Neonatal Resuscitation

Following is the algorithm in use for neonatal resuscitation:

Birth

•Clear of meconium?
•Breathing or crying?
•Good muscle tone?
•Colour pink?
•Term gestation?

Yes - Routine care [Provide warmth, Clear airway and dry]
No -

•Provide warmth
•Position, clear airway
•Dry, stimulate, reposition
•Give oxygen
Evaluate respirations, heart rate and colour.

If breathing, HR>100 and Pink, give supportive care.
If there is apnoea or HR<100

•Provide positive pressure ventilation

If ventilating, HR>100 and Pink, give supportive care.

If HR<60:

•Provide positive pressure ventilation

•Administer chest compressions 

If after this HR>60, go back to previous step (provide PPV).
If HR<60, administer epinephrine.

Malignant Glaucoma

Definition

Malignant glaucoma is characterised by a shallow anterior chamber associated with raise intraocular pressure and in the presence of a patent iridotomy. The condition usually follows intraocular surgery but has also been described following laser iridotomy and has even been associated with miotic therapy.

Mechanism

It is probably due to misdirection of the ciliary processes into or around the vitreous.

Anterior displacement of the lens iris diaphragm causes a shallow anterior chamber.

Diagnosis

1. Shallow anterior chamber with raised or normal IOP after a intraocular surgery.
2. Ultrasound biomicroscopy

Differential Diagnosis

1. Intumescent lens
   
2. Choroidal neoplasm
3. Central retinal vein occlusion
4. Secondary pupil block
   

Stapedectomy

It is a surgical procedure in which the stapes is removed and replaced with a prosthesis, a piston usually made of teflon/stainless steel/gold. Its a mode of treatment for otosclerosis (otospongiosis). Another procedure, stapedotomy is done sometimes (a hole is punched into the footplate of stapes and the implant fixed there).

Indications

1. Conductive deafness due to fixation of stapes.
   
2. Air bone gap of at least 40 dB.
   
3. Presence of Carhart's notch in the audiogram of a patient with conductive deafness.
   
4. Good cochlear reserve as assessed by the presence of good speech discrimination.
   

Contraindications

1. Poor general condition of the patient.
   
2. Only hearing ear.
   
3. Poor cochlear reserve as shown by poor speech discrimination scores
   
4. Patient with tinnitus and vertigo
   
5. Presence of active otosclerotic foci (otospongiosis) as evidenced by a positive flemmingo sign.
   
6. Conductive deafness due to Ehlers-Danlos Syndrome (EDS)
   

Complications

1. Facial palsy
   
2. Vertigo in the immediate post op period
   
3. Vomiting
4. Perilymph gush
5. Floating foot plate
6. Tympanic membrane tear
7. Dead labyrinth
8. Perilymph fistula
9. Labyrinthitis
10. Granuloma (Reparative)

Chronic Pharyngitis

Definition

It is a chronic inflammatory condition of the pharynx characterised by hypertrophy of the mucosa, seromucinous glands and sub epithilial lymphoid follicles.

2 types

1. Chronic catarrhal pharyngitis
2. Chronic hypertrophic (granular) pharyngitis

Aetiology

1. Prolonged/Repeated infections
2. Mouth breathing (due to any reason)
3. Chronic irritants (Eg. tobbacco chewing, ciggarettes etc)
4. Faulty voice production.
5. Environmental pollution.

Clinical Features

Symptoms

1. Pain in throat
2. Foriegn body sensation in throat
3. Tiredness of voice
4. Cough

Signs

1. Congestion of posterior pharyngeal wall, which may have red nodules. (Chronic hypertrophic/granular pharyngitis)
2. Hypertrophy of lateral pharyngeal bands.
3. Increased mucous secretions may cover the mucosa.

Treatment

1. Identification of cause and its correction.
2. Warm saline gargles.
3. Mandl's throat paint is useful in preventing secondary infections.
4. Cautery of lymphoid granules.

Glaucoma Surgeries

1. Canaloplasty
2. Laser trabeculoplasty
3. Nd:YAG Laser peripheral iridotomy
   
4. Diode laser cycloablation
5. Trabeculectomy
   
6. Glaucoma drainage implants
   

Types of Cataract Surgeries

1. Phacoemulsification
   
2. Extracapsular Cataract Extraction (ECCE)
   
3. Intra-capsular extraction
   

Glaucoma

Definition:

A disease of the eye characterized by high (or normal) intraocular pressure within the eyeball, damaged optic disk, atrophy of the optic nerve, hardening of the eyeball, and partial defect in the field of vision or complete loss of vision.

Classification:

4 basic types.

