Urinary tract infection

Urinary tract infection is the most common bacterial infection managed in general medical practice and accounts for 1-3% of consultations. Up to 50% women have a UTI at some time. In male UTI is uncommon. Most common presentation of UTI is acute urethritis and cystitis.

Spectrum of presentation:

1) Asymptomatic bacteriuria
2) Acute pyelonephritis
3) Symptomatic acute urethritis & cystitis
4) Acute prostatitis
5) Septicaemia

Common causes:

1) E. coli
2) Klebsiella
3) Proteus
4) Pseudomonus
5) Streptococci
6) Staphylococci epidermidis
7) In Hospitals- E. coli , Klebsiella and streptococci

Risk factors:

1) incomplete bladder emptying :

a) bladder outflow obstruction
b) neurological problems-
multiple sclerosis
diabetic neuropathy
c) gynaecological abnormalities-
uterine prolapse
d) vesico ureteric reflux

2) foreign body-

a) urethral catheter
b) ureteric stent

3)loss of host defence-

a) diabetes mellitus
b) atrophic urethritis and vaganitis in post menopausal women

Differential diagnosis:

1) urethritis
2) vaginitis

Clinical feature :

1) abrupt onset of frequency of micturation and urgency
2) dysuria
3) supra pubic pain during and after voiding
4) stranguary
5) urine may appear cloudy and have an unpleasant odur
6) microscopic or visible heamaturia
7) fever, rigor, vomitting

Investigations :

1) Dipstick examination - nitrite, leucocyte esterase and glucose
2) urine R/E - for pus cell and epithelial cell ( > 5-6)
3) urine culture (midstream urine)
4) CBC
5) Blood culture
6) USG
7) Serum urea ,electrolytes, creatinine
8) Cystoscopy

Management:

1) fluid intake at least 2 litre per day
2) regular complete emptying of bladder
3) good personal hygiene
4) emptying of bladder before and after sexual intercourse
5) if vesico ureteric reflux is present practice double micturation
6) antibiotics according to the report of urine culture

• ciprofloxacin - 500mg 12 hourly for 3 days
• trimethoprim - 200 mg 12 hourly for 3 days
• nitrofurontion - 50 mg 6 hourly for 3 days
• coamoxiclav - 500/ 125mg 8 hourly for 3 days

Seriously ill patient I/V cefuroxime -750 mg 8 hourly for 3-14 days
In pregnancy - penicillin and cephalosporins

Edited by ImAn NoOr

Common surgical symptoms

Pain

Pain anywhere should have the same features elicited. These can be summarized by the acronym SOCRATES.

• Site. Where is the pain, is it localized, in a region. or generalized?
• Onset. Gradual, rapid, or sudden? Intermittent or constant?
• Character. Sharp, stabbing, dull, aching, tight, sore?
• Radiation. Does it spread to other areas? (From loin to groin in ureteric pain, to shoulder tip in diaphragmatic irritation, to back in retroperitoneal pain, to jaw and neck in myocardial pain.)
• Associated symptoms. Nausea, vomiting, dysuria, jaundice?
• Timing. Does it occur at any particular time?
• Exacerbating or relieving factors. Worse with deep breathing, moving, or coughing suggests irritation of somatic nerves either in the pleura or peritoneum; relief with hot water bottles suggests deep inflammatory or infiltrative pain.
• Surgical history. Does the pain relate to surgical interventions?

Dyspepsia

(epigastric discomfort or pain, usually after eating).
What is the frequency?
Is it always precipitated by food or is it spontaneous in onset?
Is there relief from anything, especially milky drinks or food?
Is it positional?

Dysphagia

(pain or difficulty during swallowing).
Is the symptom new or longstanding?
Is it rapidly worsening or relatively constant?
Is it worse with solid food or fluids? (Worse with fluids suggests a motility problem rather than a stenosis.)
Can it be relieved by anything, e.g. warm drinks?
Can the patient point to a level of hold-up on the surface (usually related to the sternum)? This often accurately relates to the level of an obstructing lesion.
Is it associated with spluttering? (suggests tracheo-oesophageal fistula).

Acid reflux

(bitter or acidic tasting fluid in the pharynx or mouth).
How frequently?
What colour is it? (Green suggests bile, whereas white suggests only stomach contents).
When does it occur (lying only, on bending, spontaneously when standing)?
Is it associated with coughing?

Haematemesis

(the presence of blood in vomit).
What colour is the blood (dark red-brown coffee grounds is old or small-volume stomach bleeding; dark red may be venous from the oesophagus; bright red is arterial and often from major gastric or duodenal arterial bleeding).
What volume has occurred over what period?
Did the blood appear with the initial vomits or only after a period of prolonged vomiting (suggests a traumatic oesophageal cause).

Abdominal distension

Symmetrical distension suggests one of the cause (fluid ascites, flatus due to ileus or obstruction, fetus of pregnancy, fat, or a flipping big mass).
Asymmetrical distension suggests a localized mass.
What is the time course?
Does it vary?
It is changed by vomiting, passing stool/flatus?

