Medical Updates: February 2014

Friday, 28 February 2014

FIRST AID

HEADQUARTERS, DEPARTMENTS OF

THE ARMY, THE NAVY, AND THE AIR FORCE

DECEMBER 2002

DISTRIBUTION RESTRICTION:Approved for public release;

distribution is unlimited.

INGLE'S ENDODONTICS - 6th Ed. (2008)

Genitourinary Imaging 2nd edition

Human Osteology and Skeletal Radiology Authors Evan Matshes M.D.

Human Osteology

and Skeletal Radiology

Authors

Evan Matshes M.D.

Davidson’sPrinciples and Practice of Medicine 22nd Edition

Davidson’sPrinciples and Practice of

Medicine

22nd Edition

Edited by

Brian R. WalkerBSc MD FRCPE FRSE

ECGs for Nurses Second Edition Philip Jevon

ECGs for Nurses

Second Edition

Philip Jevon

Cellulite Pathophysiology andTreatment

Cellulite

Pathophysiology

andTreatment

Acne Symposium at the World Congress of Dermatology

Acne

Symposium at the World Congress of Dermatology

Paris, July, 2002

Pocket Atlas of Echocardiography Thomas Boehmeke, M.D. Cardiology Practice Gladbeck, Germany

Pocket Atlas of Echocardiography

Thomas Boehmeke, M.D.

Cardiology Practice

Gladbeck, Germany

Exercise Leadership in Cardiac Rehabilitation An evidence-based approach

Exercise Leadership in

Cardiac Rehabilitation

An evidence-based approach

Textbook of Oral and Maxillofacial Surgery

DENTAL  ANATOMY   AND   OCCLUSION

DENTAL ANATOMY  

AND  

OCCLUSION

Wednesday, 12 February 2014

CARRANZA’S CLINICAL PERIODONTOLOGY

CARRANZA’S CLINICAL PERIODONTOLOGY ISBN: 978-1-4377-0416-7

Fundamentalsof Fixed Prosthodontics ThirdEdition

Fundamentalsof

Fixed

Prosthodontics

ThirdEdition

Case 1: Mitral stenosis

INSTRUCTION

This patient developed dyspnoea and orthopnoea during pregnancy, please examine her.
This 55-year old patient has atrial fibrillation, please perform the relevant clinical examination.
SALIENT FEATURES

History

· Symptoms of left-sided heart failure: exertional dyspnoea, orthopnoea, paroxysmal dyspnoea.
· Less frequent symptoms: haemoptysis, hoarseness of voice, symptoms of right-sided failure (these
symptoms are somewhat more specific for mitral stenosis).
· Obtain a history of rheumatic fever in childhood.

Examination

· Pulse regular or irregularly irregular (due to atrial fibrillation). · Jugular venous pressure (JVP) may be
raised. · Malar flush.
· Tapping apex beat in the 5th intercostal space just medial to midclavicular line. · Left parasternal heave
(indicating right ventricular enlargement). · Loud first heart sound.
· Opening snap (often difficult to hear; a high-pitched sound that can vary from 0.04 to 0.10 s after the
second sound, and is best heard at the apex with the patient in the lateral decubitus position).
· Rumbling, low-pitched, mid-diastolic murmur - best heard in the left lateral position on expiration. In
sinus rhythm there may be presystolic accentuation of the murmur. If you are not sure about the
murmur, tell the examiner that you want the patient to perform sit-ups or hop on one foot to increase
the heart rate. This will increase the flow across the mitral valve and the murmur is better heard.
· Pulmonary component of second sound (P2) is loud.
Remember. The signs of pulmonary hypertension include loud P2, right ventricular lift, elevated neck
veins, ascites and oedema. This is an ominous sign of the disease progression because pulmonary
hypertension increases the risk associated with surgery (Bt Heart J 1975; 37: 74-8).

Note
· In patients with valvular lesions the candidate would be expected to comment on rhythm, the
presence of heart failure and signs of pulmonary hypertension.
· In atrial septal defect, large flow murmurs across the tricuspid valve can cause mid-diastolic
murmurs. The presence of wide, fixed splitting of second sound,
absence of loud first heart sound, and an opening snap and incomplete right bundle branch block should
indicate the correct diagnosis. However, about 4% of patients with atrial septal defect have mitral
stenosis, a combination called Lutembacher's syndrome.

