The 5 W's of post-operative fever

Wind---pneumonia, atelectasis at 1st 24- 48 hours
Water---urinary tract infection at Anytime after post op day 3
Wound---wound infections at Anytime after post op day 5
Wonderdrugs---especially anesthesia 
Walking---walking can help reduce deep vein thromboses and pulmonary embolus usually occures at Day 7-10

Lewy body dementia when compared to Alzheimer's dementia

Which of the following is more commonly seen in patients with Lewy body dementia when compared to Alzheimer's dementia?

• A) Hallucinations
• B) Lip smacking
• C) Tremor
• D) Emotional lability
• E) Repetitive behavior

The answer is A.

Although difficult to know for sure, Lewy body dementia may be the second most common dementia after Alzheimer's disease.

Lewy bodies are hallmark lesions of degenerating neurons in Parkinson's disease "deposits of the protein alpha-synuclein inside nerve cells in the brain"  and occur in dementia with or without features of Parkinson's disease. In Lewy body dementia, Lewy bodies may predominate markedly or be intermixed with classic pathologic changes of Alzheimer's disease. Symptoms, signs, and course of Lewy body dementia resemble those of Alzheimer's disease, except hallucinations (mainly visual) are more common and patients appear to have an exquisite sensitivity to antipsychotic-induced extrapyramidal adverse effects.

Essentials of Neuroimaging for Clinical Practice

The use of neuroimaging studies in psychiatry is explodingAand offers tremendous potential for practicing clinicians. Yet if you’re like many psychiatrists, you’re sometimes uncertain about which studies to use in specific situations. Until now, you’ve had to sort through the only information availableAtechnical reviews in the literatureAfor guidance. But no more. Essentials of Neuroimaging for Clinical Practice is an all-in-one resource that explains how to use these powerful techniques to improve outcomes. It demystifies neuroimaging with clear, concise, and practical advice on using today’s most advanced applications in the diagnostic workup of patients. This practical clinical guide will help you achieve a solid understanding of the full range of neuroimaging modalities: -Structural techniques such as computed tomography (CT) and magnetic resonance imaging (MRI) -Functional techniques such as positron emission tomography (PET), single photon emission computed tomography (SPECT), functional magnetic resonance imaging (fMRI), and magnetic resonance spectroscopy (MRS) -Other techniques such as electroencephalography (EEG)Aincluding quantitative EEG and event-related potentialsAand magnetoencephalography. For each modality, you’ll find: -A basic review of the techniqueAtrace the development of each modality, and become familiar with its underlying technology. -Guidance on when to use itAlearn which techniques are best to use in specific clinical situations. -Tips for ordering studiesAdiscover how to write up orders to obtain the most accurate and detailed information from each study, including when to use contrast and how to determine the best acquisition parameters. -A look at its future potential in practice and researchAexplore the current capabilities of each modality and the most promising strategies for improving diagnostic results. Filled with examples of real-life imaging studies, Essentials of Neuroimaging for Clinical Practice is a must-have tool for all practicing psychiatrists and psychologists. In addition, it will serve as an excellent clinical guide for residentsAand an outstanding text for courses in clinical neuroimaging for psychiatrists.

HERE

Tongue`s surface in Prolonged antibiotic use

Which of the following conditions is the skin finding shown in the picture associated with?

• A) Prolonged antibiotic use
• B) Sjögren's syndrome
• C) Addison's disease
• D) Chronic gastroesophageal reflux
• E) Malignant melanoma

The answer is A. 

(Black tongue) Black hairy tongue results from hyperplasia of the filiform papillae with deposition of keratin on the surface. The condition causes the tongue to have ..............

READ MORE...................>>

The Barber's Itch

Barber's itch is a type of Folliculitis "an inflammation of one or more hair follicles".
It is an infectious skin disease which arises on bearded area of the face and upper lip. The condition takes place when the hair follicles get damaged by constant friction with clothing and it may even take place due to blockage and shaving

The disease develops and the first signs of the condition are the appearance of painful pimples that develop at the hair follicles along the beard, these pimples can grow either superficial or may occur in the deeper layers of the skin associated with some common symptoms as rash, itching, and pimples or pustules near a hair follicle in the neck, groin, or genital zone.

The cause that responsible for Barber`s folliculitis may be either a bacterial or a fungal infection :
- Mustache hair is usually affected by the bacteria; staphylococci.
- Bearded hair on the cheeks and the chin is commonly affected by the fungus.

