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Photo illustrations of Bullous Myringitis

What is Bullous Myringitis ?
Bullous myringitis is painful inflammation blisters of the tympanic membrane and surrounding deep canal skin with the formation of serum or blood filled bullae. Petechial subcutaneous hemorrhages around the base of the bulla are characteristic.

Bullous Myringitis was thought that Mycoplasma pnumoniae was the most common pathogen but, recent studies have demonstrated that the pathogens are similar to otitis media. Bacteria are responsible for most cases of bullous myringitis. Streptococcus pneumoniae is the most common, followed by Haemophilus influenzae and Moraxella catarrhalis.

Examination shows a vesicular or bullous eruption over the tympanic membrane and adjacent bony canal wall. In the early stages, the vesicles are erythematous and surrounded by injected epithelium. In the later stages, they are larger and filled with fluid which may be clear and serous or blood filled. In this photograph, the bulla has now been incised with a myringotomy knife and the fluid drained. Notice the petechial hemorrhage around the base of the bulla and extending into the attic area.
Treatment of bullous myringitis requires strong analgesics because of the associated pain. Rupturing the bullae for relief of pain is controversial. Topical antibiotic eardrops are probably useful in preventing the development of a secondary bacterial otitis externa. The use of erythromycin has been advocated by those who believe that Mycoplasma is the prime etiologic agent. The tympanic membrane in this case is diffusely inflamed, with the presence of petechial hemorrhage over the attic and an associated hemotympanum

A large bulla filled with serous fluid has developed on the superficial surface of the tympanic membrane in the region of the umbo


This video shows Classification, Pharmacological actions, Mechanism of Action, Pharmacokinetics, Uses and Side effects of all Antiemetics.

How to differentiate between transmitted and expansile pulsations

If you are palpating a swelling like an abdominal swelling infront of the aorta, You have to decide whether the mass you feel is pulsatile/expansile in itself (in which case your fingers will move outwards A ) or whether the pulsation is transmitted through other tissue (in which case your fingers will move upwards B ).See diagram below

Also in transmitted pulsation you can make this pulsation disappear if you can move the swelling away from the aorta ( if you put the patient in the knee-elbow position, an enlarged intra-abdominal swelling which was transmitting aortic pulsation will get away from the aorta and the pulsations will disappear)

Wound Closure by Surigical Staples

Staples are formed from high-quality stainless steel and are available in regular and wide sizes.

Staples are composed of:

(1) a cross-member that lays on the surface of the skin perpendicular to the wound,
(2) legs that are vertically placed in the skin
(3) tips that secure the staple parallel to the cross-member.

Staples are relatively easy to place and may shorten the closure time by 70-80%.

The primary utility of staples is in the closure of wounds under high tension on the trunk, extremities, and scalp.ON the other hand they are not used in delicate tissues or wounds in finely contoured areas, over bony prominences, or in highly mobile areas.

Advantages of staples include:
* rapid speed of closure
* a decreased risk of infection
* improved wound eversion
* minimal tissue reactivity.

Disadvantages include
* the need for a second operator to evert and reapproximate skin edges during staple placement
* greater risk of crosshatch marking
* less precise wound approximation.
* The cost is usually more than that of suture material.
Surgical staples used on a skin incision in groin after inguinal hernia operation.

Common sites for Morton's neuromas

Morton's Neuroma is a painful condition of the forefoot that is caused by the entrapment of the common intermetatarsal nerve as it passes through the forefoot to the toes. Morton's Neuroma was first described by Dr. Morton, a Viennese physician, in 1876.
Where are most Morton's neuromas found?

A) In the tarsal tunnel
B) At the first metatarsal phalangeal joint
C) The second and third interdigital space
D) At the attachment of the plantar fascia
E) At the head of the fifth metatarsal

Answer and Discussion

The answer is C.
The interdigital spaces of the foot are common sites for painful neuromas, a condition termed Morton's neuroma. The second and third common digital branches of the medial plantar nerve are the most frequent sites for development of interdigital neuromas. Morton's neuromas develop as a result of chronic trauma and repetitive stress, as occurs in persons wearing tight-fitting or high-heeled shoes. Pain and paresthesias are usually mild at onset and are located in the interdigital space of the affected nerve. In some cases, the interdigital space between the affected toes may be widened as a result of an associated ganglion or synovial cyst. Pain is noted in the affected interdigital space when the metatarsal heads of the foot are squeezed together. Injection with 1% lidocaine (Xylocaine) can assist in confirming the diagnosis.

