Medical Sh*t I learned today

Posting new & interesting medical sh*t as I continue learnin' for life! About this b*tch: I grew up in TN & graduated with an MD from Poland in 2011. I hope to start a residency in 2012 in family medicine the USA.

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Being Sedentary will Kill Ya...

According to the American Heart Association’s (AHA’s) physical activity call to action..., “[p]hysical inactivity is rapidly becoming a major global concern and is the fourth leading cause of death worldwide.” A report by a World Health Organization “ranked physical inactivity fourth on a list of risk factors for noncommunicable chronic diseases, behind high blood pressure, smoking, and high blood glucose.”

Read More Here: Kraus WE, Bittner V, Appel L, et al. The National Physical Activity Plan: A Call to Action From the American Heart Association: A Science Advisory From the American Heart Association. Circulation. 2015;1-9. doi: 10.1161/CIR.0000000000000203.

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scienceyoucanlove: The root cause of diabetes may have been found. 

Fiorina and his team studied hundreds of pathways in animals with diabetes. They eventually isolated one, known as ATP/P2X7R, which triggers the T-cell attacks on the pancreas, rendering it unable to produce insulin.

“By identifying the ATP/P2X7R pathway as the early mechanism in the body that fires up an alloimmune response, we found the root cause of diabetes,” says Fiorina. “With the cause identified, we can now focus on treatment options. Everything from drug therapies to transplants that require less immunosuppression is being explored.”

Read more: http://www.bostonmagazine.com/health/blog/2013/06/13/boston-childrens-hospital-found-the-root-cause-of-diabetes/ source

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Take care of your body. It's the only place you have to live.

Jim Rohn

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Chalazion Management

The mainstays of treatment are warm compresses and gentle massage of the closed lid toward the lid margin. In some cases, as seen in this image, the cyst may begin to "point" through the skin. If this occurs, discontinue warm compresses.

Although antibiotics are not indicated for management of chalazions, they should be ordered if preseptal cellulitis cannot be ruled out. Excision should be considered if the chalazion does not resolve after several months.

Children and parents should be warned that the chalazion will increase and decrease in size as it resolves and may occur in other parts of the lids.

(Source: http://www.medscape.com/features/slideshow/eyedisorders?src=mp&spon=25#7)

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Chalazion

History: Inflammation of a blocked meibomian gland that can occur on either eyelid. They are often recurrent, so previous episodes may be elicited on history. Begins as a mildly tender, swollen eyelid and may be confused with preseptal cellulitis.

Exam: A palpable firm nodule that may be tender when acute. Unlike a stye, it occurs in the tarsal plate rather than at the lid border.

(Source: http://www.medscape.com/features/slideshow/eyedisorders?src=mp&spon=25#6)

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Stye History: The child will typically present with localized redness, pain, swelling, and occasional crusting at the base of the eyelashes. Symptoms may worsen over the course of several days. Exam: Begins as a red papule, typically at the base of the eyelashes; may appear yellow as pus develops. A lump is usually palpable and tender to palpation. Management: Warm compresses are the usual treatment. Topical antibiotic ointments may be needed if there is accompanying bacterial conjunctivitis. Styes are typically caused by staphylococcal organisms. Reassure children and parents that styes resolve without a residual lump.

(Source: http://www.medscape.com/features/slideshow/eyedisorders?src=mp&spon=25#5)

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Allergic Conjunctivitis History: Most common in spring and fall. Redness, tearing, and rubbing the eyes are universal. If the child is not rubbing, it's not allergic conjunctivitis. Exam: Swelling of the conjunctiva (chemosis) may occur. The parent will describe it as a bubble on the white of the eye. Pronounced clear follicles in the bulbar conjunctiva near the cul-de-sac is also typical. Management: A stepwise treatment approach begins with cool compresses, artificial tears, over-the-counter antihistamines (diphenhydramine [Benadryl®] is the most effective oral agent), and/or topical antihistamines (emedastine [Emadine®]) or decongestants (naphazoline [Clear Eyes®; Vasocon A]). Second-line therapy includes mast cell stabilizers (lodoxamide [Alomide®], nedocromil [Alocril®]), or a combination antihistamine/mast cell stabilizer (olopatadine [Patanol®]).

