this condition, a segment of the thoracic cage is separated from the rest of the chest (flail segment), as a result a part of the chest wall moves freely in the opposite direction as to the rest of the chest.

The related complications are :

  • pneumothorax, 
  • pleural effusion, 
  • pulmonary laceration and 
  • contusion.

Diagnosis: CT is superior to chest radiograph for most thoracic injuries. It can demonstrate pulmonary contusion, lacerations, pneumothorax and hemothorax that may be missed on plain radiographs. Spiral CT with high resolution image acquisition followed by sagittal and coronal
reconstructions clearly depict spinal and diaphragmatic injuries if associated.

Treatment includes alteration of position to make the patient most comfortable and provide relief of pain, good analgesia with intercostal block and positive pressure ventilation. Surgical fixation is usually not required.
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Age-Related Macular Degeneration

February 10, 2017, 12:44 pm
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Age-related macular degeneration increases in incidence with each decade over 50 and is evidenced by accumulation of either hard drusen (small, discrete, round, punctate nodules) or soft drusen (larger, pale yellow or gray, without discrete margins that may be confluent). Most patients with drusen have good vision, although there may be decreased visual acuity and distortion of vision. There may be associated pigmentary changes and atrophy of the retina. Vision may slowly deteriorate if atrophy occurs.
Patients with early or late degenerative changes of the macula are at risk of developing choroidal neovascularization (CNV), which is associated with distortion of vision, blind spots, and decreased visual acuity. Macular appearance may show dirty gray lesions, hemorrhage, retinal elevation, and
exudation.

Age-Related Macular Degeneration, Drusen. : Drusen are clustered in the center of the macula.

Management: Patients with drusen need ophthalmologic evaluation every 6 to 12 months or sooner if visual distortion or decreasing visual acuity develops. If a patient complains of deterioration of visual acuity or image distortion, prompt ophthalmic evaluation is warranted.

Important Clinical Points: 
1. Age-related macular degeneration is the leading cause of blindness in the United States in patients
above 65 years of age.
2. Patient may have normal peripheral vision.
3. Untreated choroidal neovascularization (CNV) can lead to visual loss within a few days.
4. Patients frequently complain of distortion with choroidal neovascularization (CNV).

Typical macular drusen and retinal pigment epithelial (RPE) atrophy (scalloped pigment loss) in age-related macular degeneration.
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Choking In An Adult - Management Algorithm

February 10, 2017, 1:06 pm
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The management of choking is rightly taught as part of first aid. Recognition of the problem is the key to success. Clues include a person experiencing a sudden airway problem whilst eating, possibly combined with them clutching their neck.Victims with severe airway obstruction may be unable to speak or breathe and become unconscious.




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A 19-yr-old woman Presents with Fever, Rash and Cough.....

February 11, 2017, 10:07 am
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A 19-yr-old woman presents with fever, rash and cough, and is pyrexial, tachycardic and tachypnoeic. She has a florid erythematous rash on her face, trunk and arms, with scattered whitish papular lesions on the buccal mucosa.




What is the most likely Dx?
A. Meningococcaemia
B. Rubella
C. Parvovirus B19
D. Secondary syphilis
E. Measles

Answer: E. Measles

Discussion: Adult measles is unusual except in non-immunised persons. The description of this Pt’s rash is classical: the rash is maculopapular, starts on the face and migrates caudally; Koplik’s spots are present in the mouth.

In contrast, meningococcaemia is a petechial/purpuric macular rash with no buccal lesions, and there is no typical migratory pattern.



Rubella is possible, but the lesions are smaller and not intense or darkly coloured: they can also spread caudally but there is no desquamation.

Parvovirus infection produces the typical raised erythema on the cheeks (‘slapped cheek’) and usually occurs in young children: bizarre variations in the rash are sometimes seen.

The rash of secondary syphilis usually affects the upper trunk, palms and soles and flexural extremities. Mucosal lesions are usually erythematous and coalesce (‘snail track’ulcers).
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