6th Cranial Nerve Palsy

Left 6th Cranial Nerve Palsy: Left eye unable to move laterally beyond midline. In this case, nerve
dysfunction was caused by diabetes-induced microvascular disease.


Sixth Left Cranial Nerve Palsy: Left eye cannot move laterally beyond midline. In this case, caused
by metastatic squamous cell cancer of the head and neck.

Femoral Nerve Block at the level of the inguinal skin crease

Femoral nerve block is commonly performed by insertion of the block needle 1-2 cm lateral to the femoral artery just below the inguinal ligament as seen in the picture which requires multiple attempts at localization of the femoral nerve Performing the block at the level of the inguinal skin crease however, has given us more consistent results in the practice as it gives more superficial position of the femoral artery and nerve, Greater width of the femoral nerve, More consistent femoral nerve-artery relationship.

Steps of of the Technique:

A 22G, 50 mm short bevel insulated needle attached to nerve stimulator (0.6 mA) is inserted adjacent to the lateral border of the femoral artery at the level of inguinal crease, a skin fold 3 to 6 cm below and parallel to the inguinal ligament. The needle is slowly advanced at an angle of 60° cephalad to the horizontal plane while seeking a quadriceps muscle twitch (rhythmic movements of the patella).

If a quadericeps muscle twitch is not obtained, the needle is withdrawn and redirected 10° laterally (The Figure below). If this maneuver does not elicit a quadericeps muscle twitch, the subsequent needle insertions should be placed at increments of 5 mm lateral to the previous insertion sites. Once a quadericeps muscle twitch is obtained at <0.4 mA, the local anesthetic of choice is injected. However, when the initial response is a sartorius muscle twitch, the quadriceps muscle twitch is sought by incrementally re-directing the needle laterally 10° at a time, and advancing the needle several mm beyond the point at which the sartorius muscle twitch was induced. After injecting 30 ml of local anesthetic the onset of blockade is expected within 3-5 minutes when the current is < 0.4 mA. The block is documented by loss of sensation in the anterio-medial thigh and saphenous nerve distribution, as well as the presence of quadriceps muscle relaxation.

Lines on anterior Abdominal Wall

This photo shows surface anatomy of some lines on the anterior abdominal wall like:

1-McBurney's point is halfway between the umbilicus and the ASIS ( anterior superior illiac spine ) and a common location that surgeons use for an incision to remove the appendix.
2-The linea alba is a fibrous structure that .................

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Glaucoma Surgery 3D Animation

Glaucoma surgery is explained using 3D computer animations

Appearance of lye strictures in X-ray

-What is the most likely diagnosis in the patient shown below?

a. Esophageal varices
b. Esophageal carcinoma
c. Reflux esophagitis
d. Lye stricture
e. Fibrovascular polyp


THE RIGHT ANSEWR : .d

There is very long segment of smoothly narrowed esophagus from just below the level of the clavicles to the EG junction. This appearance is characteristic of a stricture caused by the ingestion of a caustic material such as lye. Lye, which became component of some drain cleaners in the late ?60s, is so highly toxic that only a few drops can cause this full-thickness liquefaction necrosis of the esophagus. The acute ulcerative phase is invariably followed in several weeks by this fibrotic stage. There is a significantly higher incidence of carcinoma of the esophagus in patients with lye strictures than in the normal population.

Ultrasound use in trauma - the fast exam

instructional video describing ultrasound use in trauma - the fast exam

Lipoma arborescens (what`s it !!!)

Lipoma arborescens is a rare case affecting the synovial linings of the joints and bursae, with 'frond like' depositions of fatty tissue. They account for less than 1% of all lipomatous lesions.

Clinical presentation
Clinically presented by painless joint swelling, frequently with effusion, typically in the 5th - 7th decades. Usually these lesions are sporadic, however they can be seen in the setting of osteoarthritis, collagen vascular disorders or previous trauma.