1. Primary glaucoma

1. Primary Open Angle Glaucoma
2. Normotensive glaucoma
3. Primary Angle Closure Glaucoma
4. Other variants (ex. Pigmentary glaucoma, pseudoexfoliation glaucoma)

2. Developmental glaucoma

1. Primary congenital glaucoma
2. Infantile glaucoma
3. Glaucoma associated with hereditary of familial diseases.

3. Secondary glaucoma

1. Inflammatory glaucoma
   
2. Phacogenic glaucoma
   
3. Glaucoma secondary to intraocular hemorrhage
   
4. Traumatic glaucoma
   
5. Neovascular glaucoma
   
6. Drug-induced glaucoma
   
7. Glaucoma of miscellaneous origin
   

4. Absolute glaucoma

Stages of Labour

Usually 3 stages are described

Stage 1

It starts with the onset of labour pains and ends with the full dilatation of the cervix.

This stage lasts for 12 hrs in primigravidae and 6 hours in multiparae.

Stage 2

It is furhter divided into 2 phases.

1. Propulsive phase - starts from cervix dilatation upto the descent of the presenting part into the pelvic floor.
2. Expulsive phase - It ends with the delivery of the baby.

This stage lasts for 2 hrs in primigravidae and 30 mins in multiparae.

Stage 3

This involves the expulsion of the placenta and all the membranes.

This stage lasts for about 15 mins.

Stage 4

This stage of observation  lasts for about 1 hour after stage 3. During this stage, the general condition of the patient and the behaviour of the uterus are to be carefully watched.

Atrophic Rhinitis

Definition:

It is a chronic inflammation of nose characterized by atrophy of the nasal mucosa.

Typically seen in females nearing puberty.

Aetiology:

1. Hereditary
2. Racial (more in whites)
3. Endocrinal disturbances (oestrogen)
4. Nutritional deficiency.
5. Infections
6. Auto-immune

Pathology:

Squamous metaplasia in the mucosa, atrophy of seromucinous glands, venous blood sinusoids and neve elements, obliterative endarteritis. Turbinates undergo resorption. Paranasal sinuses are small due to arrested development.

Clinical features:

1. Anosmia
2. Degenerative changes
3. Nasal obstruction
4. Epistaxis
5. Greenish/greyish black dry crusts
6. Typically, the posterior wall of the nasopharynx can be visualised.
7. Nose may show saddle deformity

Treatment:

No definitive treatment is available for this condition. The following measures are tried to provide releif to the patient.

Medical

1. Nasal irrigation and removal of crusts (alkaline solution)
2. 25% glucose in glycerine
3. Local antibiotics
4. Oestradiol spray
5. Placental extract
6. Potassium iodide (oral)

Surgical

1. Young's / Modified Young's operation - it involves the complete or partial closure of both the nostrils, to be opened after 6 months. This allows the turbinates and the mucosa to grow.
2. Narrowing the nasal cavities - this is done by injection of teflon paste or insertion of fat/cartilage/bone/teflon strips under the mucoperiostium.

Chronic Simple Rhinitis

Aetiology and Risk factors:

1. Persistant rhinitis (due to tonsillitis, adenoids or sinusitis)
2. Chronic exposure to irritants (smoke, dust etc.)
3. Nasal obstruction
4. Vasomotor rhinitis
5. Endocrinal/metabolic factors (Hypothyroidism etc.)

Pathology:

This disease is considered an early stage of hypertrophic rhinitis.

Clinical features:

1. Nasal obstruction
2. Post nasal discharge
3. Headache
4. Oedema of turbinates

Treatment:

Medical

1. Treat cause
2. Nasal irrigation with alkaline solution
3. Nasal decongestants
4. Antibiotics

Deviated Nasal Septum (DNS)

Etiology:

1. Trauma : usually in childhood, may even be during delivery.
   
2. Developmental
3. Hereditary
4. Racial predisposition

Types:

1. Anterior dislocation.
2. C-shaped
3. S-shaped
4. Spur
5. Septal thickening.

Clinical Features:

1. Nasal obstruction (more if high deviation)
2. Headache
3. Sinusitis
4. Epistaxis
5. Anosmia (partial of complete)
6. External deformity.
7. Middle ear infection.

Treatment:

Surgical treatment is adviced if nasal obstruction is complete, total anosmia is present and in  cosmetic indications.

2 types

1. SMR (Sub-mucosal Resection) operation: Not done anymore because of the numerous complications involved and now with the availability of better options.
2. Septoplasty: (treatment of choice) The mucoperichondrial flap of one side is elevated after giving a modified Killian's incision. The defect in the cartilage &/or bone is removed. This surgery can be combined with a rhinoplasy if necessary.

Advantages of Septoplasty:

1. Conservative operation.
2. Can be done in children.
3. Can be combined with rhinoplasty.
4. Revision possible in case of recurrance/unsatisfactory results.
5. Less complications.
   

Umbilical Hernia

Types:

1. Complete or incomplete (depending on whether sac extends through defect or not.)
   
2. Irreducible (incarcerated)
   
3. Sliding (wall of hernia sac not completely formed by peritoneum)
   
4. Richter's hernia (1 side of bowel wall trapped)
   

Causes:

1. Definite familial incidence.
   
2. Prematurity
   
3. Incomplete development of: lateral umbilical ligaments (obliterated umbilical arteries), urachus, round ligament (umbilical vein), subumbilical extension of transversalis fascia (Richet umbilical fascia).
   