The symptoms of Morton's neuroma include the following;
  • A dull achy sensation in the forefoot, usually between the 3rd and 4th toes.
  • Pain that increased with the time a person spends on their feet, particularly in high heels and narrow fitting shoes.
  • Pain that is not relieved by rest. Neuroma pain takes several minutes to hours to subside.
  • Numbness of the 3rd and 4th toes.
  • A sensation of walking on something, such as a bunched up sock
  • .Occasionally, a snapping sensation or electrical shock sensation (Muldier's Sign).
The digital nerve(1) running in the narrow space between the metatarsal bones where it splits into two(2) and where a Mortons Neuroma is usually found.

Male Urological Examination

Physical exam by a urologist including kidney, testicular and prostate exam.

Review this baby; IS IT A BOY OR A GIRL?

A midwife calls the neonatal intensive care unit asking for an urgent review of a baby born 10 minutes ago. At delivery they thought it was a boy and said this to the parents. Now they are not so sure because although the baby appears to have a penis, there is no obvious scrotum and they cannot feel the testes. The baby seems otherwise normal and there was nothing remarkable about the pregnancy. It is the parents’ first child.
There are no dysmorphic features and examination of the cardiovascular, respiratory and abdominal systems are normal. The weight is 3.1 kg. There is a 1.5 cm phallus (normal in term newborn males 2.5 cm) with a single perineal opening at the base of the phallus "which is a penis-shaped object such as a dildo, or a mimetic image of an erect penis". There is pigmentation of the labioscrotal folds, which are fused with no obvious vaginal opening. There are no palpable gonads, including in the inguinal canals. The anus is normally positioned. The baby’s external genitalia can be seen in the figure below.
 Questions Are :
  •  Is this a boy or a girl?
  •  What is the most likely diagnosis and the differential?
  •  What investigations are needed?
Case Discussion
At this stage, no one can or should say whether this baby is a boy or a girl. It is imperative not to guess as it could be either a virilized female (a normal girl exposed in utero to excess androgens) or an undervirilized male. Disorders of sexual differentiation (DSD) are a medical and social emergency and families find it exceptionally difficult not knowing the sex of their baby. Pending urgent tests they should not name the baby or register the birth.
In the absence of palpable gonads, but with evidence of virilization with a small phallus and pigmentation, it is most likely that this is a virilized female. Much the commonest aetiology is congenital adrenal hyperplasia (CAH).

If the baby is an undervirilized male,there is a much larger differential, including disorders of gonadotrophin production (e.g. Kallman syndrome), defects of testosterone synthesis and end-organ insensitivity due to androgen receptor abnormalities. With very severe undervirilization, it is possible that the sex of rearing should be female. Such babies need urgent referral to a specialist centre with a team of endocrinologists, urologists, geneticists and psychologists.

Congenital adrenal hyperplasia is a group of autosomal recessive inborn errors of metabolism (IEM) (therefore commoner if parents are consanguineous), within the adrenal steroidogenic pathways that produce mineralocorticoids (aldosterone), glucocorticoids (cortisol) and androgens (testosterone). 95 % of cases are due to 21-hydroxylase deficiency (21-OHD) that catalyses late steps in the first two pathways. The consequences are the same as for any IEM – deficiency of the end product, continued drive through the pathway, build-up of precursors and diversion down alternative pathways. Lack of cortisol causes hypoglycaemia and a poor stress response. Elevated precursors divert to the androgen pathway and testosterone virilizes both male and female fetuses. Most babies are also aldosterone-deficient. Those missed at birth (usually virilized boys) classically present in the second week of life with a salt-wasting (Addisonian) crisis – vomiting and shocked with severe hyponatraemia, hyperkalaemia and acidosis.
Patients with 21-OHD need lifelong steroid replacement, initially with hydrocortisone and fludrocortisone (a mineralocorticoid analogue), and endocrine monitoring.