#The condition is aggravated by shaving ,On the other hand the sharing of towels and razors passes on the highly contagious fungal infection

Menstrual Cycle explanation

This animation video explains the biological processes of Menstruation and the physiology of Menstrual Cycle

malignant external otitis

 A 72-year-old patient withlong-standing Type 2 diabetes mellitus presents with complaints of pain in his right ear with purulent drainage. On physical exam, the patient is afebrile. The pinna of the left ear is tender, and the external auditory canal is swollen and edematous. The peripheral white blood cell count is normal. The organism most likely to grow from the purulent drainage is :

• a. Pseudomonas aeruginosa
• b. Staphylococcus aureus
• c. Candida albicans
• d. Haemophilus influenzae
• e. Moraxella catarrhalis

 The answer is a.

Ear pain and drainage in an elderly diabetic patient must raise concern about malignant external otitis. Presence of swelling and inflammation of the external auditory meatus strongly suggests this diagnosis. This infection usually occurs in older diabetics and is almost always caused by organism Pseudomonas aeruginosa.

Haemophilus influenzae and Moraxella catarrhalis frequently cause otitis media but not external otitis.

Acute otitis externa with the canal somewhat narrowed from edema and obstructed by desquamating epithelium, soft cerumen, and purulent discharge; this must be removed to visualize the tympanic membrane and to allow ototopical therapy to penetrate to all the superficially infected areas of the canal skin.

Types of Hypospadias

Hypospadias is one of the most frequent male congenital malformations and may be part of the testicular dysgenesis syndrome, It occures 1-2 of 100 boys. Hypospadias is a birth defect found in boys in which the urinary tract opening is not at the tip of the penis. Bending of the penis on erection may be associated and is as chordee.

This picture shows Proximal shaft hypospadias . Note the deficient ventral foreskin, blind urethral pit at the glanular level, and lighter pigmented urethral plate extending to the true meatus at the proximal shaft level.

The location of the urethral meatus was described if visible, and hypospadias was graded as glandular, coronal, penile, penoscrotal, scrotal, or perineal according to the anatomical position

Types of hypospadias classified by the anatomical position of the urethral meatus. 1, Glandular; 2, coronal; 3, penile; 4, penoscrotal; 5, scrotal; 6, perineal.

On examination :A dorsal hood of foreskin and glanular groove are evident, but, upon closer inspection, the prepuce is incomplete ventrally and the urethral meatus is noted in a proximally ectopic position. Rarely, the foreskin may be complete, and the hypospadias is revealed at the time of circumcision. If hypospadias is encountered during neonatal circumcision, after the dorsal slit has been performed, the procedure should be halted, and the patient should be referred for urologic evaluation.
 The most simple classification of Hypospadias is mild, moderate and severe, which can also be called first, second and third degrees of severity. This classification system is based on the location of the external opening for urine and semen (the urethral meatus). In mild or first degree hypospadias, the opening is on the underside of the head of the penis or where the head and the shaft meet. This accounts for about 80% of the cases of hypospadias.

Moderate or second degree hypospadias (15%) occurs when the hole is actually on the shaft of the penis, somewhere between the junction of head and shaft, and the lower part of the shaft. Severe or third degree hypospadias occurs when the hole is located on the lower part of the shaft just in front of the testicles or is located behind the testicles, between them and the anus.

About Visual fields

 A patient presents with a bilateral homonymous quadranopsia involving the right upper visual field. Which of the following represents the MOST likely anatomic location of the abnormality?

• (A) Prechiasmal, right side
• (B) Optic chiasm
• (C) Postchiasmal, prethalamic, left side
• (D) Occipital lobe, right side
• (E) Occipital lobe, left side

The answer is E.

Homonymous visual field cuts imply a postchiasmal location of the abnormality because this is the first point where fibers from the same visual field of both eyes join. Fibers further divide between the thalamus and occipital lobe into upper and lower quadrant visual fields. The most common location for quadranopsia defects is the occiptal lobe. Stroke, tumor, and atypical migraine may present with quadranopsia.
Visual fields are named from the perspective of the patient, i.e., the right visual field corresponds to the left side of the retina. Therefore, a right-sided visual field cut involves the left-sided neurologic tracks.

Preoperative dose of antibiotic

When vancomycin is used as a preoperative prophylactic antibiotic, it should be administered within ______ minutes of the start of surgery.

A) 15
B) 30
C) 60
D) 120
E) At the time of incision

Answer and Discussion

The answer is D.
Ideally, a preoperative dose of antibiotic should provide a sufficient antibiotic serum level throughout the surgery to combat organisms most likely to cause a site infection. It is recommended that the first dose be timed to occur within 60 minutes before the surgical incision is made. If a fluoroquinolone or vancomycin is chosen for prophylaxis, the first dose should be administered within 120 minutes of the start of surgery. If the surgery involves the use of a tourniquet (e.g., hip or knee arthroplasty), the antibiotic infusion should be completed before inflation of the tourniquet. For most surgeries, it is recommended that use of prophylactic antibiotics end within 24 hours after surgery.