The most common site of involvement is suprapatellar bursa of knee joint, and the disorder is usually unilateral . Occasional reports of hip, shoulder, wrist elbow are also reported. Other joint involvement is uncommon. Involvement of tendon sheath is even rarer.

Treatment and prognosis
The condition is benign and is cured by synovectomy. Recurrence is uncommon

For MRI images (of ankle involvement):

CLICK HERE

Mnemonic for Retroperitoneal structures list

This structures are collected in SAD PUCKER:

• Suprarenal glands


• Aorta & IVC


• Duodenum (half)


• Pancreas


• Ureters


• Colon (ascending & descending)


• Kidneys


• Esophagus (anterior & left covered)


• Rectum

Iron Deficiency Anemia: Causes and Treatment

Ileocecal Intussusception

A 45-year-old man with no notable medical or surgical history presented with a 24-hour history of intense pain in the right side of the abdomen with associated nausea and vomiting. He reported having had similar but much less severe episodes during the previous 6 months. Results of initial laboratory tests were unrevealing.
Physical examination showed moderate abdominal distention. Computed tomographic scans of his abdomen revealed an ileocecal intussusception (Panel A, arrow) with a pathologic mass, 2.5 cm in diameter, at the apex, also known as the lead point (Panel B, arrow). Diagnostic laparoscopy was performed, and the diagnosis of intussusception was confirmed.

Laparoscopically assisted ileocecal resection with primary anastomosis was performed. Gross inspection of the specimen showed a pedunculated lipoma within the terminal ileum. The patient had a rapid recovery, with complete resolution of his symptoms.

Oil Cyst or Fat necrosis

A 34 years old female Patient that complains of breast lump and a history of breast trauma. Diagnosis was of an oil cyst.
Note............egg-shell calcification.

So,What is oil cyst ?!
Oil cyst that also called Fat necrosis occurs when there is saponification of local fat, usually after a direct trauma. Middle-aged women with pendulous breasts are Most at risk.

At first, they are ill-defined and irregular spiculated dense masses. However, with time, they become more defined and well-circumscribed. The centre of the lesion becomes increasingly with homogenous with fat-density.

Laparoscopic appendectomy surgery.

Names of B vitamins

"The Rhythm Nearly Proved Contagious":
· In increasing order:

• Thiamine (B1)
• Riboflavin (B2)
• Niacin (B3)
• Pyridoxine (B6)
• Cobalamin (B12)

Histopathology Bone--Multiple myeloma

Mechanisms Linked to Sodium intake in Hypertension

Mechanisms Linked to Increases in Blood Pressure and the Therapeutic Effects of Healthful Dietary Patterns, Sodium Reduction, and Weight Loss.

Sodium intake initiates an autoregulatory sequence that leads to increased intravascular fluid volume and cardiac output, peripheral resistance, and blood pressure. The elevation in blood pressure results in a phenomenon called pressure natriuresis, in which increased renal perfusion pressure leads to increased excretion of fluid and sodium. In essential hypertension, however, sodium excretion is impaired. It is hypothesized that in most cases essential hypertension is a genetic disorder involving many individual genes, each of which influences the body's handling of sodium to varying degrees and becomes expressed in the context of an unhealthful dietary environment, particularly one characterized by excessive intake of salt.

64 MDCT/CTA/3D Evaluation of Pancreatic Masses

Blepharospasm

Blepharospasm is an abnormal tic, spasm, or twitch of the eyelid. It is sometimes referred to as Benign Essential Blepharospasm. Focal dystonia is another phrase for this condition, which involves a involuntary muscle contraction around the eyes. The cause can be fatigue, irritant or caffeine. The symptoms can last for a few days, but commonly disappear without treatment. Severe cases can be chronic.

