Fistula test Interpretation

How are the results of Fistula test interpreted?

1. In fistula over the dome of the lateral semicircular canal: Increase pressure causes conjugate horizontal deviation of the eyes towards the normal side. As pressure is maintained, jerk nystagmus develops with fast component towards the affected ear. As pressure is released, eyes return to normal
2. Fistula of the lateral semicircular canal (anterior to the ampulla) causes deviation of eyes, to the affected side
3. Vestibular erosion causes rotatory horizontal nystagmus towards the diseased ear
4. Fistula of the posterior semicircular canal causes vertical movement of eyes.

https://youtu.be/4gEM17yTl5k

Drowning

Drowning
Drowning is a major cause in head injuries and death
• Initial peak
– Toddler age group
• Second peak
– Male adolescents
• Children younger than 1 year of age
– Often drown in bathtubs, buckets, and toilets
• Children 1–4 years of age
– Likely drown in swimming pools where they haveb beenunsupervised temporarily (usually for < 5 min)
– Typical incidents involve a toddler left unattendedt temporarilyor under the supervision of an older sibling
• Adolescent and young adult age groups (ages 15–24 years)
– Most incidents occur in natural water
• Approximately 90 % of drowning occur within 10 yardso ofsafety
• Parent should be within an arm’s length of a swimmingc hild (anticipatory guidance)
Mechanism of injury
• Initial swallowing of water
• Laryngospasm
• Loss of consciousness
• Hypoxia
• Loss of circulation
• Ischemia
• CNS injury (the most common cause of death)
• Acute respiratory distress syndrome (ARDS) may develop
• Salt water drowning classically associated with:
– Hypernatremia
– Hemoconcentration
– Fluid shifts and electrolyte disturbances are rarely seenc linically
• Fresh water drowning classically associated with:
– Hyponatremia and hemodilution
– Hyperkalemia
– Hemoglobinuria and renal tubular damage
• Management of drowning and near drowning
– Cardiopulmonary resuscitation (CPR) at the scene
– Admit regardless of clinical status
– All children with submersion should be monitoredi inthe hospital for 6–8 h
– If no symptoms develop can be discharged safely
– 100 % oxygen with bag and mask immediately
– Nasogastric tube for gastric decompression
– Cervical spine immobilization if suspected cervicali injuries
– Positive end expiratory pressure (PEEP) and positivep ressure ventilations in case of respiratory arrest
– Continuous cardiac monitoring
– Bolus of normal saline or Ringer’s lactate
– Vasopressors
– Defibrillation if indicated

Mnemonics in Dermatology

Generalized Skin Hyperpigmentation

"With generalized, none of the skin is SPARED"

Sunlight

Pregnancy

Addison's disease

Renal failure

Excess iron (haemochromatosis)

Drugs (e.g. amiodarone, minocycline)

Painful Cutaneous Nodules

BENGAL CO.

Blue rubber bleb nevus

Eccrine spiradenoma

Neurilemmoma/Neuroma

Glomus tumor

Angiolipoma/Angioleiomyoma/Angiosarcoma

Leiomyoma

Cutaneous endometriosis/Calcinosis cutis

Osteoma cutis

White Patch of Skin

"Vitiligo PATCH"

Vitiligo

Pityriasis alba/Post-inflammatory hypopigmentation

Age related hypopigmentation (e.g. idiopathic guttate hypomelanosis)

Tinea versicolor, Tuberous sclerosis (ash-leaf macules)

Congenital birthmark (e.g. Hypomelanosis of Ito)

Hansen's disease (leprosy)

Common Causes of Leukocytoclastic Vasculitis

VASCULITIS

Viral (e.g. Hepatitis B and C)

Autoimmune (Systemic Lupus Erythematosus, Sjögren's syndrome, rheumatoid arthritis)

Streptococci, Staphylococci, Henoch-Schönlein purpura

Cryoglobulins, Cryofibrinogens, Churg Strauss/Wegener's granulomatosis

Ulcerative colitis, urticarial vasculitis

Lymphoproliferative disease (hairy cell leukemia)

Infectious (endocarditis, meningococcemia, gonococcemia, Rocky Mountain spotted fever)

