Hoover sign Explanation in COPD case

At first you should know that there are 2 signs named for Charles Franklin Hoover :
1-Hoover's sign of leg paresis.
2-Hoover’s sign in pulmonology which we will take about ;
It refers to inward movement of the lower rib cage during inspiration, implying a flat, but functioning, diaphragm, often associated with COPD.
COPD, and more specifically emphysema, often lead to hyperexpansion of the lungs due to air trapping. The resulting flattened diaphragm contracts inwards instead of downwards, thereby paradoxically pulling the inferior ribs inwards with its movement.

This case for A 70-year-old man with a 70 pack-year history of smoking was referred to the emergency department for an exacerbation of chronic obstructive pulmonary disease (COPD).

On examination, he breathed through pursed lips and had paradoxical indrawing of the lower rib cage margin with inspiration (Hoover sign)(Figure 1A),A chest radiograph showed distension of the lungs and flattening of the diaphragm(Figure 1B).

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Simple Terms to learn about effect of drugs on CNS

- Sedation : Reduction of anxiety
- Addiction : The state of response to a drug whereby the drug taker feels compelled to use the drug and suffers anxiety when separated from it
- Anesthesia : Loss of consciousness associated with absence of response to pain
- Anxiolytic : A drug that reduces anxiety, a sedative
- Dependence : The state of response to a drug whereby removal of the drug evokes unpleasant, possibly life-threatening symptoms, often the opposite of the drug's effects
- Hypnosis : Induction of sleep
- REM : sleep Phase of sleep associated with rapid eye movements; most dreaming takes place during REM sleep
- Tolerance : Reduction in drug effect requiring an increase in dosage to maintain the same response

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.

Causalgia

DEFINITION: A syndrome of sustained burning pain after a traumatic nerve injury combined with vasomotor and sudomotor dysfunction and later trophic changes.


Causalgias are divided into two forms:
1. Causalgia major involves peripheral nerve injury with electrical "crosstalk" (ephapse) that causes severe hyperactivity of sympathetic system (hyperpathia, vasoconstriction, and movement disorder). The major form is severe, usually caused by injury with high velocity sharp objects (e.g., butcher's knife), vibratory component major trauma (e.g., bullet), or high-voltage nerve lesions (electrocution).

2. Causalgia minor involves the same principle as causalgia major, but milder injury, e.g., injury to the dorsum of hand or foot, nerve root contusion, patient falling from a height on gluteal region resulting in "guillotine" effect, bruising of nerve root caught at the narrowed intervertebral foramen.

SO,The difference between the two categories is a matter of degree and severity. To classify causalgia as an independent illness is artificial, and causalgia is nothing but a sever form of RSD(Reflex Sympathetic Dystrophy ).

In this severe form of RSD, the course of the disease is quite accelerated from stage 1 through 4 in a matter of weeks or months. S. Weir Mitchell in 1872 first reported rapid development of atrophic changes in the skin, nails, and soft tissues of the extremity in a matter of days to weeks.
Whereas in RSD of disuse the extremity is cold, in ephaptic dystrophy the thermography reveals in the distal portion of the extremely cold extremity that there is an isolated hot spot that points to the area of scar formation and ephaptic peripheral nerve dysfunction . In this area the vasoconstrictive capability of the sympathetic nerve is paralyzed, and there is a topical hot spot. This hot spot can be appreciated only by thermograph.

CAUSALGIC PAIN:
- Usually pain occurs after the injury to a nerve trunk.
- The pain is spontaneous, severe, and quite persistent.
- There is a markedly lowered threshold for aggravation of pain. This is the case in all RSD patients, but it is more exaggerated in causalgics. So even a breeze over the skin or the touch of a bed sheet or a change of the environment or a family argument and aggravation can markedly aggravate the pain. This feature of emotional aggravation is common to all RSD patients, and it is nothing but the role of the frontal lobe and the limbic system in aggravation of hyperpathic pain.
- The pain is felt distal to the proximal nerve injury, i.e., in the hand or foot. This is typical but not invariable. The pain does not necessarily have to be a burning type of pain, and can be described in many other hyperpathic forms.

May-Thurner syndrome

The May-Thurner syndrome is the symptomatic compression of the left common iliac vein between the right common iliac artery and the lumbar vertebrae.