Besides the tic, symptoms of blepharospasm are eye dryness, excessive blinking, twitching, sensitivity to the sun and bright lights. Blepharospasm occurs spontaneously with no indicators. Patients who experience blepharospasm usually have a history of dry eyes and photo sensitivity. Other syndromes such as Meige’s syndrome have been associated with blepharospasm. Drugs used to treat Parkinson’s disease have also been known to cause blepharospasm. Rarely, blepharospasms can be caused by concussions.

Transradial Puncture

About head lice infestations

Which of the following statements is true regarding head lice infestations?

• A) Females are more likely affected.
• B) Retreatment with pyrethrin is rarely needed.
• C) Head lice can live off the body up to 1 week.
• D) Low socioeconomic children are more likely affected.
• E) Dogs are a common vector for head lice.

The answer is:  ( A ).

Head lice are thought to be the most common type and are developing resistance to commonly used pediculicides. Every year, between 6 million and 12 million people in the United States, primarily children 3 to 10 years of age, are infested with head lice. Girls are at greater risk because..............

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3- D ultrasound image WOW !!

These 3 dimensional ultrasound images show various pathologies of the urinary bladder, providing a whole new "dimension" to sonographic imaging.

3- D ultrasound image of ureterocele:
The Rt. ureterocele is seen as a small sac bulging in from the posterior wall of the bladder.


3-D ultrasound image of bladder diverticulum:
A small right sided vesical diverticulum. (UB= urinary bladder)



Vesical calculus:
This 3-D ultrasound image of a vesical calculus shows that 3-D imaging must be used in conjunction with 2-D B-mode imaging to identify pathology. This bladder calculus is difficult to distinguish from (see topmost image) ureterocele purely on 3-D ultrasound. Perhaps a cross sectional image would show the internal structure better. (All images courtesy of Ravi Kadasne, MD, UAE).

Gastric diverticulum PIC

Upper gastrointestinal endoscopic scan showing a diverticulum (arrow) in the fundus of the stomach.

Gastric diverticula are uncommon.with equal distribution among men and women, and can be congenital or acquired.Areas of weakness caused by splitting of the longitudinal muscle fibres, an absence of peritoneal membrane and perforating arterioles may predispose to the formation of a diverticulum.
Patients with gastric diverticula are often asymptomatic, although they may present with dyspepsia, vomiting and abdominal pain. Complications such as ulceration, perforation, hemorrhage, torsion and malignancy are uncommon. The condition is diagnosed incidentally by radiologic or endoscopic examination. There is no specific treatment required for an asymptomatic diverticulum.
Surgical resection is recommended when the diverticulum is large, symptomatic or complicated by bleeding, perforation or malignancy. Both open and laparoscopic resection yield good results. Perioperative gastroscopy can help locate the diverticulum in difficult situations.
WATCH THE VIDEO

Sulcus Vocalis

Sulcus vocalis is a defect or divot in the surface of the vocal cord. This can be congenital or acquired. Vibration of the vocal cord is impaired at this location, leading to a poor traveling waveform and hoarseness.

Sulcus of right vocal cord (arrow).

Another sulcus.

Apthous Ulcers

Apthous Ulcers: Large oral ulcers in patient infected with HIV.SEE VIDEO

Spirotome Bone biopsy for osteolytic lesions under CT guidance

Soft tissue biopsy from osteolytic lesions is a challenge for the interventionist. The Spirotome Bone is conceived for this intervention. The procedure is straigthforward and produces tissue specimens of high quality in sufficient amounts to allow quantitative molecular biology.

Abscess in Abdominal Wall

An 83-year-old man with hypertension presented with a 3-month history of a painful, progressively enlarging mass in the right subcostal region. He reported no associated constitutional symptoms and no history of abdominal surgery. Local examination revealed a tender, erythematous, fluctuant mass, 3 cm by 2 cm, with clinically significant surrounding induration and an underlying fixed mass (Panel A).

Computed tomography revealed that the mass was communicating with a large gall bladder mass (Panel B, arrow). Ultrasonography-guided needle biopsy, along with histologic and immunocytochemical examinations, confirmed that the mass was an adenocarcinoma of the gall bladder. The patient did not agree to any further evaluation or treatment. He was discharged with plans for palliative care and died 5 weeks later.