Thiazides, phenothiazines, and other drugs

Immune complex reactions, iodides, idiopathic

Sulfa drugs (septra), penicillin, and other antibiotics

Non-scarring alopecia

TOP HAT

Telogen effluvium, Tinea capitis

Out of iron, zinc

Physical-trichotillomania, traction alopecia

Hormonal-hypothyroidism, androgenic

Autoimmune-alopecia areata, anagen effluvium

Toxins-heavy metals, chemotherapy

Erythema Nodosum

NODOSUM5

NO cause is found in 60% of cases

Drug (iodides, bromides, sulfonamides)

Oral contraceptives

Sarcoidosis or. Löfgren's syndrome

Ulcerative colitis, Crohn's disease, Behçet's

Microbiology: any chronic infection (bacterial, viral, yersinia, tuberculosis, leprosy, deep fungal)

Behcet's syndrome: Diagnostic Criteria

PROSE

Pathergy test

Recurrent genital ulceration

Oral ulceration (recurrent)

Skin lesions (e.g. erythema nodosum, subcutaneous throm-bophlebitis, cutaneous hypersensitivity)

Eye lesions (e.g. iridocyclitis, chorioretinitis)

• Oral ulceration is central criterion, plus any 2 others

Focal Dermal Hypoplasia Syndrome/Goltz syndrome

FOCAL

Female sex (85-90%)6

Osteopathia striata

Coloboma

Absent ecto-, meso-, and neuro-dermis elements

Lobster claw deformity

SLE (Systemic Lupus Erythematosus) Diagnosis

SOAP BRAIN MD

Serositis

Oral/nasal ulcers

Arthritis

Photosensitivity

Blood (cytopenia)

Renal involvement

ANA

Immune (typical antibodies e.g. dsDNA, anti-Sm)

Neurologic (e.g. seizures, stroke)

Malar rash

Discoid rash

• 4 out of 11 criteria needed for diagnosis

Henoch-Schonlein purpura: signs and symptoms

NAPA

Nephritis

Arthritis, arthralgias

Purpura , palpable (especially on lower extremities)

Abdominal pain (intussusception to be ruled out)

Anatomy One Liners

Anatomy One-Liners
1) Ascending colon 12.5cm long
- from the caecum to the inferior surface of  the right lobe of the liver
- usually retroperitoneal
(2) Transverse colon 50cm long 

- from the right colic flexure to the left colic flexure
- suspended by transverse mesocolon attached to the anterior border of the pancreas
(3) Descending colon - 25cm long
- from left colic flexure to the sigmoid colon
- it is narrower than ascending colon
- usually, it is retroperitoneal
(4) Sigmoid colon 37.5cm long
- from pelvic brim to the third piece of the sacrum, where it becomes rectum
- suspended by sigmoid mesocolon

Mesentery:- The mesentery of the small intestine (or) mesentery proper is a broad, fan-shaped fold of peritoneum which suspends the coils of jejunum and ileum from the posterior abdominal wall
Root of mesentery - 15cm long
- directed obliquely downwards and to the right
- It extends from the duodenojejunal flexure on the left side of vertebra L2 to the upper part of the right sacroiliac joint
- It crosses the following :
(1) Third part of duodenum where the superior mesenteric vessels enter into it
(2) The abdominal aorta
(3) The inferior vena cava
(4) The right ureter
(5) The right psoas major

The free or intestinal border is 6meter long, thrown into pleats.

Development of diaphragm by
1. Septum transverum
2.pleuro peritoneal membrane
3.somites (3-5th)
4.ventral pleural sac
5.mesentry of esophagus

Tonsil develop embryologically from 2nd pharyngeal pouch
Parathyroid is developed from 3rd & 4th brachial pouches
Footplate of stapes is developed from otic capsule

Umbilical vesicle attain full development in 4th week of fetus
Urachal fistula result from persistent allantois

Tensor tympani and tensor palatine supplied by trigeminal.Levator palatine supplied by the superior laryngeal nerve.

