1. Ericsson and Kintsch (1995) hypothesize that people store not only information but also learning strategies in long-term memory for easy access. This capacity, which Ericsson and Kintsch call long-term working memory, accounts for the extraordinary skills of experts (such as medical diagnosticians) who must match current information with a vast array of patterns held in their long-term memories.
What are the risk factors?
Age > 45 yrs
Lack of dietary fibers & High protein diet (meat)
Alcoholism, Smoking
Cholecystectomy - increased bile acid secretion
Upper urinary tract
Both kidneys are situated retroperitoneally on the posterior abdominal wall.
The left kidney is higher than the right kidney.
Introduction
It's the commonest malignant tumour of the kidney, also known as hypernephroma.
The peak incidence is around the age of 50-70s, male predominance.
The tumour arises from the renal tubules.
Introduction
Urinary stones are usually divided into 2 types :
The two main disease of the prostate :
1) Benign prostatic hyperplasia (BPH)
In brief, what happens is as men ages (>45 yrs), testosterone levels are reduced and the levels can be relatively lower than the estrogen levels.
Hence, estrogenic effects over the prostate causes proliferation, first over the periurethral region.
Note that as the prostate enlarges, it compresses on and elongates the prostatic urethra. Hence, it results in symptoms of bladder outflow obstruction.
Pathology
Almost all cases of Bladder carcinomas are originating from the transitional epithelium.
Since, the urothelium is frequently exposed to carcinogens that might be excreted through the urine. Urothelium over the bladder is commonly involved since there's always residual urine.
First of all, the causes of hematuria :
What are the common causes of urinary tract obstruction?
Upper UT obstruction :
Renal, ureteric calculi
Pelvi-ureteric junction obstruction
Retroperitoneal fibrosis (idiopathic, malignancy)
Transitional cell carcinoma
Congenital (Ectopic ureter, ureterocele)
Infections (Schistosomiasis, TB)
Some key questions to be asked regarding a swelling (generally)
1. When do you first notice the lump?
REMEMBER, first noticed the lump 3 months ago is not the same as first appeared 3 months ago.
2. How do you notice it?
Below are the 3 commonest answers :
a) It's painful
b) I noticed it accidentally
c) Others told me about it
1) Dermoid cyst
Dermoid cyst is a cyst located deep to the skin and lined by the skin.
It forms either due to accident during antenatal development or even following injury, some skin is being implanted into the subcutaneous tissue.
Hematemesis means vomiting of blood.
It can be either a frank blood, or altered, coffee-ground coloured blood (altered by digestive enzyme)
The aetiology of hematemesis is usually proximal to the duodenojejunal junction.
Rectal bleeding usually indicates lower GI bleeding (below duodenojejunal junction). Bear in mind that any patient, aged >45 yrs old, with complaints of :
colickly abdominal pain, PR bleeding and changes in bowel habits
Colorectal CA must be considered unless proven otherwise.
Anatomy of the portal system :
The portal vein is formed behind the neck of pancreas, at the level of L2, by the superior mesenteric and splenic veins.
Briefly about anatomy of anal canal
The anal canal commences from the level where the rectum passes through the pelvic diaphragm towards the anal verge. The junction in between the anal canal and rectum is the anorectal ring/bundle which can be felt during PR examination.
Classifications
1) Congenital
Congenital hydrocele
Congenital indirect inguinal hernia
2) Inflammatory
Cellulitis of scrotal skin - skin appears red, shinny, warm, tender
Pyocele - pus accumulation within tunica vaginalis, fluctuates, non-transilluminant
As Housemen, you need to know about the indications, preparations, complications
Oesophagogastroduodenoscopy (OGDS)
In all trauma cases, the 1st hour is also known as the golden hour, since nearly 30% of death occurs during this period of time.
In the ATLS Protocol, it comprises of :
Primary surveilence - Management of immediately life threatening conditions
Secondary surveilence
Definite management
An ulcer is defined as a break in the continuity of the lining epithelium of tissue. Once an ulcer appears, it's usually noticed by the patients, unless it's painless, or located at non-accessible sites.
History taking
1) When do you notice the ulcer?
Remember that the ulcer might have been present for long before the patient actually notices it. This is usually in case of a neuropathic ulcer.
Just breifly describe about this uncommon, but important condition
First, we'll talk about the anatomy :
Testes are originally retroperitoneal organs, during intra-uterine life.
Just before guys are born, our balls descends down, through the inguinal canal, and enters the scrotal sac at the perineum.