Change in bowel habit

May be change in frequency, or looser or more constipated stools. Increased frequency and looser stools suggests a pathological cause.
Is it a persistent or transient?
Are there associated symptoms?
Is it variable?

Frequency and urgency of defecation

New urgency of defecation is almost always pathological.
What is the degree of urgency?
how long can the patient delay?
Is there associated discomfort?
What is passed?
Is the stool normal?

Bleeding per rectum

What colour is the blood?
Is it pink-red and only on the paper when wiping?
Does it splash in the pan? (Both suggest a case from the anal canal.)
Is it bright red on the surface of the stool? (Suggests a lower rectal cause.)
Is the blood darker, with clots or marbled into the stools? (Suggests a colonic cause.)
Is the blood fully mixed with the stool or altered? (Suggests a proximal colonic cause.)

Tenesmus

(desire to pass stools with either no result or incomplete satisfaction of defecation). Suggests rectal pathology.

Jaundice

(yellow discoloration due to hyperbilirubinaemia; ).
How quickly did the jaundice develop?
Is there associated pruritus?
Are there any symptoms of pain, fever, or malaise? (Suggests infection.)

Haemoptysis

(the presence of blood in expectorate).
What colour is the blood? (Light pink froth suggests pulmonary oedema.)
Are there clots or dark blood? (Infection or endobronchial lesion.)
How much blood? Moderate bleeds quickly threaten airways: get help quickly.

Dyspnoea

(difficulty in or increased awareness of breathing).
When does the dyspnoea occur?
quantify the amount of effort. Is it positional?

• Orthopnoea is difficulty in breathing that occurs on lying flat: quantify it by asking how many pillows the patient needs at night to remain symptom-free.
• Paroxysmal nocturnal dyspnoea is intermittent breathless at night. Both orthopnoea and paroxysmal nocturnal dyspnoea suggest cardiac failure.

Claudication

(the presence of pain in the muscles of the calf, thigh, or buttock precipitated by exercise and relieved by rest).
After what degree of exercise does the pain occur (both distance on the flat and gradients)?
How quickly is the pain relieved by rest?

Rest pain

(pain in a limb at rest without significant exercise)
How long has the pain been present?
Is it intermittent?
Does it occur mainly at night?
Is it relieved by dependency of the limb involved?

History taking and making notes

Making medical notes

All medical and paramedical professionals have a duty to record their input and care of patients in the case-notes. These form a permanent legal and medical document. There are some basic rules.

• Write in blue or black color.
• Date, time, and sign all entries: always identify retrospective entries.
• Be accurate.
• Make it clear which diagnoses are provisional.
• Abbreviations are lazy and open to misinterpretation; avoid them.
• Clearly document information given to patients and relatives.
• Avoid non-medical judgement of patients or relatives.

Basics

• Always record name, age occupation, method of presentation.
• Cover all the principal areas of medical history:
  • presenting complaint and past history relevant to it;
  • other past medical history, drug history, and systematic enquiry;
  • previous operations/allergies/drugs;
  • family history, social history, and environment.

Presenting complaint

This is a one- or two-word summary of the patient's main symptoms, e.g. abdominal pain, nausea and vomiting, swollen leg, PR bleeding.

• In emergency admissions do not write a diagnosis here (e.g. ischaemic leg). The diagnosis of referral may well turn out to be wrong.
• In elective admissions it is reasonable to write elective admission for varicose vein surgery.

History of presenting complaint

• This is a detailed description of the main symptom and should include the relevant systems enquiry.
• Try to put the important positives first, e.g. right-sided lower abdominal pain, sharp, worse with moving, and coughing, anorexia 24h.
• Include the relevant negatives, e.g. no vomiting, no PR bleeding.
• Be very clear about chronology of events.
• In a complicated history, or with multiple symptoms use headings, e.g. Current episodes, Previous operations for this problem Results of investigations.
• Summarize the results of investigations performed prior to admission systematically: bedside tests, blood tests, histology or cytology, X-rays, cross-sectional imaging, specialized tests.

Past medical history

• Ask about thyroid problems, TB, hypertension, rheumatic fever, epilepsy, asthma, diabetes, and previous surgery, specifically.
• List and date all previous operations.
• Ask about previous problems with an anaesthetic.
• Asking Have you ever had any medical problem, or been to hospital for anything? at the end often produces additional information.

Systematic enquiry

This is extremely important and often neglected. A genitourinary history is highly relevant in young females with pelvic pain. A good cardiovascular and respiratory systems enquiry will help avoid patients being cancelled because they have undiagnosed anaesthetic risks. Older patients may have pathology in other systems that may change management, e.g. the patient with prostatism should be warned about urinary retention.

• Cardiovascular. Chest pain, effort dyspnoea, orthopnoea, nocturnal dyspnoea, palpitations, swollen ankles, strokes, transient ischaemic attacks, claudication.
• Respiratory. Dyspnoea, cough, sputum, wheeze, haemoptysis.
• Gastrointestinal. Anorexia, change in appetite, weight loss (quantify how much, over how long).
• Genitourinary. Sexual activity, dyspareunia (pain on intercourse), abnormal discharge, last menstrual period.
• Neurological. 3 Fs: fits; faints; funny turns.