Derivatives of pharyngeal pouch
1st- tubotympanic recess
2nd-tonsil
3rd-inf parathyroid, thymus
4th-sup parathyroid, thyroid
5th-ultimobranchial body

Mesodermal derivatives of branchial arch
1st-malleus, incus, anterior ligament of malleus, sphenomandibular ligament
2nd-stape, styloid process, stylohyoid ligament, lesser cornu of hyoid, sup part of the hyoid
3rd-greater cornu of hyoid, lower part of the body of hyoid
4n6th-laryngeal cartilage

1st pharyngeal arch cartilage-Meckel cartilage
2nd pharyngeal arch cartilage-Reichert cartilage

TYMPANIC membrane dev from all the three germ layers
Pinna dev from 1st n 2nd pharyngeal arches
Footplate and annular ligament from otic capsule

Left umbilical vein-ligamentum teres
Rt-disappear
Ductus afteriosus-ligamentum arteriosum
Ductus venosus-ligamentum venosum
Septum primum n secondum-fossa ovalis n annulus ovalis respective
Distal umbilical art-median umb ligament
Proximal -sup vesical art

Foregut forms -Oesophagus
- The stomach
- Upper part of duodup to upto the opening of
common bile duct

Midgut forms - Rest of the duodenum
- Jejunum
- The ileum
- The appendix
- The caecum
- The ascending colon
- The right two - thirds of transverse colon

Hindgut forms -Left one-third of transverse colon
- The descending colon
- The sigmoid colon
- Proximal upper part of the rectum

Nerve supply of anal canal
(1) Above the pectinate line
- Sympathetic - Inferior hypogastric plexus - L1 & L2
- Parasympathetic- pelvic splanchnic S2, S3, S4
- Pain is carried by both of them
(2) Below the pectinate line
- somatic
- Inferior rectal S2,S3,S4 - nerves
(3) Sphincters - Internal sphincter - contraction - sympathetic nerve / relaxation - parasympathetic. N
External sphincter - inferior rectal nerve & by perineal branch of 4th sacral. N

Genital tubercle forms - clitoris
- urethral folds forms - labia minora
- genital swelling form - labia majora
- urogenital membrane gets ruptured to form the vestibule

Forebrain developmental abnormalities

Megalencephaly

• Abnormally large brain
• Less common than microencephaly 

Microencephaly

• Abnormally small brain
• Lots of causes (chromosomal abnormalities, fetal alcohol syndrome, HIV acquired in utero)

Lissencephaly

• Decrease in number of gyri
• Sometimes gyri are totally absent (agyria)

Polymicrogyria

• Small, numerous, irregularly formed gyri
• Can be caused by injury or genetic abnormality

Neuronal heterotopias

• Neurons in inappropriate locations along migrational pathways
• Associated with epilepsy

Holoprosencephaly

• Incomplete separation of cerebral hemispheres across the midline
• May have midline facial abnormalities (e.g., cyclopia, absence of olfactory cranial nerves)

Agenesis of the corpus callosum

• Absence of white matter bundles connecting cerebral hemispheres
• Patients may have other defects, or may be asymptomatic