Pathophysiology
90% of the brain metabolism requires blood-borned glucose.
During normal circumstances, the cerebral autoregulation mechanism maintains the cerebral blood flow above 70mmHg, even though the Mean Arterial Pressure (MAP), varies as much as between 50mmHg - 150 mmHg.
This refers to collection of blood in between the skull and dura mater.
More commonly seen in younger patients (children, adolescence)
Extradural hematoma is always associated with skull fractures, most frequently, the temporal bone. (since pterion is the thinnest part of skull, involvement of this area causes tearing of the middle meningeal artery)
Most of the occasions, patients with mild head injury, after history and examination, and a period of observation, will be allowed to be discharge after following criterias met:
Battle's sign
a) Full GCS score (15/15)
b) No focal neurological deficits
c) Accompanied by a responsible adult
d) Not under influence of any drugs/alcohol
e) Verbal/Written advice about the injury given
History
We have a 16 years old male here presented to the ER complaining of sudden onset of right testicular pain. The pain woke him up from his sleep and has persisted over the last 3 hrs. His mother says that he has vomited once. His previous medical history includes a similar event a year ago, but on that occasion the pain subsided quickly. He is an asthmatic and uses a salbutamol inhaler.
Introduction
Thoracic trauma accounts for about 25% of all cases of trauma.
Most of the thoracic injuries are life theratening, where the commonest cause of morbidity and mortality is hypoxia and haemorrhage.
However, ironically upto 80% of the cases can be managed conservatively.
The key to succesful management here is early physiological resuscitation and accurate diagnosis.
Anatomy of Breast
The vertical extent of breast is from 2nd-6th ribs inclusive.
The horizontal extent is from the lateral edge of sternum to the mid-axillary line.
2/3rds of the breast overlies the pectoralis major muscle, whereas 1/3 of it over the serratus anterior.
The lower medial quadrant is lying on the external oblique aponeurosis, which separates it from the rectus abdominis.
Indications for intercostal drain :
a) Pneumothorax
b) Traumatic haemopneumothorax
c) Malignant pleural effusion
d) Empyema thoracis / Complicated parapneumonic effusion
e) Post-operative drainage : esophagectomy, cardiac surgery, thoracotomy
Pathophysiology
Mostly cholesterol stones (80%), pigment stones or mixed stones.
Whether cholesterol remains as solution within bile depends on it's concentration, and the levels of phospholipids and bile acids within.
If the bile is supersaturated by cholesterol, and/or levels of phospholipids and bile acids is low, this promotes formation of cholesterol crystals.
These cholesterol crystals are toxic towards the gall bladder musculature, and hence damages it.
Both duodenal ulcers and benign gastric ulcers are believed to be related to mucosal infection by H.pylori.
Peptic ulcer disease are mainly classified as complicated and uncomplicated.
Introduction
Defined as activation of the pancreatic enzyme resulting in autolysis of the gland.
It is important to investigate for the possible causes of Acute pancreatitis before labeling it as 'idiopathic'.
Introduction
Colonic diverticular disease is very common in developed nations, which is related to their diet containing low dietary fibers.
It is estimated that in developed countries, there are about 60% of the population aged > 70 years old are affected by diverticular disease. But this condition is rare before 35 years old.
Incidence is more common among females.
Pancreatic pseudocyst is defined as single/multiple fluid collection with high amylase content, surrounded by fibrous or granulation tissue within the lesser sac.
It usually occurs around 4 weeks after an acute attack of pancreatitis, where patient complains of epigastric fullness, pain, nausea and vomiting.
Before we discuss about the main topic for today, I'll be talking briefly about pregnancy dating.
Pregnancy is dated based on the last menstrual period, LMP (1st day of menstruation) and NOT the date of conception.
The mean period of gestation is around 280 days or 40 weeks, and hence the estimated date of delivery (EDD) can be calculated, by bringing forwards the LMP for 9 months and 7 days. This rule assumes that :
The Aims of antenatal care :
1) To detect, prevent, and manage the risk factors which adversely affects both mothers and fetus
2) To provide advice, reassurance, education and support to both mothers and family members
3) To deal with minor ailments encountered by mothers during pregnancy
4) To provide a general health screening
Normal antepartum fetal CTG :
Baseline rate : 110-150 bpm
Baseline variability : 10-25 bpm
2 accelerations in 20 min
Absence of deccelerations
Nause and Vomiting in pregnancy is common, usually occurs upto 16 weeks of pregnancy. Such problems are usually dealt conservatively by :
a) Eating small meals in frequent intervals
b) Avoid food that precipitates/aggravates symptoms
However, when it's prolonged, severe, frequent, intractable, not responding towards conservative management as mentioned above, and it's severe to the extent of causing dehydration, alkalosis and hypokalemia, it is known as Hyperemesis Gravidarum.