Social history

• At what time did they last eat or drink?
• Ask who will look after the patient. Do they need help to mobilize?
• Smoking and alcohol history.

Tips for case presentation

• Practice. Every case is a possible presentation to someone!
• Always set the scene properly. Start with name, age, occupation, and any key medical facts together with the main presenting complaint(s).
• Be chronological. Start at the beginning of any relevant prodrome or associated symptoms; they are likely to be an important part of the presenting history.
• Be concise with past medical history. Only expand on things that you really feel may be relevant either to the diagnosis or to management, e.g. risks of general anaesthesia.
• For systematic examination techniques see the relevant following pages.
• Always summarize the general appearance and vital signs first.
• Describe the most significant systemic findings first but be systematic inspection, palpation, percussion, and auscultation.
• Briefly summarize other systemic findings. Only expand on them if they may be directly relevant to the diagnosis or management.
• Finally, summarize and synthesize don't repeat. Try to group symptoms and signs together into clinical patterns and recognized scenarios.
• Finish with a proposed diagnosis or differential list and be prepared to discuss what diagnostic or further evaluation tests might be necessary.

Terminology in surgery

How to describe an operation

The terminology used to describe all operations is a composite of basic Latin or Greek terms.

First describe the organ to be operated on

Examples:

• lapar-, abdomen (laparus = flank);
• nephro-, kidney;
• pyelo-, renal pelvis;
• cysto-, bladder;
• chole-, bile/the biliary system;
• col(on)-, large bowel;
• hystero-, uterus;
• thoraco-, chest;
• rhino-, nose;
• masto/mammo-, breast.

Second describe any other organs or things involved in the procedure

Examples:

• docho-, duct;
• angio-, vessel (blood- or bile-carrying);
• litho-, stone.

Third describe what is to be done

Examples:

• -otomy, to cut (open);
• -ectomy, to remove;
• -plasty, to change shape or size;
• -pexy, to change position;
• -raphy, to sew together;
• -oscopy, to look into;
• -ostomy, to create an opening in (stoma = mouth);
• -paxy, to crush;
• -graphy/gram, image (of).

Lastly add any terms to qualify how or where the procedure is done

Examples:

• percutaneous, via the skin;
• trans-, across;
• antegrade, forward;
• retrograde, backwards.

Examples of terms

• Choledochoduodenostomy an opening between the bile duct and the duodenum.
• Rhinoplasty nose reshaping.
• Pyelolithopaxy destruction of pelvicalyceal stones.
• Bilateral mastopexy breast lifts.
• Percutaneous arteriogram arterial tree imaging by direct puncture injection.
• Loop ileostomy external opening in the small bowel with two sides.
• Flexible cystourethroscopy internal bladder and urethral inspection.

QUESTION NO-6

Your patient is a 70-year-old man who under went bowel surgery for colon cancer 3days ago,He now has a fever and abdominal pain.You concerned that he may have peritonitis.which one of the following pairs of organisms is MOST likely to be the cause?

A) Bacteroides fragilis & Klebsiella pneumoniae
B) Bordetella pertussis & Salmonella enteritidis
C) Actinomyces israelii & Campylobacter jejuni
D) Clostridium botulinum & Shigella dysenteriae

Whats your diagnosis?
Write your answer in comment. Answer will be given 3days later.

QUESTION NO-5

Whats your diagnosis?
Write your answer in comment. Answer will be given 3days later.

QUESTION NO-4

Whats your diagnosis?
Write your answer in comment. Answer will be given 3days later.

QUESTION NO-3

Whats your diagnosis?
Write your answer in comment. Answer will be given 3days later.

QUESTION NO-2

Whats your diagnosis?
Write your answer in comment. Answer will be given 3days later.

Acute respiratory distress syndrome (ARDS)

What is ARDS?

Acute respiratory distress syndrome (ARDS) is breathing failure that can occur in critically ill persons with underlying illnesses. It is not a specific disease. Instead, it is a life-threatening condition that occurs when there is severe fluid buildup in both lungs. The fluid buildup prevents the lungs from working properly—that is, allowing the transfer of oxygen from air into the body and carbon dioxide out of the body into the air.

In ARDS, the tiny blood vessels (capillaries) in the lungs or the air sacs (alveoli (al-VEE-uhl-eye)) are damaged because of an infection, injury, blood loss, or inhalation injury. Fluid leaks from the blood vessels into air sacs of the lungs. While some air sacs fill with fluid, others collapse. When the air sacs collapse or fill up with fluid, the lungs can no longer fill properly with air and the lungs become stiff. Without air entering the lungs properly, the amount of oxygen in the blood drops. When this happens, the person with ARDS must be given extra oxygen and may need the help of a breathing machine.