Criterias & classifications

1.Halls criteria : Downs syndrome

2.Dukes criteria: Endocarditis/Heart failure

3.Butchers criteria :mesothelioma

4.Ann Arbours classifiacation :Hodgki.s lymphoma

5.Bismuth classification: tumors of hepatic ductal system

6.Nazers Index: Wilsons disz

7.Pagets Index : Abruptio placentae

8.Quetlet index: BMI -wt in kg/ht in meter square

9.Ponderial Index: ht in cm/cube root of body wt in kgs

10.Brocas index : Ht in cms-100

11.Corpulence index : Actual wt/desired wt

12Milans crjteria: for liver transplant in HCC

13.Mayers n cottons grading system: Subglottic stenosis

14.Spaldings criteria: abdominal pregnancy

15.GCS/Ransons criteria/APACHE score: Pancreatitis

16.Ennekings staging : Bone tumors

17.Mc Donald's criteria: Multiple Sclerosis

18.Epworths criteria : Sleep apnea

19.Framminghams criteria/Boston's criteria: CHF

20.Durie salmon system of staging: Multiple myeloma

21.Lights criteria: pleural effusion

22.GOLD's criteria :COPD

23.OKUDA staging : HCC

24.Child's Turcott pug score/MELD/PELD- Cirrhosis of liver

25.Mantrles criteria/Alvarado score: Appendicitis

26.Evan's stagng: Neuroblastoma

27.FAB: Leukemias

28.Glisson's staging: Prostrate

29.Robson's staging : RCC

30.NADA's criteria: ASD assesment of child for heart disease

31.Rye classification: Hodgkins lymphoma

32.Chang staging: Medulloblastoma

33.Jackson's ataging :Penile Carcinoma

34.Seddons classification: Nerve injury n regeneration

35.Larren's classification:Gastric Ca

36.Neer's classification: supracondylar# femur

37.Gartland's classification: Supracondylar # Humerus

38.Amsel's criteria: bacterial vaginosis

39.Mallampati scoring: for intubation

40.Forrest classification: peptic ulcer bleed

41.Hess & Hunt Scale: subarachnoid hemorrhage

42.Duke staging : colon cancer

43.Rotterdam's criteria : PCOS

44.LEEFORDT's classification : facial #

45.wells criteria: pulmonary embolism

46.Rule of wallace/Rule of 9: Burns

47.Mansons classification: Radial head #

48.Stanford classifi ation: Aortic dissection

49.Rockall scoring: adverse out come after GI bleed

50.Glasgow Blatchford score : UGI bleed for medical intervention

51.Waterlows classification: Malnutrition in children

Investigation of choice

INVESTIGATION OF CHOICE

• Single Bone Metastasis – CT
• Multiple Bone Metastasis – Bone scan
• Spine Metasta sis – MRI
• Avascular necrosis- MRI
• Bone Density/Osteoporosis- DEXA (Dual energy x ray absorptiometry)
• Aneurysm/ AV Fistula- Angiography
• Dissecting Aneurysm (Stable) - MRI (Unstable)-Trans oesophageal USG
• Pericardial Effusion- Echocardiography
• Lobulated pericardial effusion- MRI > CT
• Minimum Pericardial Effusion- Echocardiography
• Ventricular Function- Echocardiography
• Radiotherapy/Chemotherapy induced cardiotoxicity- Endomyocardial Biopsy
• Pulmonary Embolism- CECT> Pulmonary Angiography > V/Q Scan
• Interstitial lung disease(Sarcoidosis)- HRCT
• Bronchiectasis- HRCT scan
• Solitary Pulmonary Nodule- High resolution CT (HRCT)
• Posterior Mediastinal Tumor- MRI
• Pancoast Tumor (Superior Sulcus Tumor) – MRI
• Minimum Ascites/Pericardial effusion/Pleural effusion – USG
• Traumatic Paraplegia- MRI
• Posterior Cranial Fossa – MRI
• Acute Haemorrhage- CT
• Chronic Haemorrhage- MRI
• Intracranial Space Occupying Lesion- MRI
• Primary brain tumour- contrast MRI (Gold standard however remains to be biopsy)
• Metastatic brain tumor- (Gadolinium) contrast enhanced MRI
• Temporal Bone-CT
• SAH Diagnosis- unenhanced CT
• SAH aetiology- 4 vessel MR Angiography > CT Angiography > DSA
• Nasopharyngeal angiofibroma- CECT scan
• Acoustic neuroma- Gadolinium DTPA enhanced MRI
• Obstetrics- USG
• Calcifications- CT
• Blunt abdominal Trauma- CT
• Acute Pancreatitis- CT
• GERD- pH manometer > endoscopy
• Dysphagia- Endoscopy
• Congenital hypertrophic pyloric stenosis- USG
• Extrahepatic biliary atresia- perioperative cholangiogram
• Obstructive Jaundice/GB Stones- USG
• Diverticulosis – barium enema
• Diverticulitis – CT scan
• Renal TB (early) – IVP (Late)- CT
• Posterior Urethral Valve- MCU
• Ureteric stone- non contrast CT
• Renal Artery Stenosis- Percutaneous Angiography
• Extraintestinal Amoebiasis- ELISA
• Discrete swelling(solitary nodule) of thyroid- FNAC