The timing of any surgery to reduce clitoromegaly and create a vaginal orifice is controversial.
*Investigations in the first few days consider the differential diagnosis and monitor for complications:
• karyotype – result in 48 hours if laboratory warned
• pelvic and abdominal ultrasound – extremely helpful and immediately available
• 17-hydroxyprogesterone – sent after 48 hours as raised in all newborns
• full male hormone profile
• urine steroid profile – confirms site of block in steroidogenic pathway
• electrolytes and glucose – from day 2; monitor bedside glucose
• plasma renin activity – best estimation of salt status.

1- Never guess the sex of a newborn baby with abnormal genitalia.
2- Virilization of a female infant is almost always congenital adrenal hyperplasia due to 21-hydroxylase deficiency.

Treatment of choice for a case of secondary syphilis

A 20-year-old student has a macular rash, generalized lymphadenopathy, apthous ulcers, and gray-white plaques around the anal area. A dark-field examination demonstrates spirochetes. Which of the following is the treatment of choice for this patient?

  • a.Penicillin
  • b.Ceftriaxone
  • c.Tetracycline
  • d.Interferon alpha
  • e.Erythromycin

The answer is a.
Penicillin is the drug of choice for secondary syphilis. A positive darkfield examination in this patient confirms the diagnosis.
"benzathine penicillin G 2.4 million units IM or aqueous procaine penicillin G 600,000 units IM daily for ten days-In Late latent (more than 2 years), and tertiary syphilis treatment is benzathine penicillin G 2.4 million units weekly for three weeks or aqueous procaine penicillin G 600,000 units daily for 15 days.".
Ceftriaxone and tetracycline are usually considered to be alternative therapies. Interferon alpha has been used in the treatment of condyloma acuminata, a lesion that can be mistaken for syphilitic condyloma.

Images for Skin manifestations in hyperlipidemia

Xanthelasma in a 43-year-old patient with hyper-cholesterolemia.
-Severe hyperlipidemia, particularly primary forms of hyperlipidemia, can be associated with lipid deposits in the skin and in joints. However, a corneal arcus, an arcus lipoides, and xanthelasma may be present with normal cholesterol levels after the age of 40.

-Tendon xanthoma and palmar xanthoma occur in some of the primary dyslipoproteinemias.
Tendinous xanthomas are nodose, subcutaneous lesions attached to ligaments and tendons, particularly the Achilles tendon due to accumulations of lipid-laden macrophages (foam cells) in tendons.
The nodules may be yellowish, but are usually skin colored. They are often associated with other xanthomas, and indicate the presence of hypercholesterolemia or other lipid abnormality.

-Also Tubero-eruptive xanthoma that may itch and the lesions may be reddened due to inflammation and scratch effects.
 Eruptive xanthoma in hyperlipidemia.

Images for Skin manifestations in hyperlipidemia

Gross pathology of Atherosclerosis in Aorta

Atherosclerosis is the process in which deposits of fatty substances, cholesterol, cellular waste products, calcium and other substances build up in the inner lining of an artery "Plaque".

Distribution of atheromatous plaques:
  •  Lower descending aorta {ostia of the major branches}
  •  First 3 inches of coronary arteries
  •  Descending aorta
  •  Internal carotids
  •  Circle of Willis
  •  Leg arteries
This image shows Atheroscleosis of Aorta; the aorta was opned along the posterior wall . Numerous calcified and ulcerated, yellow atherosclerotic plaques (arrows) dot the inner surface. Note the narrowed aorta above the iliac bifurcation. It is calcified, stenotic and lined by clotted blood.

Clinical Consequences of Atheromatous plaques include:
* Occlusion
* Vessel rupture
* Aneurysmal dissection

Laser surgery Norwich, Norfolk, UK

CO2 laser surgery for rhinophyma. Removal of moles, lumps, cysts and skin tags with laser in Norfolk, UK.

Mnemonic for Causes of pancytopenia

Cytopenia is a reduction in the number of each type of peripheral blood cell. A reduction in all 3 types of cellular components in peripheral blood is termed pancytopenia and this involves anaemia, neutropenia, and thrombocytopenia.

"All my blood has taken some poison"

  • Aplastic anemias
  • Megaloblastic anemias
  • Bone marrow infiltration
  • Hypersplenism
  • TB
  • SLE
  • Paroxysmal nocturnal hemoglobinuria

Initially, mild impairment in marrow function is inapparent and pancytopenia may become apparent only during times of stress or increased demand (e.g., bleeding or infection). More
severe degrees of cytopenias affect the peripheral blood count even in the steady state.