Breathing failure can occur very quickly after the condition begins. It may take only 1 or 2 days for fluid to build up. The process that causes ARDS may continue for weeks. If scarring occurs, this will make it harder for the lungs to take in oxygen and get rid of carbon dioxide.

In the past, only about 4 out of 10 people who developed ARDS survived. But today, with good care in a hospital's intensive or critical care unit, many people (about 7 out of 10) with ARDS survive. Although many people who survive ARDS make a full recovery, some survivors have lasting damage to their lungs.

How the Lungs Work

To understand acute respiratory distress syndrome (ARDS), it is helpful to understand how your lungs work.

Normal Lung Function

A slice of normal lung looks like a pink sponge—filled with tiny bubbles or holes. Around each bubble is a fine network of tiny blood vessels. These bubbles, which are surrounded by blood vessels, give the lungs a large surface to exchange oxygen (into the blood where it is carried throughout the body) and carbon dioxide (out of the blood)

. This process is called gas exchange. Healthy lungs do this very well.

Here's how normal breathing works:

• You breathe in air through your nose and mouth. The air travels down through your windpipe (trachea) through large and small tubes in your lungs called bronchial (BRON-kee-ul) tubes. The larger tubes are bronchi (BRONK-eye), and the smaller tubes are bronchioles (BRON-kee-oles). Sometimes, we use the word "airways" to refer to the various tubes or passages that air uses to travel from the nose and mouth into the lungs. The airways in your lungs look something like an upsid e-down tree with many branches.

• At the ends of the small bronchial tubes, there are groups of tiny bubbles called air sacs or alveoli. The bubbles have very thin walls, and small blood vessels called capillaries are next to them. Oxygen passes from the air sacs into the blood in these small blood vessels. At the same time, carbon dioxide passes from the blood into the a ir sacs.

Effects of ARDS

In ARDS, the tiny blood vessels leak too much fluid into the lungs. This results from toxins (poisons) that the body produces in response to the underlying illness or injury. The lungs become like a wet sponge, heavy and stiffer than normal. They n

o longer provide the effective surface for gas exchange, and the level of oxygen in the blood falls. If ARDS is severe and goes on for some time, scar tissue called fibrosis may form in the lungs. The scarring also makes it harder for gas exchange to occur.

People who develop ARDS need extra oxygen and may need a breathing machine to breathe for them while their lungs try to heal. If they survive, ARDS patients

may have a full recovery. Recovery can take weeks or months. Some ARDS survivors take a year or longer to recover, and some never completely recover from having ARDS.

Other Names for ARDS

• Adult respiratory distress syndrome

• Stiff lung

• Shock lung

• Wet lung

There is a similar condition in infants called Infant Respi

ratory Distress Syndrome (also called IRDS, RDS, and hyaline membrane disease). It mainly affects premature infants whose lungs are not well developed when they are born.

What Causes ARDS?

The causes of acute respiratory distress syndrome (ARDS) are not well understood. It can occur in many situations and in persons with or without a lung disease.

There are two ways that lung injury leading to AR

DS can occur: through a direct injury to the lungs, or indirectly when a person is very sick or has a serious bodily injury. However, most sick or badly injured persons do not develop ARDS.

Direct Lung Injury

A direct injury to the lungs may result from breathing in h

armful substances or an infection in the lungs. Some direct lung injuries that can lead to ARDS include:

• Severe pneumonia (infection in the lungs)

• Breathing in vomited stomach contents

• Breathing in harmful fumes or smoke

• A severe blow to the chest or other accident that bruises the lungs

Indirect Lung Injury

Most cases of ARDS happen in people who are very ill or who have been in a major accident. This is sometimes called an indirect lung injury. Less is known about how indirect injuries lead to ARDS than about how direct injuries to the lungs cause ARDS. Indirect lung injury leading to ARDS sometimes occurs in cases of:

• Severe and widespread bacterial infection in the body (se psis)

• Severe injury with shock

• Severe bleeding requiring blood transfusions

• Drug overdose

• Inflamed pancreas

It is not clear why some very sick or seriously injured people develop ARDS, and others do not. Researchers are trying to find out why ARDS develops and how to prevent it.

Who is At Risk for ARDS?

Acute respiratory distress syndrome (ARDS) usually affects people who are being treated for another serious illness or those who have had major injuries. It affects about 150,000 people each year in the United States. ARDS can occur in people with or without a previous lung disease. People who have a serious accident with a large blood loss are more likely to develop ARDS. However, only a small portion of people who have problems that can lead to ARDS actually develop it.

In most cases, a person who develops ARDS is already in the hospital being treated for other medical problems. Some illnesses or injuries that can lead to ARDS include:

• Serious, widespread infection in the body (sepsis)

• Severe injury (trauma) and shock from a car crash, fire, or other cause

• Severe bleeding that requires blood transfusions

• Severe pneumonia (infection of the lungs)

Acne (Pimples)

What is acne? What are the different types of acne?