Nowadays, neurological complications of Hyperemesis Gravidarum is rare, more common complications are : Mallory-Weiss Tear and Esophageal rupture
Maternal steroid
Current recommendation of :
12mg Betamethasone 2 doses, 24 hrs apart OR
6mg Dexamethasone 4 doses, 6 hrs apart
Given during 28-34th week of pregnancy, within 7 days of delivery is said to improve the outcome. Betamethasone is actually more superior than dexamethasone since it more readily crosses the placental barrier as compared to dexamethasone.
There are two definitions of post-term pregnancy :
a) From WHO and FIGO : pregnancy which has complete a total of 42 weeks or 294 days, starting from the first day of LMP
b) From American O&G Association : period of gestation of 2 weeks beyond estimated date of delivery
Definition
The umbilical cord, upon rupture of membranes, lies either within the vagina or protruding out of the introitus.
There's 5 components in it's definition :
a) Blood pressure of >140/90, two readings, 4 hours apart
b) With significant proteinuria
c) Occurs de novo after 20th week of pregnancy
d) In previously normotensive mothers
e) And subsides completely after 6 weeks of delivery
Defined as bleeding from genital tract after 22nd week of gestation.
Ectopic pregnancy
H/O suggestive of ectopic pregnancy :
Abdominal pain
PV bleeding
Amenorrhoea
Previous ectopic pregnancy
IUD in situ
Previous abdominal/pelvic surgery
Previous h/o of PID
Defined as benign tumour of uterine smooth muscle, known as leiomyoma.
A firm tumour with whorled appearance.
Can arise from the :
a) Submucous fibroid
Arises from adjacent and protruding into endometrial cavity
b) Intramural fibroid
Arising centrally from the myometrium
c) Subserous fibroid
Arising from the outer border of myometrium
Endocrinal changes :
a) Placental hormones
During pregnancy, two important hormones are produced from syncytiotrophoblast.
Stages of labour
First stage of labour is divided into 2 phases, latent and active.
Latent phase : onset of true labour pain -> cervical dilatation of 3cm and full effacement.
What is CTG?
It's a method of fetal well-being assessment, to monitor the fetal heart rate in relation to the uterine contraction.
Definition
Also known as abnormal uterine bleeding.
It's an irregular uterine bleeding, caused by disruption of normal cyclical pattern of ovarian hormonal stimulation of the endometrial lining.
Definition
Onset of uterine contraction with frequency and intensity sufficient to cause progressive cervical dilatation and effacement prior to term gestation (22 – 37 weeks)
Definition
Gestational diabetes mellitus
A state of carbohydrate intolerance, first identified during pregnancy, usually the latter half (hence no effect over organogenesis), and resolves after delivery.
Pre-gestational diabetes mellitus
Pregnancy in an overt diabetic, can be either type I or II.
Changes in carbohydrate metabolism
The carbohydrate metabolism is altered in such a way that more glucose is made available to the fetus.
Increased levels of placental hormones and cortisol increases the FFA mobilisation, causing maternal hyperglycemia. These hormones have counter-regulatory effects over the action of insulin.
Definition
One or more fetus developing in-utero.
Monozygotic
Twin resulted from fertilisation of a single ovum by one sperm.
The time when the separation of the zygote occurs decides the no. of placenta and amniotic sac.
A pregnant mother came to you with eclamptic fits :
First, guard the mother against cardiorespiratory compromise and secondary injury due to seizure activity,
a) Give supplementary oxygen
b) Place the mother in left lateral position
This is to relieve compression of gravid uterus against Inferior vena cavae
And also to prevent aspiration during convulsions
c) Raised guardrails and padding to prevent maternal injury
d) Use padded tongue blade in between teeth and perform oral suction as required
Classifications of Hypertensive disorders in pregnancy
1. Gestational hypertension
2. Pre-eclampsia / Eclampsia
3. Chronic hypertension
4. Superimposed pre-eclampsia
Defined as the distribution and the determinants of health related states and events in a particular population and it's application in controlling health problems.
Major study designs
1) Observational
2) Experimental
a) Observational
i) Descriptive studies
Features :
No comparison is being made. (hence, no control group is required)
Application of statistical test of significance is therefore not required.