4. Increased intra-abdominal pressure.
   

This condition is rarely symptomatic.

Treatment:

Surgery is the treatment of choice.

Indications:

1. Incarceration
2. Symptoms clearly referable to hernia.
3. Large sac

2 types of surgeries may be performed

1. Simple transverse repair of fascial defect.
   
2. Mesh or plug repair.
   

Diffuse Malignant Mesothelioma

Pathogenesis:
The disease spreads over surfaces of viscera and body cavities.
Clinical Features:

• Chest pain
• Dypsnea
• Occasionally abdominal pain, nausea, vomiting and weight loss.

Prognosis is very bad, mostly fatal and shows poor response to treatment.

This disease can only be prevented by avoiding exposure to asbestos.

Types of Leg Amputations

1. Amputation of digits
2. Partial foot amputation (Chopart, Lisfranc)
3. Ankle disarticulation (Syme, Pyrogoff)
4. Below-knee amputation (transtibial)
5. Knee-bearing amputation (knee disarticulation)
6. Above knee amputation (transfemoral)
7. Van-ness rotation/rotationplasty (Foot being turned around and reattached to allow the ankle joint to be used as a knee.)
8. Hip disarticulation
9. Hemipelvectomy

Eisenmenger's Syndrome

Description:

It is predominantly right-to-left shunt or reversal of left-to-right shunt, which usually resuts from severe pulmonary vascular obstruction.

Complications:
1. Stroke
2. Hemoptysis
3. Hyperviscosity
4. Hemostatic abnormalities.
5. Thrombocytopenia
6. Prolonged bleeding, prothrombin or partial thromboplastin times.
7. Vitamin K-dependent clotting factors deficiencies.
8. Abnormal fibrinolysis.
9. Cholelithiasis
10. Hypertrophic osteoarthropathy
11. Hyperuricemia and goutrenal dysfunction.
12. Sudden death.

Clinical Features:
Symptoms : dyspnea on exertion, chest pain, syncope, hemoptysis, angina.
Signs : cyanosis (constant or exercise), ascites, pedal edema, clubbing.

Investigations:
1. Blood tests :
a) 100% O2 does not correct arterial desaturation.
b) polycythemia (Hb > 20 g/dl common)
2. Imaging studies : echocardiography, Doppler, hemogram, catheterization
ECG shows right ventricular hypertrophy changes.

Treatment:
Surgery is indicated if medical treatment does not improve the oxygen saturation levels.
Phlebotomy may be necessary.

Acute otitis media

Causes:
1. Viruses - most commonly rhinovirus, RSV and coronavirus.
2. Bacteria - Streptococcus pneumoniae, Moraxella (Branhamella) catarrhalis, H. influenzae and Streptococcus pyogenes (rare).

Pathogenesis:
Eustachian tube is port of entry for middle-ear pathogens from nasopharynx, but also is primary route of clearing middle ear secretions. This causes inflammatory edema of nasopharynx. Following this exudative and transudative fluid collect in middle ear, which allows for overgrowth of nasopharyngeal bacteria in middle ear. This suppuration may lead to spontaneous rupture, usually anterior-inferior quadrant following which discharge is seen, which is initially serosanguineous and later becomes mucopurulent.

Complications:
1. Hearing loss
2. Mastoiditis
3. Meningitis

Clinical Features:
1. Redness with bulging of tympanic membrane.
2. Mobility may be impaired.

Treatment:
A: Medical
1. Analgesics (ibuprofen and acetaminophen)
2. Antibiotics (amoxicillin is drug of choice)
3. Decongestants and/or Antihistamines (not in children)

B: Surgical
1. Tympanostomy tubes reduce recurrences of otitis media when middle ear effusion present.
2. Myringotomy to drain the pus.
3. Adenoidectomy is not very effective.

Astigmatism

Definition:
It is the condition in which an optical system has different foci for rays that propagate in two perpendicular planes. If an optical system with astigmatism is used to form an image of a cross, the vertical and horizontal lines will be in sharp focus at two different distances.

Types:
A: Based on axis of the principal meridians
1. Regular
- With the rule
- Against the rule
- Oblique
- Bioblique
2. Irregular

B. Based on focus of the principal meridians
1. Simple
- Myopic
- Hypermetropic
2. Compund
- Myopic
- Hypermetropic
3. Mixed

Symptoms:
1. Blurring of vision
2. Squinting
3. Asthenopic symptoms
4. Headache

Treatment:
Astigmatism may be corrected with eyeglasses, contact lenses, or refractive surgery.
Spherical lenses correction along with a cylindrical lens for correction of the residual error is used.

Myopia

Definition:
It is that dioptric condition of the eye in which parallel rays of light are brought to focus at a point in front of the retina, in an eye with accomodation at rest.

