Rheumatic Fever Case



An 11 year old male presents with fever up to 39 degrees (102 degrees F), joint pain and swelling, along with shortness of breath. The fever comes and goes at random times of the day. The symptoms have been present now for 4 days. Two days ago, his right knee was painful and swollen, but today it has improved. The joints involved today include the right ankle and left knee. They are quite tender, painful and also swollen. The shortness of breath occurs with walking, but he is now unable to walk because of the joint pain. He also has some shortness of breath with lying down flat when he is trying to sleep.

Examination:

VS T 38.2, P 160, RR 32, BP 100/60, oxygen saturation 94% in room air. He is tired appearing with tachypnea and tachycardia.

HEENT: Enlarged, erythematosus tonsils with exudates.

Lungs are clear but with tachypnea.

Heart sounds are tachycardic with a holosystolic murmur 3/6 heard at apex with radiation to axilla.

No gallops are heard. His PMI is prominent (size of silver dollar) at the 7th intercostal space in the mid-axillary line.

His abdomen is soft with normoactive bowel sounds. His liver edge is 6 to 7 cm below the RCM.

His left knee is swollen and extremely tender with warmth. He has difficulty with range of motion but can flex his knee 30 degrees passively. His right ankle is very swollen and warm. He has limited subtalar motion. Both his knee and ankle are very tender even to touch.

Neuro: No abnormal movements of arms, hands, or tongue are noted. He is unable to walk due to pain.

Clinical course:

 

The child is admitted to the hospital.

Initial laboratory work includes a erythrocyte sedimentation rate of 110, a CRP of 9.5, and a chest X-ray with cardiomegaly present.

EKG reveals a prolonged PR interval. ASO titer is 754 and streptozyme is 1:600.

The diagnosis of acute rheumatic fever (ARF) is made and he is initially started on salicylate therapy at 75 mg/kg/day, and his arthritis improves dramatically.

However, the next day an echocardiogram confirms severe mitral insufficiency.

Due to the significant cardiac disease with elements of congestive heart failure he is switched to corticosteroids and improves.

His heart size decreases over the next 2 weeks, and when it normalizes he is switched back to salicylates for a total treatment duration of 8 weeks.

He does have a persistent murmur after this time however. He is started on intramuscular benzathine penicillin, which is given every 4 weeks for streptococcal prophylaxis.

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MCQs : Thyroid



1- what is the vertical extension of the thyroid in relation to the vertebrae ?

a- C4 to T1
b- C5 to T1
c- C6 to T1
d- C3 to T1

answer : B

2- the thyroid develops from ?

a- ectoderm
b- mesoderm
c- dorsal pharyngeal gut endoderm
d- ventral pharyngeal gut endoderm

answer : D

3- screening method for medullary carcinoma of thyroid ?

a- serum calcitonin
b- serum calcium
c- serum ALP
d- serum acid phosphatase

answer : A

4- medullary carcinoma of thyroid arises from ?

a- parafollicular cells
b- cells lining the acini
c- capsule of thyroid
d- stroma of the gland

answer : A

5- which of the following is/are used in the management of thyroid malignancy?

a- Iodine 131
b- Iodine 125
c- Technitium 99
d- Phosphorus 32
e- strontium

answer is A

6- characteristic eye sign in dysthyroid status ?

a- exopthalmos
b- ptosis
c- optic neuropathy
d- myopathy

answer : A

7- hurthle cells are seen in ?

a- hashimoto's thyroiditis
b- follicular cell carcinoma
c- hurthle cell thyroid adenoma
d- all the above

answer is D

8- C cells populate which part of the lateral lobe of the thyroid ?

a- upper one-third of the lateral lobe of thyroid
b- middle one-third of the lateral lobe of thyroid
c- lower one-third of the lateral lobe of the thyroid
d- distributed equally all over the lateral lobe of the thyroid

answer :B

9- pick out the correct statements .

a- the external laryngeal nerve runs close to the superior thyroid artery .
b- the recurrent laryngeal nerve runs close to the inferior thyroid artery .
c- the external laryngeal nerve runs close to the inferior thyroid artery .
d- the recurrent laryngeal nerve runs close to the superior thyroid artery .

answer : both A and B are correct . ( so the surgeon has to be very careful while ligating those arteries, while performing thyroidectomy ).