RIGHT VENTRICULAR FAILURE IN COPD

Severe pulmonary hypertension increases right ventricular afterload and eventually leads to the clinical syndrome of right heart failure with systemic congestion and inability to adapt right ventricular output to peripheral demand at exercise. Many patients with advanced COPD present with ankle edema but normal right atrial pressures (at rest). This apparent paradox has stimulated speculation that edema in COPD might be a renal rather than a right ventricular problem .


However, it is now better realized that edema in COPD is likely to be initially caused by repeated stretching of the right atrium from increased right ventricular diastolic pressures at exercise or conceivably with oxygen desaturation during sleep, causing increased sympathetic nervous system tone and activation of the renin-angiotensin-aldosterone system, with resultant renal salt and water retention.
 Renal salt and water retention may be aggravated by hypercapnia, which directly increases proximal tubular reabsorption of sodium, but also activates the sympathetic nervous system and the renin-angiotensin-aldosterone system, which causes additional distal tubular sodium reabsorption through amiloride-sensitive sodium channels.

In summary, and as summarized in , systemic congestion in COPD is caused by right heart failure, involving mechanisms that are very similar to those accounting for systemic and pulmonary congestion in left heart failure, but with an important additional contribution of hypercapnia .

Male Reproductive System: Hormone Pathways

A lecture on the hormones that play a role in the male reproductive system, with emphasis on the hormonal pathways.

Ultrasound of Amoebic Liver Abscess

Amoebic liver abscess is usually single but can be multiple. Typically located in the right lobe of liver subcapsular close to the diaphragm and posterolateral, though it can be situated in any location. It`s size may vary from few centimeters to a large size occupying almost entire right lobe of liver.

Very early stage :

In the initial stage, cell death occurs but entire dissolution and liquefaction is not complete as the contents are not liquid. This may be termed as solid abscess. On ultrasound these lesions are usually small and probably are the most challenging as compared to the other stages of the liver abscesses. The margins of the abscess may be ill defined, the abscess is hypoechoic as compared to the surrounding liver. However, there is no true liquefaction at this stage and therefore there is poor or no posterior acoustic enhancement. The demarcation between the abscess and the surrounding liver is also poor.

At this stage, the differential diagnosis of fat spared area in a fatty liver or an early neoplastic lesion have to be considered.

Recently formed amoebic abscesses :

An abscess of recent onset has a distinct central liquified area. This is seen on ultrasound as a sonolucent or an hypoechoic area usually with fine internal echoes. Because of the liquefaction, there is associated posterior acoustic enhancement. The cavity may be round, oval or branching. The walls of the abscess at this stage are usually not very thick and sometimes the demarcation between the wall and the surrounding tissue can be poor. Sometimes the walls may be thicker and these may be seen as shaggy, ill-defined echogenic areas along the walls (see Picture). It is at this stage of the abscess that aspiration may be required. Small amount of air in the abscess because of secondary infection or following an aspiration is seen as highly reflective dots.

It is at this stage of the abscess that differential diagnosis of a cyst in the liver, a cyst with haemorrhage, cystic metastatic deposit or sometimes a hydatid cyst and haematoma are to be considered.

Abscesses of some duration :

The basic difference between an acute abscess and an abscess of some duration is that; in the latter the body has had time to wall up the lesion by producing a layer of fibrous tissue around it. On sonography an abscess shows thick walls which may vary from a few mm to 1.5 cm in thickness. The echogenicity of the abscess also varies, abscesses generally become more sonolucent at this stage, some abscesses become more echogenic because of organisation of fluid.

Healing Stage :

The abscess heals, the liquid contents dry up, which has been described as putty appearance. On ultrasound it is seen again as a lesion with thick walls fairly echogenic as compared to surrounding organs. This shadow can be seen on ultrasound for a long time, even years. It is usually at this stage that the differential diagnosis of a neoplasm, haemangioma or granuloma in liver come into picture.