Classification (based on etiology):
1. Axial myopia
2. Refractive myopia

• Curvature myopia
• Index myopia

Treatment:

1. Eyeglasses
2. Contact Lenses
3. Refractive Surgery

Cataract - Diagnosis

1. Slit-lamp biomicroscopy : To detect location and density of opacity within lens.
2. Potential visual acuity with removal of cataract can be estimated with potential acuity meter (PAM) or laser interferometer.
3. B-scan ultrasound can be used to detect retinal detachment or tumors if severe cataract prevents retinal examination.
4. Glare testing and contrast sensitivity testing can quantitatively estimate functional impact of cataract on vision.

Cataract (contd..)

Risk Factors:

• Inhaled steroids
• Tobacco use
• Exposure of UV-B light
• Allopurinol
• Trabeculectomy
• Diabetes
• Psychotropic medications (antipsychotics, antidepressants, lithium, anticonvulsants, benzodiazepines)
• Alcohol consumption
• Obesity
• Medications for hypertension, and angina

Cataract - Classification (contd..)

Classification based on location of the opacity:
1. Anterior cortical cataract
2. Anterior polar cataract
3. Anterior subcapsular cataract
4. Posterior cortical cataract
5. Posterior polar cataract
6. Posterior subcapsular cataract (PSC)
7. Nuclear cataract
Grading:

• Grey
• Yellow
• Amber
• Brown/Black

Cataract - Classification

Etiological Classification
1. Age-related cataract

• Immature Senile Cataract (IMSC)
• Cataract (MSC)
• Senile Cataract (HMSC)

2. Congenital cataract

• Sutural cataract
• Lamellar cataract
• Zonular cataract
• Total cataract

3. Secondary cataract

• Drug-induced cataract (e.g. Corticosteroids)

4. Traumatic cataract

• Blunt trauma
• Penetrating trauma

Cataract

Definition:

A cataract is a clouding that develops in the crystalline lens of the eye or in its envelope, varying in degree from slight to complete opacity and obstructing the passage of light.

Pterygium

Definition:
Pterygium is a raised, wedge-shaped growth of the conjunctiva. It is most common among those who live in tropical climates or spend a lot of time in the sun.

Pathology:
Pterygium in the conjunctiva is characterized by elastotic degeneration of collagen and fibrovascular proliferation. It has an advancing portion called the head of the pterygium, which is connected to the main body of the pterygium by the neck. Sometimes a line of iron deposition can be seen adjacent to the head of the pterygium called Stocker's line. The location of the line can give an indication of the pattern of growth.
Anatomically, the pterygium is comprised of several segments:

• Fuchs' Patches (minute gray blemishes that disperse near the pterygium head).
• Stocker's Line (a brownish line composed of iron deposits).
• Hood (fibrous nonvascular portion of the pterygium).
• Head (apex of the pterygium, typically raised and highly vascular).
• Body (fleshy elevated portion congested with tortuous vessels).
• Superior Edge (upper edge of the triangular or wing shaped portion of the pterygium).
• Inferior Edge (lower edge of the triangular or wing shaped portion of the ptyerygium).

Symptoms:
Symptoms of pterygium include

1. Persistent redness
2. Inflammation
3. Foreign body sensation
4. Dry and itchy eyes.
5. In advanced cases the pterygium can affect vision as it invades the cornea with the potential of induced astigmatism and corneal scarring.

Treatment:
The majority of pterygia are inactive and can be treated with topical drops. Decongestant eye drops to make the eye appear less red and artificial tear drops to make the eye more comfortable when the pterygium flares up, can be used. If these are sufficient to maintain comfort and cosmesis then surgery is not indicated.
If this fails:

1. The 90 Sr plaque is a concave metal disc about 1-1.5cm in diameter which is hollow and filled with an insoluble strontium salt. The side placed on the eye is a very thin and delicate silver film that will contain the strontium but allow the beta particles to escape. The dose of radiation to the conjunctiva is controlled by the time that the plaque is left in contact with the surface. The integrity of the plaque surfaces is paramount to prevent exposure to patients and so is wipe tested to see if radioactive matter is escaping.
2. Conjunctival auto-grafting is a surgical technique that is effective and safe procedure for pterygium removal. When the pterygium is removed, the conjunctiva is also extracted, which is replaced from another peice of conjunctiva from the same patient.

Hordeolum

Definition:
A common staphyloccal infection of the lid glands, essentially an abscess, with pus formation.


Classification:
Two types

1. Internal hordeolum - relatively large, affecting the meibomian glands. May point towards the skin or towards the conjunctivae.

2. External hordeolum - also known as a stye. It is smaller and more superficial. It is an infection of the glands of Moll or Zeiss and it always points toward the skin side of the lid margin.

Clinical features:
The patient complains of redness, swelling, and pain in the eyelid and swelling which is:

1. At the base of an eyelash (external hordeolum)
2. Deep within the lid (internal hordeolum)

Treatment:

Both types of hordeola are treated with warm compresses for 10-15 minutes 3-4 times a day. If the condition does not improve within 48 hours, incision and drainage of the pus is indicated. Antibacterial ophthalmic ointment is also helpful.