10- treatment of medullary carcinoma of the thyroid with lymphnode metastasis?

a- subtotal thyroidectomy + radioiodine
b- subtotal thyroidectomy + radiotherapy
c- neartotal thyroidectomy + radioiodine
d- neartotal thyroidectomy + radiotherapy
e- total thyroidectomy + radiotherapy

answer : E

11- what is near total thyroidectomy ?

a- right lobectomy + isthmusectomy
b- left lobectomy + isthmusectomy
c- bilateral lobectomy with isthmusectomy
d- right lobectomy + isthmusectomy + left half lobectomy
e- right and left lobectomy

answer : D

 12- papillary carcinoma of thyroid with bone metastasis is treated by?

a- subtotal thyroidectomy + radioiodine
b- subtotal thyroidectomy + radiotherapy
c- near total thyroidectomy + radioiodine
d- near total thyroidectomy + radiotherapy
e- total thyroidectomy + chemotherapy

answer : C and D

13- most common cause of thyroiditis is ?

a- hashimoto's thyroiditis
b- reidl's thyroiditis
c- subacute thyroiditis
d- viral thyroiditis

answer : A

14-  thyroglossal cyst may occasionally give rise to which carcinoma ?

a- papillary
b- anaplastic
c- medullary
d- follicular

answer : A

15- a post-thyroidectomy patient develops signs and symptoms of tetany. The management is ?

a- I.V calcium gluconate
b- Bicarbonate
c- Calcitonin
d- Vitamin D

Answer : A

16- hypoparathyroidism following thyroid surgery occurs with in ?

a- 24 hours
b- 2-5 days
c- 7-14 days
d- 2-3 weeks

Answer : B

17- a patient undergoes thyroid surgery following which he develops perioral tingling . his blood calcium is 8.9 meq/l. next step in the management is ?

a- vitamin D orally
b- oral calcium and vitamin D
c- intravenous calcium gluconate and serial monitoring
d- wait for calcium to decrease to less than 7 meq/l before taking further action

answer : B

18- a patient after undergoing thyroid surgery presents with perioral paraesthesia . serum calcium level is 7 mg/dl . what will be the best management ?

a- oral vitamin D3
b- oral vitamin D3 and calcium
c- I.V calcium gluconate
d- Oral calcium

Answer : D

19- which of the following is not a complication of total thyroidectomy ?

a- bleeding
b- airway obstruction
c- hoarseness
d- hypercalcemia

answer : D

20- in post operative room after thyroid surgery , patient developed sudden respiratory distress , dressing was removed and it was found to be slightly blood stained and wound was bulging . what will be the first thing to be done ?

a- tracheostomy
b- cricothyroidectomy
c- laryngoscopy and intubation
d- remove the stitch and take the patient to O.T

answer : D

21- a patient presents with neck swelling and respiratory distress few hours after a thyroidectomy surgery. Next management would be ?

a- open immediately
b- tracheostomy
c- wait and watch
d- oxygen by mask

answer : A

22- after thyroidectomy patient developed stridor within 2 hours. All are likely causes of stridor except ?

a- hypocalcemia
b- recurrent laryngeal nerve palsy
c- laryngomalacia
d- wound hematoma

answer : A . hypocalcemia due to hypoparathyroidism after thyroid surgey normall results with in 2-5 days .


23- papillary carcinoma of the thyroid ( PCT ) patients are ?

a- euthyroid
b- hypothyroid
c- hyperthyroid
d- T3 thyrotoxicosis

Answer : A

24- HURTHLE cell carcinomas are derived from which cells ?

a- follicular cells
b- para follicular cells
c- oxyphilic cells
d- lymphocytes

answer : C

25- the malignancy which is common on long standing goiter ?

a- PCT
b- MCT
c- FCT
d- Anaplastic

Answer : C . Follicular carcinoma of the thyroid .


26- least malignant thyroid cancer ?

a- papillary
b- medullary
c- anaplastic
d- follicular

answer : a ( mean the more differentiation ) and the commonest tumor is it .

27- which of the following gene defects is associated with development of the medullary carcinoma of the thyroid ?

a- RET proto oncogene ( on chromosm 10 )
b- FAP gene
c- RB gene
d- BRCA 1 gene

Answer :A
RET proto gene : associated with medullary thyroid carcinoma, hirschsprung's disease and pheochromocytoma and rearrangement of RET gene leads to papillary thyroid carcinoma

28-  psammoma bodies are seen in all of the following conditions except ?

a- serous cystadenoma of ovary
b- papillary carcinoma of thyroid
c- meningioma
d- mucinous cystadenoma of ovary

answer : D

29- all of the following are early life threatening complications of thyroid operation except ?

a- tracheomalacia and collapse of larynx
b- wound hematoma with compression of the trachea
c- hypocalcemia
d- thyroid storm

answer : C

30- in pregnancy ?