Good video explains Action Potentials

This video explains the process by which a nerve cell receives, conducts, and transmits signals.

This video is from:
Essential Cell Biology, 3rd Edition

Agents for Spinal anesthesia

"Little Boys Prefer Toys":

• Lidocaine
• Bupivicaine
• Procaine
• Tetracaine

NOTES :
1-Lidocaine provides a short duration of anesthesia and is primarily useful for surgical and obstetrical procedures lasting less than one hour.

2-Tetracaine Vs Bupivacaine:Tetracaine and bupivacaine are used for procedures lasting 2 to 5 hours. Tetracaine appears to provide a somewhat longer duration of anesthesia and a more profound degree of motor block than does bupivacaine. On the other hand, compared with tetracaine, bupivacaine has been demonstrated to be associated with a decreased incidence of hypotension.
In addition, bupivacaine may be better than tetracaine for use in orthopedic surgical procedures since it appears to be associated with a lower incidence of tourniquet pain.

3-Vasoconstrictors can prolong the duration of spinal anesthesia of all three agents. However, the greatest duration is seen when vasoconstrictors are added to tetracaine solutions.

Guidelines for color of bruises

1. Red to blue: about 1 to 2 days old
2. Blue to purple: about 3 to 5 days old
3. Green: about 6 to 7 days old
4. Yellow to brown: about 8 to 10 days old
5. Resolved: at least 13 to 28 days old
6. It is likely safest to describe bruises as either: "new" (red, purple, or blue) or

"old" (green, yellow, or brown)

Note: The presence of bruises that have various ages may signify multiple episodes of injury caused by ongoing physical abuse.

Ultrasound-Guided Femoral Nerve Block

Electrotherapy in Physiotherapy

ANKYLOGLOSSIA and it`s solving

Ankyloglossia or tongue-tie is a congenital malformation caused by a short lingual frenulum that prevents the tongue from protruding. Occasionally, it could interfere with breast feeding.The patient in the photo is a young woman that was unable to extend her tongue. However, the short frenulum did not interfere with eating, swallowing, or speech. 

A grooved probe is used to retract the tongue and tense the frenulum.  The picture shows the site and horizontal direction of the frenulum incision.

The horizontally incised frenulum is now pulled vertically, allowing the release of the tongue. The incision is sutured vertically with absorbable stitches.

Post-operative appearance of the tongue that can now protrude down to the chin.

Chest X-rays of the Kyphotic Patient

The radiographer has, by force of habit, angled the X-ray tube caudally for the AP sitting projection. This is a positioning trap in bedside radiography of kyphotic patients. The result is extreme foreshortening of the chest. Even the use of a horizontal ray would have resulted in significant foreshortening of the lung fields (see the lateral image).

This is a lateral chest image taken on a patient with a moderately severe thoracic kyphosis. A triangular positioning sponge has been placed behind the patient. Note that the patient's chest is angled forward considerably and this position is associated with the patient's thoracic kyphosis.

Foley Catheter

A Foley catheter is a thin, sterile tube inserted into the bladder to drain urine. Because it can be left in place in the bladder for a period of time, it is also called an indwelling catheter. It is held in place with a balloon at the end, which is filled with sterile water to hold it in place. The urine drains into a bag and can then be taken from an outlet device to be drained. Laboratory tests can be conducted on your urine to look for infection, blood, muscle breakdown, crystals, electrolytes, and kidney function. The procedure to insert a catheter is called catheterization.