(Source: http://www.medscape.com/features/slideshow/eyedisorders?src=mp&spon=25#3)

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Viral Conjunctivitis History: Viral illness within the previous week may sometimes be reported, but this is not always the case. Copious tearing and foreign body sensation are typical. Exam: Redness and swelling of the lids are common. Prominent follicles in the bulbar conjunctiva may be seen. Management: Artificial tears may be soothing. There is no response to topical antibiotics. However, some school systems may have policies mandating use of antibiotics in order for the child to be readmitted. Viral conjunctivitis is highly contagious and may last for weeks. Wipe down the examination room. Children are contagious for about 7-10 days after symptoms develop and may shed virus for the 3-4 days before redness appears.

(Source: http://www.medscape.com/features/slideshow/eyedisorders?src=mp&spon=25#3)

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Bacterial Conjunctivitis History: Painless, rapid onset. Exam: Red conjunctiva is found with all etiologies and is not a reliable indicator that the cause is bacterial. Discharge is always present and may be any color. Photophobia is not typical. Management: Bacterial conjunctivitis responds quickly to topical antibiotic drops, and there is no need to use the newest, greatest antibiotic! If the child is a contact lens wearer, ask about lens hygiene. Patients should not wear contact lenses if their eyes are red. Contact lens wearers who report pain should be referred to an eye care professional.

(Source: http://www.medscape.com/features/slideshow/eyedisorders?src=mp&spon=25#2)

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What are the steps to evaluating this patient?

History: When evaluating a red eye, ask about the presence of tearing, discharge, itching, pain, foreign body sensation, photophobia, and vision changes. Exam: Always check vision.  Children with suspected conjunctivitis who have symptoms for >1 week or do not respond to therapy within 48-72 hours should be referred.

(Source: http://www.medscape.com/features/slideshow/eyedisorders?src=mp&spon=25#1)

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Can you guess the culprits?  Can we say... tobacco, diet, alcohol, and obesity?

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Not a solution, but some good ideas:

25 percent of Americans between 18 and 25 don’t have health insurance, but that doesn’t mean we have to go without medical care altogether. From Living Social deals to clinical trials, here are five strategies to get health care on the cheap.

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- Parkinson's is a Clinical Diagnosis (based on evidence of the symptoms shown in the picture above). - That means that there are NO biochemical or imaging studies used to make the diagnosis.  Nevertheless, an autopsy exam of the brain may confirm the diagnosis.

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Lyme Disease in Pregnancy... What's the deal? Lyme disease can become serious if left untreated, so how should I manage a pregnant woman who thinks she might have contracted it? Step 1: Review how Lyme disease is contracted & presents

 Lyme disease is transmitted by tick bites (some ixodid ticks harbor the infective bacterium Borrelia burgdorferi) and the risk is ONLY significant when the tick remains attached to the body for 40-70 hours and is engorged (i.e. puffed up from having a tasty blood meal) at the time of removal. Freely moving tick over the body (aka, it's crawling & not attached/feeding) means low chances of infection.  

After the blood meal and a (3-30 days post-tick bite) incubation period, Lyme disease will present with a red, expanding rash called erythema migrans (EM) in 70-80% of patients.  

The next stage is a more disseminated disease which may present as: more "EM lesions in other areas of the body, Facial or Bell's palsy (loss of muscle tone on one or both sides of the face), Severe headaches and neck stiffness due to meningitis (inflammation of the spinal cord), Pain and swelling in the large joints (such as knees), Shooting pains that may interfere with sleep, and Heart palpitations and dizziness due to changes in heartbeat" (www.cdc.gov/lyme/signs_symptoms/index.html).  

Later stages have a more chronic presentation & can mimic other diseases like arthritis, so it's better to catch it early! :)

Step 2: Perform a good history & physical

Ask about exposure: did they remove a freely-moving tick, a recent bite, or an engorged tick?  If they have had tick contact but it was not the 3rd type (& NO rash), then it is best to send the patient home without any prophylaxis and reminded them to return, if they observe a change in their health or observe an area or redness around the site of tick bite.

Check for a rash (see step 1) & ask about any later-stage symptoms. (Take note that transient redness at the site of tick bite is due to reaction of saliva... Don't confuse this with erythema migrans!!)

Step 3: If there has been exposure & the patient is pregnant

Offer treatment with IV amoxicillin, if there is evidence of disease (see step 1 & 2)

Offer prophylactic treatment with amoxicillin if the patient is low risk (no EM, no engorged tick removal) & the patient exhibits increased anxiety about the disease. NB (i.e. important note): I have read different sources on this issue of prophylactic treatment for pregnant women... So, at this point I would consult your doc/hospitals protocols...

Remember: Pregnant patients have an equal infective risk as non-pregnant patients. That is, being pregnant does not make a patient more likely to be infected.