Chalazion

Description:

A chalazion, also known as a meibomian gland lipogranuloma, is a cyst in the eyelid that is caused by inflammation of a blocked meibomian gland, usually on the upper eyelid.

Signs and symptoms:

1. Swelling on the eyelid
2. Eyelid tenderness
3. Sensitivity to light
4. Increased tearing
5. Heaviness of the eyelid

Treatment:

• The primary treatment is application of warm compresses for 10 to 20 minutes at least 4 times a day. This may soften the hardened oils blocking the duct and promote drainage and healing.
• Topical antibiotic eye drops or ointment.
• Corticosteroid injections
• Surgery under local anesthesia.

Complications:

• A large chalazion can cause astigmatism due to pressure on the cornea.
• Hypopigmentation may occur with corticosteroid injection.
• Sebaceous cell carcinoma (recurring chalazion).

Legg-Calvé-Perthes Syndrome (Perthes Disease)

Definition:
Legg-Calvé-Perthes syndrome is a degenerative disease of the hip joint, where a loss of bone mass leads to some degree of collapse of the hip joint, that is, to deformity of the ball of the femur and the surface of the hip socket. The disease is typically found in young children and small dogs, and it can lead to osteoarthritis in adults. Perthes can also sometimes continue into adulthood.
It is the idiopathic avascular osteonecrosis of the capital femoral epiphysis of the femoral head. It is caused by an interruption to the blood supply of the head of the femur close to the hip joint. It is equivalent to adult avascular necrosis.

Cause:
The direct cause is a reduction in blood flow to the joint, though what causes this is unknown. It is thought that the artery of the ligamentum teres femoris closes too early, not allowing time for the medial circumflex femoral artery to take over.[citation needed]Genetics does not appear to be a determining factor, though it may be involved. When the disease is genetic in origin, it typically runs along the male line. Some evidence suggests that parental smoking may be a factor, though this is not yet proven, or more recently that a deficiency of some blood factors used to disperse blood clots may lead to blockages in the vessels supplying the joint, but that, too, has not been proven.

Symptoms:
Symptoms are hip or groin pain, exacerbated by hip/leg movement. There is a reduced range of motion at the hip joint and a painful or antalgic gait. There may be atrophy of thigh muscles from disuse and an inequality of leg length. In some cases, some activity can cause severe irritation or inflammation of the damaged area including standing, walking, running, kneeling, or stooping repeatedly for an extended period of time.
Signs:
The first signs are complaints of soreness from the child, particularly when tired. The pain is usually in the hip, referred to the knee. It is predominantly a disease of boys (4:1 ratio). Whereas Perthes is generally diagnosed between 5 and 12 years of age. Typically the disease is only seen in one hip.

Treatment:
The goal of treatment is to avoid severe degenerative arthritis. Orthopedic assessment is crucial. Younger children have a better prognosis than older children. Currently, there are studies conducted on bisphosphonates for treatment of Perthes. Analgesic medication may be given as necessary.

Rheumatic Fever

Definition:
Rheumatic fever is a multisystem inflammatory disease that occurs as a sequel to
pharyngeal infection with the bacterium, Group A Streptococcus pyogenes. Major
features are arthritis and carditis.

Clinical Features:
These are varied. They include fever, pain (with or without swelling) in one or more
joints, endocarditis, pericarditis, myocarditis, pleurisy, subcutaneous nodules, a
characteristic skin lesion (erythema marginatum) and an even more characteristic
disturbance of central nervous system function, Sydenham’s chorea. Carditis is
more frequent in the youngest age groups, and the majority of rheumatic fever
attacks occurring in adults are manifested primarily by arthritis.

1. Arthritis usually affects larger joints, particularly wrists, elbows, knees and ankles.
   Hips are less often affected, small joints of hands and feet rarely, and spine almost
   never. Characteristically, fleeting arthritis occurs but more commonly, only arthralgia alone occurs. Untreated, the joint pains settle within 1-4 weeks. The
   arthritis of rheumatic fever does not lead to permanent damage to the joints
   affected.
2. Carditis is the most important clinical manifestation of rheumatic fever, being the
   one with permanent effects. Endocarditis is detected clinically by new or changing murmurs, and pericarditis by a friction rub. Heart failure is the most serious presentation,
   occurring in younger patients.
3. Chorea is now rare. The latent period is 1 to 6 months. It features jerky, purposeless
   movements, exaggerated by tension but disappearing in sleep. It occurs
   predominantly in females.
4. Other less common manifestations include erythema marginatum, an evanescent
   macular eruption and subcutaneous nodules, which may
   appear as painless lumps in people with long-standing carditis.

Recurrence:

An attack of rheumatic fever greatly increases the chances that a subsequent
streptococcal throat infection will be followed by another attack of rheumatic
fever. The risk of recurrence is greater in children, in patients with pre-existing
rheumatic heart disease, and in those experiencing symptomatic throat infection.
The risk declines with advancing age, but nevertheless rheumatic patients remain at
increased risk well into adult life.