A Foley catheter is used with many disorders, procedures, or problems such as these:

1.Retention of urine leading to urinary hesitancy, straining to urinate, decrease in size and force of the urinary stream, interruption of urinary stream, and sensation of incomplete emptying
2.Obstruction of the urethra by an anatomical condition that makes it difficult for you to urinate: prostate hypertrophy, prostate cancer, or narrowing of the urethra
3.Urine output monitoring in a critically ill or injured person
4.Collection of a sterile urine specimen for diagnostic purposes
5.Nerve-related bladder dysfunction, such as after spinal trauma (A catheter can be inserted regularly to assist with urination.)
6.Imaging study of the lower urinary tract
7.After surgery

Risks:

-The balloon can break while the catheter is being inserted. In this case, the doctor will remove all the balloon fragments.
-The balloon does not inflate after it is in place. Usually the doctor will check the balloon inflation before inserting the catheter into the urethra. If the balloon still does not inflate after its placement into the bladder, the doctor will then insert another Foley catheter.
-Urine stops flowing into the bag. The doctor will check for correct positioning of the catheter and bag or for obstruction of urine flow within the catheter tube.
-Urine flow is blocked. The doctor will have to change the bag or the Foley catheter or both.
-Patient urethra begins to bleed. The doctor will have to monitor the bleeding.
The Foley catheter may introduce an infection into the bladder. The risk of infection in the urine increases with the number of days the catheter is in place.
-If the balloon is opened before the Foley catheter is completely inserted into the bladder, bleeding, damage and even rupture of the urethra can occur. In some individuals, long-term permanent scarring and strictures of the urethra could occur.

Too see Procedure......

HERE

USMLE ALGORITHMS: Cushing Syndrome

This video explains the complete workup of Cushing Syndrome, the causes, the diagnosis, and the full management. It is very thorough. I hope you enjoy

Generalized skin hyperpigmentation: causes

"With generalized, none of skin is SPARED ":

• Sunlight


• Pregnancy


• Addison's disease


• Renal failure


• Excess iron (haemochromatosis)


• Drugs (eg busulphan)

SIngle Incision Laparoscopic GastroJejunostomy for an advanced cancer stomach

Radiographic Anatomy of Scapula

A good position of the patient moves the scapula away from the lung field. The medial border and inferior angle of the scapula are easily seen especially if the scapula is not moved away from the field.

Normal Adult Scapula, AP view

a-------------acromion
c------------- coracoid process
g------------ glenoid fossa
s------------ spine
lb----------- lateral border
ia----------- inferior angle
is----------- infraspinous portion

Asian Ear Cleaning Tools

Ear cleaning is a very intimate process and feels extremely pleasant and stimulating when conducted by a trusted person. It has been traditionally performed in Asian countries for ages. People who experienced the sensation of having their ears cleaning during a trip to Japan, Thailand or Vietnam describe it as "Amazing", "Incredibly soothing" and "extremely relaxing". It has also been said that the procedure is like "intercourse for your ear".

As a sense organ the ear has a lot of nerve endings that are connected to other parts of our body, particularly internal organs. The stimulation to touch is therefore exciting and relaxing. Most people fall asleep within minutes due to the comfort this provides.

Trousseau sign of latent tetany

Trousseau’s sign presents as carpopedal spasm occurring after a few minutes of inflation of a sphygmomanometer cuff above systolic blood pressure "about 3 minutes inflate of cuff >SBP". Occlusion of the brachial artery causes flexion of the wrist and metacarpophalangeal joints, hyperextension of the fingers, and flexion of the thumb on the palm, producing the characteristic posture called main d’accoucheur (The Figure). Trousseau’s sign is
thought to be both sensitive and specific for hypocalcemic tetany. In addition to the obvious visual manifestations, patients with a positive Trousseau’s sign may also experience paresthesia of the fingers, muscular fasciculations or twitches of the fingers, and a sensation of muscular cramping or stiffness.

Pathophysiology:

The proposed mechanism for Trousseau’s sign is increased excitability of the nerves in the arm and forearm, ostensibly caused by hypocalcemia, which, in turn, causes the muscular contractions. These conditions are exacerbated by ischemia produced by the sphygmomanometer, resulting in the twitching that defines the sign.