Picture: which tick do you think just had a tasty meal of blood... Read more about Lyme disease here: (www.cdc.gov/lyme)

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Placenta acrcreta, previa, abruptio: How to keep it straight

I confess, these terms are hard for me to keep straight.  So, I'm posting about it as a teach-myself moment.  As a bit of background, remember that the placenta is the organ that develops in a pregnant woman in order to interface with the baby in the uterus.  These three terms refer to problems with the placenta that Obgyn doctors watch out for & monitor, if found.  Here's the skinny:

Placenta Accreta: occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle. (Important note: this is the most common "too-deep" attachment problem, but there is also Placenta Increta, when it attaches into the uterine muscle, & Placenta Percreta, when it  penetrates through the uterine wall & attaches to another organ such as the bladder.)

My memory device for this: I think of the placenta as "creeping in" to the uterus...

Placenta Previa: is when the placenta lies low in the uterus and partially or completely covers the cervix (the cervix is the transitional zone between the uterus & the vagina).

My memory device for this: I think of the placenta as making a "preview" into the birth canal...

Placenta abruptio: is when the placenta separates from its attachment to the uterus wall.  Note that this can cause severe hemorrhage (bleeding) and is a medical emergency, which must be evaluated quickly.

My memory device for this:  I think of the placenta as "abruptly" tearing away from the wall of the uterus before parturition (i.e. birth), when it normally is also "delivered".

Read more here: www.americanpregnancy.org/pregnancycomplications

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Falling on an outstretched hand + residual wrist pain = scaphoid fracture  

As you can see in the picture above, one bone is particularly at risk when a paitent tries to break their fall with an outstretched hand; namely, the scaphoid bone of the wrist (carpel) bones.  Although actually located in what we call our hand, these carpel bones form the bridge between the bones of the arm (radius & ulna) and the hand (metacarpals).  If you want to feel your scaphoid bone, locate your anatomical snuff box--see link at the bottom of this post--and press.  You can just barely feel your scaphoid.  

So, what happens when you fall hard and break your scaphoid?  First, your doctor will do a physical exam and check for movement, tenderness, and other signs of a fracture (a broken bone).  They will also take an X-ray to better visualize the bones of the hand and arm.  However, often a break in the scaphoid is very hard to see, and there is quite a bit of inflammation in the body right after trauma which may "press" the broken parts of bone together and obscure the fracture line the doc is looking for in the X-ray image.  IF (& this happens often) the doc doesn't see a fracture line, she may diagnose a sprain (an over-stretching or tear injury to a ligament--the tough, fibrous tissue that connects bones to other bone).

BUT, if the patient has residual pain in the wrist, then they should return to their doc for a second X-ray.  This X-ray may show the break in the scaphoid and the diagnosis of a fracture can be made.

What are possible complications of a scaphoid fracture?  Avascular necrosis

The blood supply to the scaphoid bone is minimal and comes from the radial side of the arm.  

If the vessel supplying the scaphoid is damaged in the initial trauma, then the bone fragment distal to (i.e. away from) the supply will be cut off and die.  When a tissue dies--and, yes, bone is a tissue--this is called an instance of "necrosis". 

Although this result is not life threatening, it can be avoided by early diagnosis of the fracture & swift treatment.

Helpful image of the "anatomical stuff box": http://en.wikipedia.org/wiki/Anatomical_snuff_box

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McArdle's Disease: an overview

(also called  glycogen storage disease (GSD) type five or GSD V)

What is McArdle's Disease?

GSD V is due to an inherited absence (autosomal recessive) of myophosphorylase.  This enzyme is used most importantly in skeletal muscle to convert glyogen (storage form of sugar) to glucose (sugar used as an energy source).  Thus, during the initial phase of exercise, the muscle cannot break glycogen effectively and the muscle cannot function properly.  However, in later exercise, skeletal muscles use fuel from the bloodstream (glucose & free fatty acids).

How does McArdle's present?

Adults (around age 30 is the youngest) have:

Exercise intolerance with myalgia, early fatigue, muscle stiffness, & cramping, which are all relieved by rest. 

Following a short rest, most patients experience a “second wind” phenomenon & can resume exercise without difficulty.

Note: A fatal infantile form, characterized by hypotonia, generalized muscle weakness, and progressive respiratory insufficiency, has been seen. Additionally, a late-onset form that presents in the sixth decade of life has been described.

Learn more here: http://emedicine.medscape.com/article/946577-overview