Diagnosis:

Revised Jones' criteria - evidence of preceding strep infection (positive throat culture or rapid streptococcal antigen test, increased or rising anti-strep Ab, recent scarlet fever) plus 2 major or 1 major and 2 minor criteria.

Major criteria

1. Polyarthritis
2. Carditis
3. Chorea
4. Subcutaneous nodules
5. Erythema marginata

Minor criteria

1. History of acute rheumatic fever
2. Rheumatic heart disease
3. Fever
4. Arthralgias
5. Increased WBC, increased ESR, increased C-reactive protein
6. Prolonged PR interval on ECG

Complications:

The major complication of rheumatic fever is valvular disease of the heart giving rise to pansystolic blowing mitral murmur, less commonly diastolic aortic murmur at left sternal border.

Treatment:

• Treat streptococcal infection with antibiotics : penicillin G 600,000-1.2 million units as 1 injection or PO for 10 days
• Erythromycin if allergic to penicillin
• Anti-inflammatory treatment - aspirin is treatment of choice for ARF
• Sedating drugs for severe chorea - phenobarbital, chlorpromazine, haloperidol

Developmental Dysplasia of the Hip (DDH)

Causes:

• Intrauterine malpositioning.
• Genetic factors
• Maternal hormones.
• Post-natal postural influence (hence rare in India)

Complications:

• Recurrence of dislocation
• Incomplete reduction
• Avascular necrosis of femoral head
• Residual deformity of hip joint
• Late onset of premature osteoarthritis

Clinical Features:

• Clunks are sensations felt when femoral head dislocates with Barlow maneuver or relocates with Ortolani maneuver

Diagnosis:

X-ray findings

1. Shenton's line should be continuous.
2. Acetabular index more vertical (closer to 90).

Treatment:

Depends on age.

1. Newborn - 3 months

• Pavlick harness
• manipulative reduction
• hip spica cast

2. 3-6 months

• Pavlick harness
• Manipulative reduction
• Hip spica cast
• Ooccasionally open reduction necessary.

3. 6-12 months

• pre-reduction traction, open or closed reduction, hip spica cast

Osteogenesis Imperfecta

Description:

Also called Brittle bone disease it is a congenital connective tissue disorder.

Clinical features:

• Fragility of bone
• Osteopenia
• Variable degrees of short stature
• Progressive skeletal deformities
• HEENT - blue sclerae (translucent thin connective tissue over choroid)
• 50% hearing loss (maturity-onset deafness)
• Dentinogenesis imperfecta

Osteopetrosis

Definition:
Osteopetrosis also known as marble bone disease and Albers-Schonberg disease is an extremely rare inherited disorder whereby the bones harden, becoming denser, in contrast to the more prevalent osteomalacia, in which the bones soften.

Variants:

1. Autosomal recessive (malignant type)
2. Autosomal dominant (benign type)
3. Carbonic anhydrase II deficiency (Type 3 Renal tubular acidosis)

Pathogenesis:


Pathologic alteration of osteoclastic bone resorption leads to thickening of cortical and lamellar bone.

Clinical Features:

• Brittle bones
• May have blindness, deafness and cranial nerve involvement if skull base involvement
• Osteopetrosis tarda
• Fractures related to brittle osteopetrotic bones or osteomyelitis
• Osteopetrosis congenita
• Failure to thrive
• Growth retardation
• Sshort stature
• Intracranial calcifications
• Sensorineural hearing loss
• Psychomotor retardation

Lab Investigations:

• X-rays

• Blood tests: anemia, elevated acid phosphatase level in some cases.
• Imaging studies: markedly increased density of skeleton, osteopetrosis tarda often detected as incidental finding, typical dense deformed sclerotic bones.

Differential Diagnosis:

• Hypervitaminosis D
• Hypoparathyroidism
• Paget's disease
• Diffuse bone metastasis of breast or prostate cancer .
• Intoxication with fluoride, lead or beryllium.
• Hematological disorders such as myelofibrosis, sickle cell disease and leukemia.

Complications:

• Multiple fractures
• Anemia (decreased marrow space)
• Hepatosplenomegaly
• Hypersplenism

Treatment:

1. Surgery

• Surgery useful if significant alterations of facial profile, recurrent fractures with subsequent deformity or severe related degenerative joint disease.
• Bone marrow transplant is only curative treatment for osteopetrosis congenita.
• Placental blood transplant (umbilical cord blood) as useful source of allogeneic hematopoietic stem cells for bone marrow reconstitution.

2. Medical

• Interferon gamma-1b
• 1,25-dihydroxyvitamin D

Prognosis:

• Good for osteopetrosis tarda, poor for other types.
• Osteopetrosis congenita usually results in death by 2 years from severe anemia, bleeding or infection.