Acne (acne vulgaris, common acne) is not just a problem forteenagers; it can affect people from ages 10 through 40. It is not unusual for women, in particular, to develop acne in their mid- to late-20s, even if they have not had breakouts in years (or ever). On the positive side, those few individuals who have acne into their 40s may well grow out of it. Acne can appear on the skin as any of the following:

• congested pores ("comedones"),
• whiteheads,
• blackheads,
• pimples ("zits"),
• pustules, or
• cysts (deep pimples, boils). The pus in pustules and cysts is sterile and does not actually contain infectious bacteria.These blemishes occur wherever there are many oil (sebaceous) glands, mainly on the face, chest, and back.

What causes acne?

No one factor causes acne. Acne happens when oil (sebaceous) glands come to life around puberty, stimulated by male hormones from the adrenal glands of both boys and girls. Sebum (oil) is a natural substance which lubricates and protects the skin, and under certain circumstances, cells that are close to the surface block the openings of sebaceous glands and cause a buildup of oil underneath. This oil stimulates bacteria (which live on everyone's skin and generally cause no problems) to multiply and cause surrounding tissues to become inflamed.Inflammation near the skin's surface produces a pustule; deeper inflammation results in a papule (pimple); deeper still and it's a cyst. If the oil breaks though to the surface, the result is a "whitehead." If the oil accumulates melanin pigment or becomes oxidized, the oil changes from white to black, and the result is a "blackhead." Blackheads are therefore not dirt, and do not reflect poor hygiene.Here are some factors that don't usually cause acne, at least by themselves:

• Heredity: With the exception of very severe acne, most people do not have the problem exactly as their parents did. Almost everyone has some acne at some point in their life.

• Food: Parents often tell teens to avoid pizza, chocolate, greasy and fried foods, and junk food. While these foods may not be good for overall health, they don't cause acne or make it worse. Although some recent studies have implicated milk and dairy products in aggravating acne, these findings are far from established.


• Dirt: As mentioned above, "blackheads" are oxidized oil, not dirt. Sweat does not cause acne, therefore, it is not necessary to shower instantly after exercise for fear that sweat will clog pores. On the other hand, excessive washing can dry and irritate the skin.

• Stress: Some people get so upset by their pimples that they pick at them and make them last longer. Stress, however, does not play much of a direct role in causing acne.


• Hormones: Some women break out cyclically, but most women (and men) don't. Some oral contraceptive pills may help relieve acne, but unless a woman has abnormal menstrual periods and excessive hair growth, it's unlikely that hormones play much of a role in causing acne. Pregnancy has a variable effect on acne; some women report that they clear up completely, and others get worse, while many others see no overall change.


• Cosmetics: Most cosmetic and skin-care products are not pore-clogging ("comedogenic"). Of the many available brands, those which are listed as "water-based" or "oil-free" are generally a better choice.In occasional patients, the following may be contributing factors:

• Pressure: In some patients, pressure from helmets, chinstraps, collars, suspenders, and the like can aggravate acne.


• Drugs: Some medications may cause or worsen acne, such as those containing iodides, bromides, or oral or injected steroids (either the medically prescribed prednisone or the steroids that bodybuilders or athletes take). Other drugs that can cause or aggravate acne are anticonvulsant medications and lithium, which is used to treat bipolar disorder. Most cases of acne, however, are not drug-related.


• Occupations: In some jobs, exposure to industrial products like cutting oils may produce acne.

What other skin conditions can mimic acne?

• Rosacea: This condition is characterized by pimples in the middle third of the face, along with redness, flushing, and superficial blood vessels. It generally affects people in their 30s and 40s and older. There is sometimes no "bright line" separating acne from rosacea; however, there are no blackheads or whiteheads in rosacea.
• Pseudofolliculitis: This is sometimes called "razor bumps" or "razor rash." When cut close to the skin, curly neck hairs bend under the skin and produce pimples. This is a mechanical problem, not a bacterial one, and treatment involves shaving less (growing a beard, laser hair removal.) Pseudofolliculitis can, of course, occur in patients who have acne too.

• Folliculitis: Pimples can occur on other parts of the body, such as the abdomen, buttocks, or legs. These represent not acne but inflamed follicles. If these don't go away on their own, doctors can prescribe oral or external antibiotics, generally not the same ones used for acne.


• Gram-negative folliculitis: Some patients who have been treated with oral antibiotics for long periods develop pustules filled with bacteria resistant to the antibiotics which have previously been used. Bacterial culture tests can identify these germs, leading the doctor to prescribe different antibiotics or other forms of treatment.

When should you start acne treatment?

Since everyone gets acne at some time, the right time to treat it is when it bothers you. This can be when severe acne flares suddenly, mild acne that just won't go away, or even when a single pimple decides to show up the week before your prom or wedding. The decision is yours.

What can you do about acne on your own?

Think back to the three basic causes of acne and you can understand why the focus of both home treatment and prescription therapy is to (1) unclog pores, (2) kill bacteria, and (3) minimize oil. But first a word about...