a- thiouracil is contraindicated
b- surgery is contraindicated
c- radioiodine is contraindicated
d- none

answer: C


31- lateral aberrant thyroid refers to ?

a- congenital thyroid abnormality
b- metastatic foci from primary in the thyroid
c- struma ovarii
d- lingual thyroid

answer : B

32- a patient presented with headache and flushing . he has a family history of his relative having died of a thyroid tumor. The investigation that would be required for this patient will be ?

a- chest x-ray
b- measurement of 5-HIAA
c- measurement of catecholamine
d- intravenous pyelography

answer : C . measurement of catecholamines . headache and flushing suggest symptoms of adrenal tumor and a history of thyroid tumor in the relative suggest the MEN syndrome type 2a or 2b . so the adrenal tumor is probably pheochromocytoma and so catecholamines have to be measured .


33- cancer that develops after irradiation ?

a- PCT
b- MCT
c- FCT
d- Anaplastic

Answer : A

34- mutated p53 gene is formed in most of ?

a- anaplastic carcinomas
b- PCT
c- MCT
d- FCT

Answer : A

35- treatment of choice for medullary carcinoma of thyroid is ?

a- total thyroidectomy
b- partial thyroidectomy
c- iodine 131 ablation
d- hemithyroidectomy

answer : A

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Lecture Notes : Hernias



Definition :
It is a protrusion of any viscus from its proper cavity. The protruded parts are generally contained in a sac-like structure, formed by the membrane with which the cavity is naturally lined.

Epidemiology :

- Approximately 25% of males and 2% of females have inguinal hernias in their lifetimes representing the most common hernia in males and females.

- Approximately 75% of all hernias occur in the groin; two thirds of these hernias are indirect and one third direct.

- Indirect inguinal hernias are the most common hernias in both men and women; a right-sided predominance exists.

- Incisional and ventral hernias ( epigastric ) account for 10% of all hernias.

- Only 3% of hernias are femoral hernias.

- The incidence of inguinal hernias in children ranges up to 4.5%, while umbilical hernias occur in approximately 1 out of every 6 children

- The incidence of incarcerated or strangulated hernias in pediatric patients is 10-20%; 50% of these occur in infants younger than 6 months .

Types : according to location

1- inguinal hernias : indirect and direct

- what are the normal structure which pass through the inguinal canal ?

in males : the spermatic cord and its coverings + the ilioinguinal nerve
in females : the round ligament of the uterus + the ilioinguinal nerve.

 

The classic description of the contents of spermatic cord in the male are:

 

3 arteries: artery to vas deferens (or ductus deferens), testicular artery, cremasteric artery;

3 fascial layers: external spermatic, cremasteric, and internal spermatic fascia;

3 other structures: pampiniform plexus, vas deferens (ductus deferens), testicular lymphatics;

3 nerves: genital branch of the genitofemoral nerve (L1/2), autonomic and visceral afferent fibres, ilioinguinal nerve (N.B. outside spermatic cord but travels next to it)

 

The ilioinguinal nerve passes through the superficial ring to descend into the scrotum, but does not formally run through the canal.

 

2- Femoral :

- more common in females

- because it is small space >> frequently it can be incarcerated or strangulated

- located medial to femoral vein and lateral to lacunar ligament

 

3- umbilical hernia :

- congenital hernia 

- repaired if it persist in children older than 2-4 years

 

4- Richter hernia :

- occurs when only the antimesenteric border of the bowel herniates through the fascial defect.

- The Richter hernia can occur with any of the various abdominal hernias and is particularly dangerous, as a portion of strangulated bowel may be reduced unknowingly into the abdominal cavity, leading to perforation and peritonitis.

 

5- Incisional hernia :

- iatrogenic hernia occurs in 2-10% 

- recurrence rates approach 20-45%

 

6- Spigelian hernia :

- rare

- defect in the spigelian fascia >> the lateral edge of the rectus muscle at the semilunar line ( costal arch of pubic tubercle)

- The two subtypes are interstitial and subcutaneous

- best defined using CT

 

7- Obturator hernia :

- passes through the obturator foramen

- female-to-male ratio of 6:1  >> larger

- Because of its anatomic position, this hernia presents more commonly as a bowel obstruction .

 

- Types of Hernia - Condition

• Reducible hernia: This term refers to the ability to return the contents of the hernia into the abdominal cavity, either spontaneously or manually.
• Incarcerated hernia: An incarcerated hernia is no longer reducible. The vascular supply of the bowel is not compromised; however, bowel obstruction is common.
• Strangulated hernia: A strangulated hernia occurs when the vascular supply of the bowel is compromised secondary to incarceration of hernia contents.