Chronic Sinusitis

Clinical features:
HEENT examination elicits tenderness and edema. Mild mucopurulent rhinorrhoea, nasal obstruction and facial pain/frontal headache, with or without upper toothache.
Diagnosis:
2 major criteria or 1 major and 2 minor criteria
Major criteria

• Purulent nasal discharge
• Purulent pharyngeal drainage
• Cough

Minor criteria

• Periorbital edema
• Headache
• Facial pain
• Tooth pain
• Earache
• Sore throat
• Foul breath
• Increased wheeze
• Fever

Treatment:

Medical

• Corticosteroids
• Administering nasal steroids with head inverted may be more effective in cases of sinusitis refractory to traditionally applied nasal steroids.
• Antibiotics may provide short-term relief but not long-term benefit.
• Saline nasal irrigation
• Intranasal hypertonic saline washes

Surgery

• Surgical drainage if medical treatment fails
• Functional Endoscopic Sinus Surgery (FESS)
• Adenoidectomy is an alternative

Complications:

• Suppurative CNS complications
• Pott's puffy tumor
• Frontal bone osteomyelitis and subperiosteal abscess.

Mooren's Ulcer (Chronic Serpiginous Ulcer)

Definition:
Mooren's ulcer is strictly a peripheral ulcerative keratitis (PUK) with no associated scleritis.

Clinical Features:

1. It commences as one or more grey infiltrates which break down to form small
   spreading ulcers which eventually coalesce. The ulcer undermines the epithelium
   and superficial lamellae at the advancing border, forming a characteristic
   overhanging edge, the base becoming vascularized.
2. Erosion of the epithelium is accompanied by pain and watering of the eye.
3. Perforation is rare but intermittent progression over several months is usual until a
   thin nebula forms over the whole cornea with diminution of sight.
4. In about 25% of cases both corneae are affected but not always simultaneously.

Exact aetiology is unknown. It is suspected to be a degenerative condition.

Treatment:

1. Topical steroids
2. Conjunctival resection
3. Systemic immunosuppressives
4. Additional surgical procedure
5. Rehabilitation

Abdominal Aortic Aneurysm (AAA)

An unruptured AAA

Causes:
95% cases due to atherosclerosis in United States. Mycotic abdominal aortic aneurysm is caused by bacterial infection, most commonly Salmonella

Pathogenesis:
Intimal dissection causes aortic dilatation and creation of false lumen, into which blood collects.

Risk factors:

1. Smoking
2. Clinical vascular disease
3. Male
4. Old age
5. Hypertension
6. Hyperlipidemia
7. Family history of AAA

Signs and Symptoms:
Normal vital signs may be present initially with rupture, but patients can become severely hypotensive rapidly.
Abdomen usually presents as asymptomatic palpable pulsatile nontender mass, with bruits. Abdominal palpation is an important symptom.

Diagnosis:
Abdominal ultrasound or other imaging.

Treatment:

• Surgery recommended for AAA > 5.5 cm or symptomatic AAA of any diameter.

• Surgery for AAA <>
• Intervention not recommended for asymptomatic infrarenal or juxtrarenal AAA <>

Senile Dementia of Alzheimer Type

Clinical Presentation:

• Usually presents with memory deficit or personality changes
• Recent memory loss that affects job performance, difficulty performing familiar tasks, problems with language, disorientation of time and place, poor or decreased judgment, problems with abstract thinking, misplaced things, changes in mood or behavior, changes in personality, loss of initiative.
• May present as new-onset auditory hallucinations in elderly

Histology:

Prognosis:
Median survival is 4-6 years after initial diagnosis of Alzheimer disease

Carpal Tunnel Syndrome

Definition:
Carpal tunnel syndrome (CTS) is a compression neuropathy caused by constriction
of the median nerve where it passes beneath the flexor retinaculum of the wrist. It is
a common condition. The crude incidence rate in the UK of about one per thousand
person-years in hospital-diagnosed patients and twice that in primary care.

Clinical Features:

1. Tingling (paraesthesia), numbness, or discomfort in the thumb, index and
   middle fingers. Distressing tingling is often prominent by night, and the patient
   may need to exercise the fingers or shake the hand in attempt to gain relief.


2. Weakness and/or clumsiness of the hand, particularly in carrying out fine
   movements such as those concerned in writing, typing, sewing and other tasks
   necessitating pinch grip.


3. There is often forearm or elbow pain, aching in nature, poorly localised and
   exacerbated by activity. Some patients have shoulder pain. In advanced cases
   of median nerve entrapment, there is impaired sensation and thenar atrophy.

Aetiology:

Carpal tunnel syndrome usually presents as an isolated phenomenon but it is often
associated with other conditions especially where there is fluid retention or
inflammation. These include, diabetes mellitus (where it may be due to diabetic
mono-neuropathy rather than compression), the prolonged use of oral
contraceptives, pregnancy, Colles' or scaphoid fractures, other direct trauma, electric
shock, tenosynovitis, rheumatoid disease, osteoarthritis and gout. Obesity and short
stature are independent risk factors.