Mindmap for Appendicitis

Revise appendicitis faster with this mindmap!

Click here for enlargment

Acanthosis nigricans in diabetes mellitus

You note the shown skin disorder during a general medical evaluation. You explain to the patient they are at risk for the development of:

A) Alzheimer's disease

B) tuberculosis

C) diabetes mellitus

D) Grave's disease

E) melanoma



 The answer is C. (Diabetes mellitus) 
Although the majority of cases of acanthosis nigricans are benign and associated with obesity, the disease can represent the onset of malignancy as well as a variety of conditions related to insulin resistance.
Acanthosis nigricans has been reported in association with a number of malignancies, particular gastrointestinal cancers (e.g., gastric, hepatocellular) and lung cancer. The suspicion for malignancy increases in patients with extensive or rapidly progressive lesions, when there is mucous membrane involvement, or when there is prominent sole and palm disease.

The common finding in all non-malignancy associated cases of acanthosis nigricans is insulin resistance. This explains the relationship between this skin disorder and diseases such as diabetes mellitus, Cushing's syndrome, and hypothyroidism (most likely due to weight gain and subsequent insulin resistance), and with obesity.

Photos of Melanosis coli "Pseudomelanosis coli"

Melanosis coli, also pseudomelanosis coli, is a disorder of pigmentation of the wall of the colon, often identified at the time of colonoscopy.
The most common cause of melanosis coli is the extended use of laxatives, this darkening of the colonic mucosa caused by the accumulation of lipofuscin particles within the macrophages of the lamina propria of the colonic mucosa as a result of long term exposure to anthraquinone-containing laxatives as Senna and other plant glycosides. However, other causes are identified, including an increase in colonic epithelial apoptosis.

This is the photograph of the colon, and there is an extremely dark appearance to the wall of the colon. This is seen in patients who have taken laxatives over many years and the pigment from the laxative gets deposited in the wall of the bowel giving an extremely dark appearance to it. This is a benign condition, not cancerous, and does not become cancerous, but often it is quite obvious.

- Melanosis coli is a misnomer, as the pigmentation is due to lipofuscin-laden macrophages - not melanin pigment. Pseudomelanosis coli is a more appropriate descriptor, but not in common usage.

The differential diagnosis of brown pigmentation of the colon is:

* Pseudomelanosis coli.
* Hemosiderin-laden macrophages (old haemorrhage).
* Melanin (rare).

Vacuum Assisted Delivery: A Brief Summary of Key Principles

Decompression sickness "divers' disease"

A 55-year-old male diver begins complaining of back pain and urinary retention 1 h after a dive. What is the MOST likely diagnosis?

• (A)Barotrauma to the bladder
• (B)Lumbar strain
• (C)Neurotoxin from a marine envenomation
• (D)Nitrogen narcosis
• (E)Decompression sickness

The answer is E.

Barotrauma is the most common affliction of divers and usually affects the ears, sinuses, lungs, and, rarely, the gastrointestinal tract. The bladder is not involved.

Decompression sickness (DCS),also known as divers' disease, the bends or caisson disease, is caused by formation of gas bubbles in tissues after ascent from a dive and results in vascular occlusion, usually in the venous circulation. DCS may have cutaneous manifestations including rash and pruritus. It classically causes joint and back pain and may be associated with neurologic symptoms secondary to spinal cord involvement.

Patients with neurologic or other severe forms of DCS should be referred for hyperbaric oxygen therapy. Nitrogen narcosis is due to the anesthetic effects of breathing nitrogen at high partial pressures and causes divers to become altered on deep dives.

Superior vena cava syndrome

A 72-year-old man who was overweight and had a history of hypertension and heavy smoking presented with a swollen neck. He had no dysphagia. He reported that he had experienced increased snoring and daytime sleepiness during the previous 3 weeks.
An otolaryngologic examination was unremarkable except for an unusually narrow upper airway. On inspection, the patient's hands were swollen and showed signs of pitting edema (Figure 1A). Inflammatory parameters and complete blood count were normal.

Contrast-enhanced computed tomography scans of the neck and chest revealed an enlarged retropharyngeal space (Figure 1B) and a mass compressing the superior vena cava (Figure 1C). A transthoracic needle biopsy showed a non–small-cell carcinoma. Radiotherapy resulted in clinical improvement and a rapid reduction in compression of the superior vena cava.

The exact incidence of superior vena cava syndrome remains unknown, It has mainly malignant causes.
Nonmalignant causes can include aneurysm of the aorta, thromboses after implanted intravascular catheters or fibrosing mediastinitis.