Lifestyle: Moderation and regularity are good things, but not everyone can sleep eight hours, eat three good meals, and drink eight glasses of water a day. You can, however, still control your acne even if your routine is frantic and unpredictable. Probably the most useful lifestyle changes you can make are to apply hot compresses to pustules and cysts, to get facials (see below), and never to pick or squeeze pimples. Playing with or popping pimples, no matter how careful and clean you are, nearly always makes bumps stay redder and bumpier longer. People often refer to redness as "scarring," but fortunately it usually isn't in the permanent sense. It's just a mark that takes months to fade if left entirely alone.

Open the pores

Cleansing and skin care: Despite what you read in popular style and fashion magazines, there is no magic product or regimen that is right for every person and situation.

• Mild cleansers: Washing once or twice a day with a mild cleansing bar or liquid (for example, Dove, Neutrogena, Basis, Purpose, and Cetaphil are all inexpensive and popular) will keep the skin clean and minimize sensitivity and irritation.
• Exfoliating cleansers and masques: A variety of mild scrubs, exfoliants, and masques can be used. These products contain either fine granules or salicylic acid in a concentration that makes it a very mild peeling agent. These products remove the outer layer of the skin and thus open pores. Products containing glycolic or alpha hydroxy acids are also gentle skin exfoliants.
• Retinol: Not to be confused with the prescription medication Retin-A, this derivative of vitamin A can help promote skin peeling.

Kill the bacteria

• Antibacterial cleansers: The most popular ingredient in over-the-counter antibacterial cleansers is benzoyl peroxide.
• Topical (external) applications: These products come in the form of gels, creams, and lotions, which are applied to the affected area. The active ingredients that kill surface bacteria include benzoyl peroxide, sulfur, and resorcinol. Some brands promoted on the Internet and cable TV (such as ProActiv) are more costly but not really any better than ones you can buy in the drugstore.

Benzoyl peroxide causes red and scaly allergic skin in a small number of people, which goes away as soon as you stop using the product. Keep in mind that benzoyl peroxide is a bleach, so do not let products containing benzoyl peroxide leave unsightly blotching on colored clothes, shirts, towels, and carpets.

Reduce the oil

You cannot stop your oil glands from producing oil (unless you mess with your hormones or metabolism in ways you shouldn't). Even isotretinoin (Accutane, see below) only slows down oil glands for a while; they come back to life later. What you can do is to get rid of oil on the surface of the skin and reduce the embarrassing shine.

• Use a gentle astringent/toner to wipe away oil.
  

Polymyositis

Polymyositis (pol-e-mi-o-SI-tis) is an uncommon connective tissue disease. It's a type of inflammatory myopathy, which is characterized by muscle inflammation and weakness. The most noticeable characteristic of polymyositis is weakness of the skeletal muscles, which control movement.

Polymyositis can occur at any age, but it mostly affects adults sometime between their 30s and 50s. It's more common in blacks than in whites, and women are affected more often than men are. Polymyositis signs and symptoms usually develop gradually, over weeks or months.

Periods of remission in polymyositis, during which symptoms improve spontaneously, rarely occur. However, treatment can improve your muscle strength and function.

symptoms

Signs and symptoms of polymyositis usually appear gradually, so it may be difficult to pinpoint when they first started. They may also fluctuate from week to week or month to month.

Progressive muscle weakness is the most common polymyositis symptom. It typically affects the muscles closest to the trunk, such as those in your hips, thighs, shoulders, upper arms and neck. The weakness is symmetrical, affecting both the left and right sides of your body, and tends to gradually worsen.

Although the muscle weakness starts subtly, after it progresses over the course of the disease it can make it difficult for you to climb stairs, rise from a seated position, lift objects or reach overhead.

Other polymyositis signs and symptoms include:

• Difficulty swallowing (dysphagia)
• Difficulty speaking
• Mild joint or muscle tenderness
• Fatigue
• Shortness of breath

Causes
Polymyositis is in a group of diseases or disorders of the muscles called inflammatory myopathies. The cause of most inflammatory myopathies is unknown.

Infections caused by bacteria, parasites or viruses can cause inflammatory myopathies, but in most cases of polymyositis, doctors aren't able to identify a preceding infection. Some doctors think certain people may have a genetic susceptibility to the disease.

Inflammatory myopathies share many characteristics with autoimmune disorders, in which your immune system attacks normal body components. Normally, your immune system works to protect your healthy cells from attacks by foreign substances, such as bacteria and viruses. If you have polymyositis, an unknown cause may act as a trigger for your immune system to begin producing autoimmune antibodies (autoantibodies) that attack your body's own tissues.

Many people with polymyositis show a detectable level of autoantibodies in their blood.

complications

Possible complications of polymyositis include:

• Difficulty swallowing. If the muscles in your esophagus are affected, you may have problems swallowing (dysphagia), which in turn may cause weight loss and malnutrition.
• Aspiration and pneumonia. Difficulty swallowing may also lead to entrance of food or liquids, including saliva, into your lungs (aspiration), which can lead to pneumonia.
• Breathing problems. If your chest muscles are affected by the disease, you may experience breathing problems, such as shortness of breath or in severe cases, respiratory failure.
• Calcium deposits. Late in the disease, particularly if you've had the disease for a long time, deposits of calcium can occur in your muscles, skin and connective tissues (calcinosis).