Colles' Fracture

Causes

The fracture is most commonly caused by people falling backward onto a hard surface and breaking their fall with extended outstretched hands.

Displacements

1. Proximal impaction
2. Dorsal displacement
3. Dorsal tilt
4. Ulnar tilt

Treatment

Treatment of depends on the severity of the fracture. An undisplaced fracture may be treated with a cast alone.The cast is applied with the distal fragment in palmar flexion and ulnar deviation. A fracture with mild angulation and displacement may require closed reduction. Significant angulation and deformity may require an open reduction and internal fixation or external fixation.

Radiograph showing a typical Colle's Fracture

Myositis Ossificans

Types:

• Nonhereditary Myositis Ossificans


• Myositis Ossificans Progressiva

Clinical Features:

Myositis ossificans usually presents with pain, tenderness, focal swelling, and joint muscle reduction, in the aftermath of a painful muscle contusion which resolved more slowly than expected, if at all.
The condition rarely is asymptomatic, and may sometimes be diagnosed from radiographs obtained for unrelated problems.
Most (i.e. 80%) ossifications arise in the thigh or arm, and are caused by a premature return to activity after an injury. Other sites include intercostal spaces, erector spinae, pectoralis muscles, glutei, and the chest. Hazy densities are sometimes noted ca. one month after injury, while the denser opacities eventually seen may not be apparent until two months have passed

Treatment:

Treatment is initially conservative, as some patients' calcifications will spontaneously be reabsorbed, and others will have minimal symptoms. In occasional cases, surgical debridement of the abnormal tissue is required, although success of such therapy is limited.

Radiograph of both feet

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Paget's disease of Bone

Paget's disease, otherwise known as osteitis deformans, is a chronic disorder that typically results in enlarged and deformed bones. It is named after Sir James Paget, the British surgeon who first described this disease. The excessive breakdown and formation of bone tissue that occurs with Paget's disease can cause bone to weaken, resulting in bone pain, arthritis, deformities, and fractures. Paget's disease may be caused by a slow virus infection (i.e., paramyxoviruses such as measles and respiratory syncytial virus), present for many years before symptoms appear. There is also a hereditary factor since the disease may appear in more than one family member.
Paget's disease is rarely diagnosed in people less than 40 years of age. Men are more commonly affected than women. Prevalence of Paget's disease ranges from 1.5 to 8 percent depending on age and country of residence. Prevalence of familial Paget's disease ranges from 10 to 40 percent in different parts of the world. Because early diagnosis and treatment is important, after age 40, siblings and children of someone with Paget's disease may wish to have an alkaline phosphatase blood test every 2 or 3 years. If the alkaline phosphatase level is above normal, other tests such as a bone-specific alkaline phosphatase test, bone scan, or x-ray can be performed.

Source : Wikipedia

Acute Myocardial Infarction

Acute myocardial infarction (AMI or MI), more commonly known as a heart attack, is a medical condition that occurs when the blood supply to a part of the heart is interrupted, most commonly due to rupture of a vulnerable plaque. The resulting ischemia or oxygen shortage causes damage and potential death of heart tissue. It is a medical emergency, and the leading cause of death for both men and women all over the world.

Important risk factors are a previous history of vascular disease such as atherosclerotic coronary heart disease and/or angina, a previous heart attack or stroke, any previous episodes of abnormal heart rhythms or syncope, older age—especially men over 40 and women over 50, smoking, excessive alcohol consumption, the abuse of certain drugs, high triglyceride levels, high LDL ("Low-density lipoprotein") and low HDL ("High density lipoprotein"), diabetes, high blood pressure, obesity, and chronically high levels of stress in certain persons.

The term myocardial infarction is derived from myocardium (the heart muscle) and infarction (tissue death due to oxygen starvation). The phrase "heart attack" is sometimes used incorrectly to describe sudden cardiac death, which may or may not be the result of acute myocardial infarction.

Classical symptoms of acute myocardial infarction include chest pain (typically radiating to the left arm), shortness of breath, nausea, vomiting, palpitations, sweating, and anxiety. Patients frequently feel suddenly ill. Women often experience different symptoms from men. The most common symptoms of MI in women include shortness of breath, weakness, and fatigue. Approximately one third of all myocardial infarctions are silent, without chest pain or other symptoms.

Immediate treatment for suspected acute myocardial infarction includes oxygen, aspirin, glyceryl trinitrate and pain relief, usually morphine sulfate. The patient will receive a number of diagnostic tests, such as an electrocardiogram (ECG, EKG), a chest X-ray and blood tests to detect elevated creatine kinase or troponin levels (these are chemical markers released by damaged tissues, especially the myocardium). Further treatment may include either medications to break down blood clots that block the blood flow to the heart, or mechanically restoring the flow by dilatation or bypass surgery of the blocked coronary artery. Coronary care unit admission allows rapid and safe treatment of complications such as abnormal heart rhythms.