Pathology CASE 10

CASE 10

INTRODUCTION

A 21-year-old nulliparous woman complains of lower abdominal "heaviness." She takes an oral contraceptive and is in a monogamous relationship. On examination, she has a normal-sized, nontender uterus, and a 9-cm right adnexal mass is palpated. Her pregnancy test is negative. On sonography, the mass appears cystic and solid.

· What is the most likely diagnosis?

· What are some of the histologic findings expected in this mass?

ANSWERS TO CASE 10: Ovarian Teratoma

Summary: A 21-year-old nulliparous woman has a 9-cm right adnexal mass that on sonography appears cystic and solid.

· Most likely diagnosis: Benign cystic teratoma of the ovary.

· Expected histologic findings in this mass: Any tissue may be found, but the most common are sebum, skin, hair, teeth, thyroid, and neurologic tissues.

CLINICAL CORRELATION

Introduction

This young woman has an ovarian mass that on ultrasound has cystic and solid components, a classic presentation of a benign cystic teratoma (dermoid cyst) of the ovary. Although benign cystic teratomas are often asymptomatic, larger dermoids (as in this case) can present with pelvic pain, pressure, fullness, or dyspareunia. The patient's pregnancy test was reported as negative; however, in rare cases, degenerating ectopic pregnancies can be missed with urine human chorionic gonadotropin (hCG) assays because of the low sensitivity of urine pregnancy tests in the presence of very low (<25 mIU/mL) serum hCG levels. The fact that the patient is engaged in a monogamous relationship should decrease the risks of her contracting gonorrhea or Chlamydia, hence decreasing the possibility of pelvic inflammatory disease and tuboovarian abscess (TOA). The patient also gives a history of oral contraceptive (OC) use, which also serves to decrease the risk of pelvic inflammatory disease and/or TOA. Oral contraceptives also greatly decrease the likelihood of the mass being a physiologic ovarian mass (follicular cyst, hemorrhagic corpus luteum cyst, etc.). The ultrasound shows a complex (both cystic and solid) ovarian mass, which also is not consistent with an abscess or a physiologic ovarian or paraovarian cyst.

Although some disagreement exists over the timing and indications for surgery in complex masses under 6 cm or simple cysts of any size, a 9-cm complex ovarian mass almost always needs to be explored surgically. This is due primarily to the small but not insignificant risk of malignancy. Upon confirmation of benign intraoperative findings, efforts should be directed at salvaging all normal tissue from the affected ovary and removing only that tissue which has undergone neoplastic degeneration.

Pathology CASE 9

CASE 9

INTRODUCTION

A 54-year-old woman notes a 6-month history of progressive vaginal discharge with an odor. She also has noted vaginal spotting after intercourse. She had gone through menopause 2 years earlier and took an oral contraceptive for 10 years. She has smoked one pack of cigarettes per day for 20 years. She denies a cough or dyspnea. She complains of right back pain and right leg swelling. The speculum examination shows a 4-cm irregular fungating mass arising from the cervix.

· What is the most likely diagnosis?

· What is the next step?

· What is the likely pathophysiology for this condition?

ANSWERS TO CASE 9: Cervical Cancer

Summary: A 54-year-old postmenopausal woman has a 6-month history of an odiferous vaginal discharge and postcoital spotting. She has smoked one pack of cigarettes per day for 20 years. She complains also of right back pain and right leg swelling. The speculum examination shows a 4-cm irregular fungating mass arising from the cervix.

· Most likely diagnosis: Cervical cancer.

· Next step: Biopsy of the lesion to confirm the diagnosis, followed by staging to assess the extent of the disease.

· Likely pathophysiology: Human papillomavirus.

CLINICAL CORRELATION

Introduction

This patient most likely has cervical cancer. Indications leading the clinician to the diagnosis in this case include the patient's risk factors and presenting symptoms. Her risk factors for cervical cancer include age, a history of oral contraceptive use, and a history of smoking. The presenting symptoms of malodorous vaginal discharge and postcoital bleeding are characteristic of cervical cancer. The history should guide the clinician to examine the cervix. In this case, a grossly visible lesion was seen on the cervix during speculum examination. The next step in management is to biopsy the lesion for a definitive diagnosis.