Associated conditions

QUESTION NO- 1

Your patient is a 3 year old girl with fever and pain in her right ear. On physical examination, the ear drum is found to be perforated and a bloody exudate is seen. A gram stain of the exudate reveals gram-positive diplococci.
Of the following, which one is the MOST likely cause?

a) streptococcus pyogenes
b) staphylococcus aureus
c) corynebacterium diptheriae
d) streptococcus pneumoniae


Write your answer in comment. Answer will be given 3days later.

Helicobacter Pylori

What is Helicobacter pylori?

Helicobacter pylori (H. pylori) is a bacterium that causes chronic inflammation of the inner lining of the stomach (gastritis) in humans. This bacterium also is the most common cause of ulcers worldwide. H. pylori infection is most likely acquired by ingesting contaminated food and water and through person to person contact. In the United States, 30% of the adult population is infected. (50% of infected persons are infected by the age of 60.) The infection is more common in crowded living conditions with poor sanitation. In countries with poor sanitation, 90% of the adult population can be infected. Infected individuals usually carry the infection indefinitely unless they are treated with medications to eradicate the bacterium. One out of every six patients with H. pylori infection will develop ulcers of the duodenum or stomach. H. pylori also is associated with stomach cancer and a rare type of lymphocytic tumor of the stomach called MALT lymphoma.

How is H. pylori infection diagnosed?

Accurate and simple tests for the detection of H. pylori infection are available. They include blood antibody tests, urea breath tests, stool antigen tests, and endoscopic biopsies.

Blood tests for the presence of antibodies to H. pylori can be performed easily and rapidly. However, blood antibodies can persist for years after complete eradication of H. pylori with antibiotics. Therefore, blood antibody tests may be good for diagnosing infection, but they are not good for determining if antibiotics have successfully eradicated the bacterium.

The urea breath test (UBT) is a safe, easy, and accurate test for the presence of H. pylori in the stomach. The breath test relies on the ability of H. pylori to break down the naturally occurring chemical, urea, into carbon dioxide which is absorbed from the stomach and eliminated from the body in the breath. Ten to 20 minutes after swallowing a capsule containing a minute amount of radioactive urea, a breath sample is collected and analyzed for radioactive carbon dioxide. The presence of radioactive carbon dioxide in the breath (a positive test) means that there is active infection. The test becomes negative (there is no radioactive carbon dioxide in the breath) shortly after eradication of the bacterium from the stomach with antibiotics. Despite the fact that individuals having the breath test are exposed to a minute amount of radioactivity, the breath test has been modified so that it also may be performed with urea that is not radioactive.

Endoscopy is an accurate test for diagnosing H. pylori as well as the inflammation and ulcers that it causes. For endoscopy, the doctor inserts a flexible viewing tube (endoscope) through the mouth, down the esophagus, and into the stomach and duodenum. During endoscopy, small tissue samples (biopsies) from the stomach lining can be removed. A biopsy specimen is placed on a special slide containing urea (e.g., CLO test slides). If the urea is broken down by H. pylori in the biopsy, there is a change in color around the biopsy on the slide. This means that there is an infection with H. pylori in the stomach.

The most recently-developed test for H. pylori is a test in which the presence of the bacterium can be diagnosed with a sample of stool. The test uses an antibody to H. pylori to determine if H. pylori is present in the stool. If it is, it means that H. pylori is infecting the stomach. Like the urea breath test, in addition to diagnosing infection with H. pylori, the stool test can be used to determine if eradication has been effective shortly after treatment.

Why treat H. pylori?

Chronic infection with H. pylori weakens the natural defenses of the lining of the stomach against the ulcerating action of acid. Medications that neutralize stomach acid (antacids), and medications that decrease the secretion of acid in the stomach (H2-blockers and proton pump inhibitors or PPIs) have been used effectively for many years to treat ulcers. H2-blockers, include ranitidine (Zantac), famotidine (Pepcid), cimetidine (Tagamet), and nizatidine (Axid). PPIs include omeprazole (Prilosec), lansoprazole (Prevacid), rabeprazole (Aciphex), pantoprazole (Protonix), and esomeprazole (Nexium). Antacids, H2-blockers and PPIs, however, do not eradicate H. pylori from the stomach, and ulcers frequently return promptly after these medications are discontinued. Hence, antacids, H2-blockers or PPIs have to be taken daily for many years to prevent the return of the ulcers and the complications of ulcers such as bleeding, perforation, and obstruction of the stomach. Eradication of H. pylori prevents the return of ulcers and ulcer complications even after the medications are stopped. Eradication of H. pylori also is important in the treatment of the rare condition known as MALT lymphoma of the stomach. Treatment of H. pylori to prevent stomach cancer is controversial and discussed later.