Classically, compression of the superior vena cava leads to visible swelling and venous distension in the face, neck, chest and upper limbs. Other symptoms of varying severity can occur, from cough, hoarseness and dyspnea to headache, confusion and visual symptoms. In patients who are overweight, swelling of the neck may go unnoticed, and signs such as obstructive sleep apnea or edema of the upper limb may point to the diagnosis.

Characteristic shape of Molluscum contagiosum infection

A 4-year-old preschooler presents with the skin lesions shown here. The area affected is just below the chin on the child's right side. The lesions have been present over the last month, and the child has reported no symptoms associated with them. The most likely diagnosis is

• A) varicella
• B) herpes zoster
• C) Rhus dermatitis
• D) molluscum contagiosum
• E) scabies

 The answer is D. (Molluscum contagiosum) 

Molluscum contagiosum is a common, superficial viral infection of the skin that typically occurs in infants and preschoolers. The incidence decreases after the age of 6 to 7 years. The condition can be spread via sexual contact in young adults.
The lesions are dome-shaped, waxy, or pearly-white papules with a central white core and are 1 to 3 mm in diameter. Frequently, groups of lesions are found. The lesions may resolve spontaneously. Treatment involves removal with a sharp needle or curette, application of liquid nitrogen, antiwart preparations, electrodessication and curettage, or trichloroacetic peels for extensive areas. Typically, infants or young preschool-age children should not be treated aggressively.

Typical flesh-colored, dome-shaped and pearly lesions

Illustration of Vaginal Delivery on a model

Synthesis and metabolism of vitamin D in the regulation of calcium, phosphorus, and bone metabolism.

Click for photo enlargement

During exposure to solar UVB radiation, 7-dehydrocholesterol in the skin is converted to previtamin D3, which is immediately converted to vitamin D3 in a heat-dependent process. Excessive exposure to sunlight degrades previtamin D3 and vitamin D3 into inactive photoproducts. Vitamin D2 and vitamin D3 from dietary sources are incorporated into chylomicrons and transported by the lymphatic system into the venous circulation. Vitamin D (hereafter, “D” represents D2 or D3) made in the skin or ingested in the diet can be stored in and then released from fat cells.
Vitamin D in the circulation is bound to the vitamin D–binding protein, which transports it to the liver, where vitamin D is converted by vitamin D-25-hydroxylase to 25(OH)D. This is the major circulating form of vitamin D that is used by clinicians to determine vitamin D status. (Although most laboratories report the normal range to be 20 to 100 ng/mL [50 to 250 nmol/L], the preferred range is 30 to 60 ng/mL [75 to 150 nmol/L].) This form of vitamin D is biologically inactive and must be converted in the kidneys by 25-hydroxyvitamin D-1α-hydroxylase (1-OHase) to the biologically active form 1,25(OH)2D.
 Serum phosphorus, calcium, fibroblast growth factor 23 (FGF-23), and other factors can either increase (+) or decrease (−) the renal production of 1,25(OH)2D. 1,25(OH)2D decreases its own synthesis through negative feedback and decreases the synthesis and secretion of PTH by the parathyroid glands. 1,25(OH)2D increases the expression of 25-hydroxyvitamin D-24-hydroxylase (24-OHase) to catabolize 1,25(OH)2D to the water-solubl biologically inactive calcitroic acid, which is excreted in the bile.

1,25(OH)2D enhances intestinal calcium absorption in the small intestine by interacting with the vitamin D receptor–retinoic acid x-receptor complex (VDR-RXR) to enhance the expression of the epithelial calcium channel (transient receptor potential cation channel, subfamily V, member 6 [TRPV6]) and calbindin 9K, a calcium-binding protein (CaBP). 1,25(OH)2D is recognized by its receptor in osteoblasts, causing an increase in the expression of the receptor activator of RANKL.
RANK, the receptor for RANKL on preosteoclasts, binds RANKL, which induces preosteoclasts to become mature osteoclasts. Mature osteoclasts remove calcium and phosphorus from the bone, maintaining calcium and phosphorus levels in the blood. Adequate Ca2+ and phosphorus (HPO42−) levels promote the mineralization of the skeleton.

8 clinical criteria predict management in an ICU

Which of the following would indicate the patient must be monitored in an intensive care unit setting following an overdose?

• A) PaCO2 >45 mmHg
• B) Seizures
• C) QRS duration ≥ 0.12 seconds
• D) Second- or third-degree atrioventricular block
• E) All of the above

Answer and Discussion
The answer is E.
The presence of any of eight clinical criteria predict a complicated hospital course that could be best managed in an ICU:

1- PaCO2 >45 mmHg
2- A need for emergency intubation
3- The presence of postingestion seizures
4- Unresponsiveness to verbal stimuli
5- A non-sinus cardiac rhythm
6- Second- or third-degree atrioventricular block
7- Systolic blood pressure <80 mmHg
8- QRS duration ≥ 0.12 seconds