Severe pancytopenia is defined as follows :
i)Absolute neutrophil count < 500/mm3
ii)Platelet count < 20,000/mm3
iii) Corrected reticulocyte count < 1%
The peripheral smear shows pancytopenia with circulating blasts "High power"

Wound Healing Phases

A video showing the phases of normal wound healing

Illustrated photos of Milia

Definition of Milia :
Milia form as multiple, firm, white lesions that range from 1 to 4 mm in diameter. They are very common, benign, keratin-filled cysts.

Milia usually appear on the face and most commonly affect the eyelids, nose, and malar region, sometimes on the genitalia; It is formed at base of hair follicle or sweat gland.
Milia are commonly associated with newborn babies 40% of newborns, but can appear on people of all ages.

Other names: milk spot or an oil seed.Milium is the single of milia.

Types of Milia :
1- Primary or spontaneously.
2- secondary caused by trauma, radiotherapy, skin infection, or bullous diseases.

In children milia often disappear within two to four weeks.Options include simple excision, electrodessication of the surface, or puncture and expression of the contents

Techniques of Ossiculoplasty - Incus Transposition

Aftere elevating tympanomeatal flap, drilling of attic area was done. Remnant incus removed. With a diamond burr and acetabulum made in the body which accomodates head of stapes.
underlaying of the temporalis fascia graft done.

Non-healing ulcer of Basal cell carcinoma

A 60-year-old retired construction worker presents with a non-healing skin lesion on the back of his hand that occasionally bleeds when he gets out of the shower. The most likely diagnosis is
  • A) basal cell carcinoma
  • B) squamous cell carcinoma
  • C) superficial spreading malignant melanoma
  • D) actinic keratosis
  • E) keratoacanthoma

The answer is A. (Basal cell carcinoma)
Basal cell carcinoma is the most common form of skin cancer. The lesions are induced by ultraviolet radiation in susceptible individuals. Risk factors include age older than 40, light complexion, positive family history, and male sex. The lesion in the photo has pearly, raised borders with telangiectasia and a central ulcer that may crust. Sun-exposed areas are most commonly affected. Diagnosis is achieved with shave or excisional biopsy.

Treatment is accomplished with excision, electrodessication and curettage, liquid nitrogen application, Moh's surgery, radiation treatment, and topical 5-fluorouracil cream. Almost 50% of patients with basal cell carcinoma will have another within 5 years.

Anatomy of spinal nerves exiting through the intervertebral foramina

The spinal cord is an extension of the brainstem (the lowest part of the brain), extending from the base of the skull down to the low back. Along its length, it gives off 31 pairs of spinal nerves, which branch to form the peripheral nerves of the neck, trunk, and extremities. The origins of the spinal nerves as they emerge from the spinal cord are called nerve roots.

This image shows a dissection of the cervical region, showing a posterior view of cervical spinal nerves exiting the intervertebral foramina on the right side.

The spinal nerves exit from the vertebral column through openings between adjacent vertebrae. These openings, called intervertebral foramina, are located just in front of the facet joints. The spinal nerves are named and numbered according to the vertebral levels at which they exit. There are eight paired cervical nerves (C1-C8), twelve thoracic (T1-T12), five lumbar (L1-L5), five sacral (S1-S5), and one coccygeal (Co1).
Note :
-There are eight pairs of cervical nerves, although there are only seven cervical vertebrae. The C1 nerves exit above the C1 vertebra (between C1 and the base of the skull).
-Although the spinal nerves correspond to their respective vertebral levels, the spinal cord itself is shorter than the vertebral column, extending only as far as the L1 vertebra. Below that level, the spinal canal contains only the roots of the lumbar, sacral, and coccygeal nerves, as they descend to exit at the appropriate levels. This bundle of descending nerve roots is called the cauda equina (Latin for "horse's tail").

The on the right views a portion of the spinal cord, showing its right lateral surface. The dura is opened and arranged to show the nerve roots.

Nerve Roots:—
Each nerve is attached to the medulla spinalis by two roots, an anterior = ventral, and a posterior = dorsal, the latter being characterized by the presence of a ganglion, the spinal ganglion.

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