The normal anatomy is that the artery which runs to the right leg (= right common iliac artery) lies on top of the vein coming from the left leg (= left common iliac vein). This close proximity leads, in some people, to pressure of the artery onto the vein and to varying degrees of narrowing of the vein. This is referred to as "May Thurner syndrome". It is not a disease but a congenital anatomic variant. Mild and moderate degrees of narrowing are typically asymptomatic. More severe degrees can lead to obstruction of blood flow from the leg and thus to leg swelling and pain. The narrowed vein can also clot, resulting in left leg DVT.

The syndrome is named after the authors R. May and J. Thurner, who first described this phenomenon in 1957. It has also been termed the iliac compression syndrome. It is probably the reason why more DVTs occur in the left than in the right leg.

Compression of the iliac vein has been documented in approximately 50% of patients with left iliac vein thrombosis.

Several surgical treatment strategies have been employed in the past:

1. venous bypass surgery of the narrowed area;


2. cutting of the iliac artery and repositioning of the artery behind the iliac vein;


3. construction of a tissue sling or flap to lift it off the iliac vein;

Since 1995 venous stents have been placed into the narrowed area, to pry them open . Unfortunately, there are no large studies that
(a) investigate the long-term success of the procedure, i.e. how often the stents improve symptoms and remain patent.
(b) whether patients should remain on long-term (lifelong) coumadin (warfarin) or not. Stents appear beneficial at least in the short-term improvement of symptoms, within the first 1-2 years of stent placement .

Markel sign in heel jar test ,and others!!

Abdominal pain upon vibration (the heel jar test) is commonly known as which of the following?

• a.Markel sign
• b.Blumberg sign
• c.Rovsing sign
• d.Obturator sign
• e.Iliopsoas sign
• f.Courvoisier sign
• g.Dance sign

The answer is (a).
The Markel sign(which is a maneuver to detect peritoneal irritation) is tested by the heel jar test; the patient stands on his or her toes, then allows his or her heels to hit the floor, thus jarring the body and causing abdominal pain in peritonitis.
The Rovsing sign occurs when palpation of the LLQ causes pain in the RLQ.
The obturator sign is pain occurring when the bent leg is rotated laterally and medially.
The iliopsoas sign occurs when the patient tries to raise the leg up against the hand of the examiner pushing down against the leg above the knee.

-The Markel sign,obturator sign, iliopsoas sign, and Rovsing sign are seen in appendicitis. A patient with appendicitis may also have pain on rectal examination if the posterior appendix is involved.

The Courvoisier sign is a palpable nontender gallbladder, which suggests neoplasm.
The Dance sign is the absence of bowel sounds in the RLQ due to intussusception

Marjolin Ulcer-MRI

Malignant degeneration of untreated chronic wounds is a well-known complication. These rare, aggressive tumors that originate in chronically nonhealing wounds are called Marjolin’s ulcer. This is a 15 year old boy with long standing burn scar on the forearm.

Shock Index

Classic Triads

Beck’s ,Cushing's ,Waddell's triads:
Beck’s triad
Beck's triad was described by the thoracic surgeon Calude S. Beck in 1935. It's components are:

1. Distended neck veins
2. Distant heart sounds
3. Hypotension

i.e. rising venous pressure, falling arterial pressure, and decreased heart sounds found in the presence of pericardial tamponade.



Cushing's triad (not to be confused with the Cushing reflex) is a sign of increased intracranial pressure. It is the triad of:

1. Hypertension (progressively increasing systolic blood pressure)

2. Bradycardia

3. Widening pulse pressure (an increase in the difference between systolic and diastolic pressure over time)

Cushing's triad suggests a cerebral hemorrhage in the setting of trauma or an space occupying lesion (e.g. brain tumor) that is growing and a possible impending fatal herniation of the brain. Cushing's triad is named after an American neurosurgeon Harvey Williams Cushing (1869-1939).



Waddell's triad
is recognized in clinical practice as associated with high-velocity accidents such as motor vehicle, auto-pedestrian, or bicycle crashes

Waddell's triad consists of

1. Femur fracture
2. Intra-abdominal or intrathoracic injury
3. Head injury,