The prevalence and incidence can be multi-centric, when >2 centres are used.
The main purpose of observational studies is to generate a hypothesis.
Open fractures are always assumed to be infected, and a small puncture wound is as liable as a laceration towards infection.
The most useful classification for open fracture is the Gustillo's classification :
a) Type I
It is essentially a low energy fracture.
There is only little soft tissue damage.
The wound is small (<1cm), and is clean
There is no comminution.
a) Osteosarcoma
Osteosarcoma, in it's classical intra-medullary type, is a highly malignant metaphyseal bone tumour which rapidly spreads to the periosteum and the surrounding soft tissues.
It is more common among children and adolescence, especially around the age of 15-25 years old.
Most commonly affects the long bones around the knee joint, for eg : distal end of femur, proximal end of tibia, and proximal end of humerus.
Introduction
Intervertebral disc comprises of 3 important components :
1) cartilage end-plate 2) nucleus pulposus 3) annular fibrosus
The cartilage end-plate is a thin articular plate situated in between the adjacent vertebral bodies and the disc proper. The disc receives nutrition from the vertebral bodies via these cartilage end-plates.
Nucleus pulposus is a gelatinous substance located slightly posterior to the central axis of the vertebra. It is surrounded by concentric fibro-cartilaginous rings, known as annular fibrosus.
Introduction
Scaphoid fracture accounts for about 75% of carpal bone injury.
Common among young adults, rare in elderly and children.
The most common part of scaphoid bone fractured is the waist, which is the narrowest part.
Introduction
Patella is a sesmoid bone, with continuation from the quadriceps tendon, and patellar ligament.
It also receives insertion from vastus medialis and lateralis to it's medial and lateral edge.
The extensor snap is completed as the quadriceps muscles extends beyond the patella, and inserts into the proximal tibia (the medial and lateral retinacular fibres)
Introduction
Supracondylar fracture of the femur in young adults is a result of high energy injury, usually seen in road traffic accidents. Whilst in older age group, it may be an osteoporotic fracture.
Condylar fracture of the femur commonly associated with supracondylar fracture (fracture above the condyles extending into the knee joint), however, it can occur as an isolated fracture, for example fall from a height which results in the tibia thrusted into the intercondylar fossa of the femur.
Introduction
As in Rheumatoid arthritis, ankylosing spondylitis (AS) is a generalised chronic inflammatory disorder, which mainly involves the sacro-iliac joint (SI) and the spine. Typical presentation will be recurrent back pain and stiffness, with variable involvement of the shoulder, hip and other peripheral joints.
It's a male predominant disease (9:1), which typically affects teens and young adults aged between 15-25 years old. There is a strong familial aggregation and the genetic marker for AS is HLA-B27.
What you understand by union, non-union and consolidation?
Union is an incomplete repair, as the callus en-sheathing around the site of fracture undergoes calcification.
Palpation over the site usually causes slight tenderness, but attempts of moving the bone - the bone moves as one, and attempts of angulation causes pain.
X ray reveals that the fracture line is still visible, however, there is formation of fluffy bones (callus) around the periosteum that surround the fracture site.
Since repair is incomplete, stress towards the unprotected bone is avoided.
Monteggia-Fracture dislocation
Defined as fracture of the upper 1/3 of ulnar, together with dislocation of the head of radius.
The mechanism of injury is usually fall on an out-stretched hand with hyper-pronation of the forearm.
Occasionally, it can be caused by direct blow towards the back of forearm.
Clinical features
The deformity over the site of fracture (upper 1/3 of ulnar) is usually obvious.
However, the dislocated radial head can be obscured by the presence of swelling.
First, examination should be started with inspection of the patient's back while he/she is standing.
a) Inspection - Posterior
1) Is there any shoulder asymmetry?
2) Is there any prominent crease over the flanks?
3) Any scoliosis?
Back pain is one of the commonest presenting complaint in an Orthopedic clinic.
Often, a definite diagnosis is not possible.
However, it is useful if we classify the problem under 3 headings :
Circulatory changes in newborn
During in-utero life, the right atrial pressure is greater than left atrial pressure, since there's less pulmonary blood flow, and greater amount of systemic and placental venous return to right atrium.
Hence, the flap valve of foramen ovale remains patent, allowing blood flow from right to left atrium.
Once the baby takes his/her first breath, the pulmonary vascular resistance decreases, amount of pulmonary blood flow increased by 6 folds. In addition, placental venous return is excluded from the venous return to right atrium, hence left atrial pressure is now greater than right atrial pressure.