Watch an Angiogram Procedure

In this video, Dr. Mark A. Turco, Director of the Center for Cardiac and Vascular Research at Washington Adventist Hospital (Takoma Park, Maryland), performs an angiogram on a female patient with a history of heart disease in her family. Her stress test had indicated that she might have blockages in the blood vessels that carry blood to and from her heart. In his cath lab at Washington Adventist Hospital, Dr. Turco is able to see whether there are blockages and, if so, begin developing a treatment plan for her.

Maxillary Artery Branches Mnemonic

"DAM I AM Piss Drunk But Stupid Drunk I Prefer, Must Phone Alcoholics Anonymous"


Deep auricular
Anterior tympanic
Middle meningeal
Inferior alveolar
Accessory meningeal
Masseteric
Pterygoid
Deep temporal
Buccal
Sphenopalatine
Descending palatine
Infraorbital
Posterior superior alveolar
Middle superior alveolar
Pharyngeal
Anterior superior alveolar
Artery of the pterygoid canal

causes of coma, mnemonic

There are several medical causes of coma. One of the easiest ways to remember these causes is to use the mnemonic AEIOU TIPS:

* A - alcohol (overdose / withdraw / Wernicke's encephalopathy)
* E - epilepsy or exposure (heat stroke, hypothermia) or electrolytes
* I - insulin (diabetic emergency - high/low sugar)
* O - overdose or oxygen deficiency
* U - uremia (metabolic) or underdose
* T - trauma (head injury) or toxicology
* I - infection / inflammation
* P - psychosis or poisoning
* S - stroke / SAH / shock / syncope

Schwannoma (Histology)

Notice the whirly swirly pattern and how the cell nuclei are closely bunched together... almost as if they're forming a fence (Verocay bodies). Schwannomas are benign spindle cell tumors that occur along the edges of peripheral nerves. They can usually be removed without damaging the nerve itself.

Glasgow Coma Scale

A 29-year-old woman was an unbelted passenger in a motor vehicle accident. On arrival to the hospital, the paramedics inform you that she opens her eyes in response to verbal stimuli. She is incoherent and withdraws from painful stimuli. Which of the following is the patient’s calculated Glasgow Coma Scale (GCS)?

• a.15
• b.3
• c.9
• d.5
• e.12

The answer is (C). The Glasgow Coma Scale (GCS) is often used to quantify consciousness and assess cerebral cortex and brain stem function by assessing the patient’s verbal response, motor response, and eye opening response to stimuli.
It may be repeated at intervals to detect improvement or deterioration and is now widely used in coma assessment. The minimum score is 3 and the maximum score is 15.
Three behaviors are assessed in the GCS:

Presentation of Atrophic vaginitis

A 64 y old woman presents with vaginal bleeding similar to “spotting” that has occurred daily for 1 mo. Her last menses was at age 50 and she has been healthy her entire life. She denies fever,weight loss, or abdominal pain.Physical examination is normal.
the most likely diagnosis is?

• a.Atrophic vaginitis
• b.Endometriosis
• c.Uterine leiomyoma
• d.Endometrial carcinoma
• e.Polycystic ovarian syndrome

The answer is ( a ).
The most commoncause of postmenopausal vaginal bleeding is atrophic vaginitis (with or without trauma).
Endometriosis is the most common cause of infertility;patients present with dyspareunia (painful intercourse), abnormal vaginal bleeding, and pelvic pain. Uterine leiomyomas (uterine fibroids) change in size with the menstrual cycle but regress in size during menopause. Often the fibroid is palpable on pelvic examination. Polycystic ovarian syndrome (Stein-Leventhal syndrome) affects younger women (15–30). The etiology of polycystic ovary syndrome is unknown; patients present with amenorrhea, obesity, hirsutism, and infertility. All postmenopausal women with vaginal bleeding require a biopsy to rule out endometrial carcinoma.