Pathology CASE 8

CASE 8

INTRODUCTION

A 55-year-old woman presents to the emergency department with profuse bright red bleeding with emesis diagnosed as bleeding esophageal varices. She also is icteric and is suspected of having cirrhosis. She has been followed for several years for Sjogren syndrome and Raynaud syndrome. Investigation into the cause of her cirrhosis reveals negative hepatitis antibodies but elevated antimitochondrial antibodies.

· What is the most likely underlying etiology for her liver disease?

· What is the most likely mechanism?

ANSWERS TO CASE 8: Primary Biliary Cirrhosis

Summary: A 55-year-old woman has cirrhosis and elevated antimitochondrial antibodies.

· Most likely diagnosis: Primary biliary cirrhosis.

· Most likely mechanism: The etiology of primary biliary cirrhosis is not known; however, evidence points toward an autoimmune basis to the disease.

CLINICAL CORRELATION

Introduction

This 55-year-old woman presents with bleeding esophageal varices and cirrhosis. The first priorities in her management include ABC: airway, breathing, and circulation. She should receive oxygen by a nasal cannula, and two large-bore intravenous lines should be established. Her blood pressure and heart rate should be monitored to assess for volume loss and replacement with blood as needed. Because of her liver disease, she may have a coagulopathy caused by depletion of vitamin K-dependent factors (factors II, VII, IX, and X). Transfusion with coagulation factors and initiation of vitamin K may be indicated. Endoscopic examination to determine the etiology of the upper gastrointestinal bleeding is paramount. Bleeding esophageal varices may be treated with sclerotherapy injected into the bleeding vessels. Also, a tamponade may be attempted with special esophageal devices.

Pathology CASE 7

CASE 7

INTRODUCTION

A 62-year-old man returns home from playing bingo, complaining of midline abdominal pain. He denies being hit or suffering any other trauma. Over the next few hours the pain does not remit but becomes more severe and is localized to the lower right quadrant. He also develops nausea and vomiting. He denies diarrhea and has not had similar episodes. The patient lies down in bed, and over the next 24 hours, the pain worsens and he develops fever and chills and is brought to the emergency center. On examination, he has a temperature of 102°F and appears ill. His abdomen is mildly distended and has hypoactive bowel sounds. The abdomen is diffusely tender to palpation, particularly in the right lower quadrant.

· What is the most likely diagnosis?

· What additional tests would help in making an accurate diagnosis?

ANSWERS TO CASE 7: Appendicitis

Summary: A 62-year-old man complains of midline abdominal pain. He denies being hit or suffering any other trauma. Over the next few hours, the pain worsens and is localized to the lower right quadrant. He also develops nausea and vomiting and, after 24 hours, develops fever and chills and an acute abdomen.

· Most likely diagnosis: Acute appendicitis.

· Additional diagnostic tests: CT scan of the abdomen and pelvis.

CLINICAL CORRELATION

Introduction

This older man has a typical picture of a ruptured appendicitis with sepsis. He originally had mild right lower quadrant abdominal pain, but it worsened, and after 24 hours he developed fever and chills. Perhaps the most worrisome finding on physical examination is that he "appears ill." He probably has sepsis, which is a systemic condition of infection-mediated illness. The chills probably reflect bacteremia. The emergency physician should expeditiously manage this situation, because delay could lead to morbidity or mortality, particularly in a geriatric patient. The blood pressure is not mentioned, but the patient could be in septic shock. Treatment should be addressed in a systematic manner: airway, breathing, and circulation (ABC) with oxygen administered, two large-bore intravenous lines (IVs), volume repletion for the probable volume depletion and sepsis, blood cultures, urine culture, and antibiotic therapy aimed at gram-negative bacilli and anaerobic bacteria. Blood work to be obtained includes a complete blood count and a chemistry panel to assess electrolytes and serum creatinine for kidney function. After stabilization, the patient should be taken to the operating room. If the diagnosis is unclear, a CT scan of the abdomen sometimes can help distinguish other abdominal pathologies, such as diverticulitis.