History :

- can be presented by the patient or detected in routine physical examination

- patient can be presented with :
1- lump
2- pain
3- nausea , vomiting or symptoms of intestinal obstruction ( in incarcerated hernia )
4- sepsis ( in strangulated )

- swelling in femoral region + groin pain >> femoral hernia

- Obturator hernia

• Because this hernia is hidden within deeper structures, it may not present as a swelling
• The patient may complain of abdominal pain or medial thigh pain, weight loss, or recurrent episodes of bowel or partial bowel obstruction
• Pressure on the obturator nerve causes pain in the medial thigh that is relieved by thigh flexion. This same pain may be exacerbated by extension or external rotation of the hip (Howship-Romberg sign)

- in physical examination >> Strangulated hernias are differentiated from incarcerated hernias by the following:

• Sever pain
• Fever or toxic appearance
• Pain that persists after reduction of hernia

- Causes with the risk factors :

 

Any condition that increases the pressure in the intra-abdominal cavity may contribute to the formation of a hernia, including the following:

• Marked obesity
• Heavy lifting
• Coughing
• Straining with defecation or urination
• Ascites
• Peritoneal dialysis
• Ventriculoperitoneal shunt
• Chronic obstructive pulmonary disease (COPD)
• Family history of hernias

 

- Differential Diagnoses

• Epididymitis
• Hidradenitis Suppurativa
• Hydrocele
• Lymphogranuloma Venereum
• Testicular Torsion

- in lab studies :

CBC >> -nonspecific
               -leukocytosis in strangulation

electrolyte ,BUN and Cr >> - rare
                                              - evaluate hydration status in pt with vomiting

urinalysis >> narrow DDx

lactate >> - elevated level indicate hypoperfusion
                 - normal not rule out strangulation

- complication
1- incarceration
2- intestinal obstruction
3- if it was strangulation and missed >> perforation and peritonitis
4- recurrence

- Treatment :

elective herniorrhaphy >> to prevent the chance of incarceration or strangulation

emergent herniorrhaphy >> if strangulation is suspected or acute incarceration is present



 

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Lecture Notes : Spleen



- Blood Flow to the spleen is 300 ml/min
                        the liver is 1600 ml/min
                        the tow kidneys is 1100 ml/min
                        the brain is 750 ml/min

- Spleen is very soft and easly rupture during sugery .
- How you can identify the splenic artery during surgery ?
          it will be tortorous lie above the upper border of pancrease
- Common organe is rupture due to blunt trauma is Liver while the common organe is rupture due to penetrating trauma is Small Intestine . ( according to recent study )
- The comments benign tumer of the spleen is Hemangioma
- The comments tumer which cause spleenomegally is Lymphoma
- congenital abnormalities of the spleen are
1- abscence of the spleen
2- splenunculi
3- Hamartoma
4- Splenic cyst

- the common cyst of the spleen is Pseudocyst ( 4 times more than true cyst )
- in a case of splenic hematoma due to rupture spleen , what you can do ?
do Nothing , because if you drainge the hematoma you will rupture the capsule and stop the tamponad effect and cause rebleeding .

- Pregnant women presented with sudden sever abdomenal pain and shock >> think about spleic atrery aneurysm .

- Predisposing factors for splenic infarction are

1- massive enlagrment

2- sickle cell disease

3- myeloproliferative syndrome

4- embolism

- the splenic infarction looks like a traingle its base on the surface of spleen .

- causes of massive huge splenomegally are 

1- CML

2- Myelofibrosis

3- Malaria

4- Kala-azar ( Visceral leishmaniasis)

- Hypersplenism is a syndrome of 

1- splenomegally

2- pancytopenia

3- hyperactive BM

- Indecations of splenectomy :

1- trauma ( comments ) > ITP > hypersplenism

2- part of other operations

3- staging of Hodjkens lymphoma

4- Hematological : ITP , hypersplenism , H.spherocytosis

5- in association with shunt operation

- Complication of splenectomy are :

 1- Hemorrhage .  ( highly vascular organe )

2- Leucocytosis and thrombocytosis 

3- overwhelming sepsis

4- gastric and pancreatic fistula

- overwhelming sepsis occure in splecectomized pateint due to blood diesaes more than trauma

- the patient must receive pneumovax 2 weeks before surgery as a prophylaxis to sepsis .

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Kumar & Clark's Clinical Medicine 7th Edition

http://www.4s.io/office/MkFWzTPc/Kumar__Clarks_Clinical_Medicin.html

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