Pachyderma due to scabies

A 65-year-old white man with a history of multiple myeloma presented with thick, leathery, gray skin of the torso and extremities. Panel A shows the left axilla. The patient reported intense pruritus and thickening of his skin during the previous 6 months, despite treatment with oral and topical corticosteroids. Because of chronic immunosuppression due to his underlying malignant condition, a specimen obtained from scrapings of the skin was prepared and examined. It showed scabies mites, eggs, and scybala (fecal pellets) (Panel B), which confirmed a diagnosis of crusted scabies.

The patient was treated with oral ivermectin and topical permethrin, with noticeable improvement within 1 month; subsequently, the patient was lost to follow-up.
Crusted scabies is a rare variant of scabies and occurs most commonly in immunosuppressed patients.
It presents as: erythematous or gray hyperkeratotic patches or plaques that can resemble the hide of a pachyderm (elephant, rhinoceros, or hippopotamus); “pachyderma” refers to thick skin, like that of a pachyderm. Patients with crusted scabies have a very high burden of mites and are extremely infectious. Thus, a prompt diagnosis is needed to avoid transmission to others. No such transmission was documented in this case.

A popliteal cyst, also called a Baker's cyst, is a soft, often painless bump that develops on the back of the knee. A cyst is usually nothing more than a bag of fluid. These cysts occur most often when the knee is damaged due to arthritis, gout, injury, or inflammation in the lining of the knee joint. Surgical treatment may be successful when the actual cause of the cyst is addressed. Otherwise, the cyst can come back again.

Symptoms :
The symptoms caused by a popliteal cyst are usually mild. You may have aching or tenderness with exercise or your knee may feel unsteady, as though it's going to give out. You may feel pain from the underlying cause of the cyst, such as arthritis, an injury, or a mechanical problem with the knee, for instance a tear in the meniscus. Along with these symptoms, you may also see or feel a bulge on the back of your knee. Anything that causes the knee to swell and more fluid to fill the joint can make the cyst larger. It is common for a popliteal cyst to swell and shrink over time.

Sometimes a cyst will suddenly burst underneath the skin, causing pain and swelling in the calf. A ruptured popliteal cyst gives symptoms just like those of a blood clot in the leg, called thrombophlebitis. For this reason, it is important to determine right away the cause of the pain and swelling in the calf. Once the cyst ruptures, the fluid inside the cyst simply leaks into the calf and is absorbed by the body. In this case, you will no longer be able to see or feel the cyst. However, the cyst will probably return in a short time.

Suturing Workshop

A discussion and demonstration of suturing techniques with Lee Dresang, MD from the University of Wisconsin Department of Family Medicine.

Babinski Response

Babinski Response: Note upgoing great toe upon stimulation of lateral foot in patient with
upper motor neuron lesion.

Hyperlipidemia: Cholesterol Guidelines

Dr. Melissa Stiles interviews Dr. Patrick McBride about the NCEP Adult Treatment Panel III Cholesterol Guidelines.
Part 1


Part 2

Berry aneurysm

A berry aneurysm refers to an intracranial aneurysm with a characteristic shape which accounts for the vast majority of intracranial aneurysms as well as non-traumatic subarachnoid haemorrhages. They occur at branch points, usually of sizable vessels, but sometimes at the origin of small perforators which may not be seen on imaging.

This photo on the right is Photo of a Norwegian blueberry.

Pathology

The aneurysmal pouch is composed of thickened hyalinised        intima with the muscular wall & internal elastic lamina being absent.

Comments required on a radiology report:

* size : ideally 3 axis maximum size meansurements
* neck : maximal width of the neck of the aneurysm
* shape and lobulations
* orientation : the direction in which the aneurysm points is often important in both endovascular and surgical planning

This small berry aneurysm projecting inferiorly from the ACOM had pushed into the optic chiasm causing a bitemporal hemianopia, similar to that seen in pituitary lesions.

SAH angiogram