PATHOLOGY CASE 6

CASE 6

INTRODUCTION

A 22-year-old woman has had recurrent episodes of diarrhea, crampy abdominal pain, and slight fever over the last 2 years. At first the episodes, which usually last 1 or 2 weeks, were several months apart, but recently they have occurred more frequently. Other symptoms have included mild joint pain and sometimes red skin lesions. On at least one occasion, her stool has been guaiac-positive, indicating the presence of occult blood. Colonoscopy reveals several sharply delineated areas with thickening of the bowel wall and mucosal ulceration. Areas adjacent to these lesions appear normal. Biopsies of the affected areas show full-thickness inflammation of the bowel wall and several noncaseating granulomas.

· What is the most likely diagnosis?

· What are the common complications of this disease?

ANSWERS TO CASE 6: Crohn Disease

Summary: A 22-year-old woman has a 2-year history of recurrent diarrhea, abdominal pain, slight fever, joint pain, and red skin lesions. Colonoscopy reveals several sharply delineated areas with thickening of the bowel wall and mucosal ulceration, which on biopsy show full-thickness inflammation of the bowel wall and several noncaseating granulomas.

· Most likely diagnosis: Crohn disease.

· Common complications of this disease: Malabsorption and malnutrition, fibrous strictures of the intestine, and fistulae to other organs, such as from bowel to skin or bowel to bladder.

PATHOLOGY CASE 5

CASE 5

INTRODUCTION

A 57-year-old man complains of severe upper abdominal pain extending to his midback. He also has had fatigue and a loss in appetite over the last several weeks. Physical examination reveals generalized jaundice but no other significant findings. An upper endoscopy does not identify any mucosal ulcerations or masses. A CT scan of the abdomen shows a large mass in the head and body of the pancreas.

· What is the most likely diagnosis?

· What is the likely prognosis of this condition?

ANSWERS TO CASE 5: Pancreatic Carcinoma

Summary: A 57-year-old man has severe upper abdominal pain radiating to his midback, fatigue, loss of appetite, and generalized jaundice. A large mass in the head and body of the pancreas is noted on CT imaging.

· Most likely diagnosis: Pancreatic carcinoma.

· Likely prognosis of this condition: Poor prognosis with 5-year survival less than 5 percent.

CLINICAL CORRELATION

Introduction

The vast majority of pancreatic carcinomas involve exocrine glands and are known as adenocarcinomas. The etiology is largely unknown. However, point mutations of the K-ras gene have been observed in over 90 percent of the tumors, suggesting abnormalities at the genetic level. Pain and nonspecific systemic symptoms such as weakness and weight loss are the usual first signs of malignancy. Obstructive jaundice is seen commonly because of the preference for tumors to occur in the head of the pancreas. The symptomatic course of pancreatic carcinoma is typically brief and progressive. Radiologic workups, including abdominal CT and ultrasound, are diagnostic for the cancer and are used for staging. No specific biological tests are available for screening or early detection. Cancer of the pancreas is now the fifth most common cause of cancer-related death in the United States. The median survival period from the time of diagnosis to demise is arguably the worst of any of the cancers. The median survival for untreated advanced cases is about 3.5 months; with good treatment this increases to about 6 months. The 5-year relative survival rate of patients with this cancer is only 3 to 5 percent. Even though a Whipple operation is considered the treatment of choice for localized and early disease, fewer than 15 percent of pancreatic tumors overall are resectable at the time of diagnosis. The prognosis of pancreatic carcinoma is one of the most dismal among any malignancies ever known.

PATHOLOGY CASE 4

CASE 4

INTRODUCTION

A 45-year-old man with a family history of colon cancer undergoes a screening colonoscopy. No invasive carcinomas are identified, but two small pedunculated tubular adenomas are removed and one villous adenoma measuring 5 mm in diameter is biopsied.

· What is the most likely diagnosis?

· What are the syndromes that could predispose this individual to colon cancer?

· What other dietary factors could play a role in the development of colon cancer?

ANSWERS TO CASE 4: Colon Adenoma

Summary: A 45-year-old man with a family history of colon cancer underwent colonoscopy for rectal bleeding. Colonoscopic findings included several small pedunculated polyps in the right colon, all measuring less than 5 mm.

· Most likely diagnosis: Hyperplastic polyps or tubular adenomas.

· Syndromes predisposing to colon cancer: Familial adenomatous polyposis (FAP) and hereditary nonpolyposis colon cancer (HNPCC) are two common inherited colon cancer syndromes.

· Dietary factors that play a role in the development of colon cancer: Diets rich in fat and red meat and low in fiber may contribute to the development of colon cancer.