How is H. pylori treated?

H. pylori is difficult to eradicate from the stomach because it is capable of developing resistance to commonly used antibiotics. Therefore, two or more antibiotics usually are given together with a PPI and/or bismuth containing compounds to eradicate the bacterium. (Bismuth and PPIs have anti-H. pylori effects.) Examples of combinations of medications that are effective are:

• a PPI, amoxicillin (Amoxil) and clarithromycin (Biaxin)
• a PPI, metronidazole (Flagyl), tetracycline and bismuth subsalicylate

These combinations of medications can be expected to cure 70%-90% of infections. However, studies have shown that resistance of H. pylori (failure of antibiotics to eradicate the bacteria) to clarithromycin is common among patients who have prior exposure to clarithromycin or other chemically similar macrolide antibiotics (such as erythromycin). Similarly, H. pylori resistance to metronidazole is common among patients who have had prior exposure to metronidazole. In these patients, doctors have to find other combinations of antibiotics to treat the H. pylori. Antibiotic resistance is another reason why antibiotics should be used carefully and judiciously for the right reasons, and indiscriminate use of antibiotics for improper reasons should be discouraged.

Some doctors may want to confirm eradication of H. pylori after treatment with a urea breath test or a stool antigen test, particularly if there have been serious complications of the infection such as perforation or bleeding in the stomach or duodenum. Endoscopic biopsies to determine eradication of the bacteria are not necessary, and blood tests are not good for determining eradication since it takes many months for the antibodies to H. pylori to decrease. The best tests for determining eradication are the breath and stool tests discussed previously. Patients who fail to eradicate H. pylori with treatment are retreated, often with a different combination of medications.

Hay Fever (Allergic Rhinitis)

What is hay fever? What are the symptoms and signs?

Hay fever is a misnomer. Hay is not a usual cause of this problem, and it does not cause fever. Early descriptions of sneezing, nasal congestion, and eye irritation while harvesting field hay promoted this popular term. Allergic rhinitis is the correct term used to describe this allergic reaction, and many different substances cause the allergic symptoms noted in hay fever. Rhinitis means "irritation of the nose" and is a derivative of rhino, meaning nose. Allergic rhinitis which occurs during a specific season is called "seasonal allergic rhinitis." When it occurs throughout the year, it is called "perennial allergic rhinitis." Rhinosinusitis is the medical term that refers to inflammation of the nasal lining as well as the lining tissues of the sinuses. This term is sometime used because the two conditions frequently occur together.

Symptoms of allergic rhinitis, or hay fever, frequently include nasal congestion, a clear runny nose, sneezing, nose and eye itching, and excess tear production in the eyes. Postnasal dripping of clear mucus frequently causes a cough. Loss of the sense of smell is common, and loss of taste sense occurs occasionally. Nose bleeding may occur if the condition is severe. Eye itching, redness, and excess tears in the eyes frequently accompany the nasal symptoms. The eye symptoms are referred to as "allergic conjunctivitis" (inflammation of the whites of the eyes). These allergic symptoms often interfere with one's quality of life and overall health.

Allergic rhinitis can lead to other diseases such as sinusitis and asthma. Many people with allergies have difficulty with social and physical activities. For example, concentration is often difficult while experiencing allergic rhinitis.

Why does an allergic reaction occur?

An allergic reaction occurs when the immune system attacks a usually harmless substance called an allergen that gains access to the body. To more simply describe this complex immune process, we will make an analogy to a war within the body. The immune system calls upon a protective substance called immunoglobulin E (IgE) antibodies ("E" for "erythema" or redness) to fight these invading allergic substances or allergens. Even though everyone has some IgE, an allergic person has an unusually large army of these IgE defenders -- in fact, too many for his/her own good. This army of IgE antibodies attacks and engages the invading army of allergic substances of allergens.

As is often the case in war, innocent bystanders are affected in battle. These innocent bystanders are special cells called mast cells. These cells are frequently injured during the warring of the IgE antibodies and the allergic substances. When a mast cell is injured, it releases a variety of chemicals into the tissues and blood, one of which is known as histamine. These chemicals frequently cause allergic reactions. These chemicals are very irritating and cause itching, swelling, and fluid leaking from cells. Through various mechanisms, these allergic chemicals can cause muscle spasm and can lead to lung and throat tightening as is found in asthma and loss of voice.

What causes allergic rhinitis?

Any substance can cause an allergy if exposed to a person in the right way. But for all practical purposes and with few exceptions, allergic rhinitis is caused by proteins. Commonly, allergic rhinitis is a result of an allergic person coming in contact several times with protein from plants. Many trees, grasses, and weeds produce extremely small, light, dry protein particles called pollen. This pollen is spread by the wind and is inhaled. These pollen particles are usually the male sex cells of the plant and are smaller than the tip of a pin or less than 40 microns in diameter.

Even though pollen is usually invisible in the air, pollen is a potent stimulator of allergy. Pollen lodges in the nasal lining tissues (mucus membranes) and other parts of the respiratory tract where it initiates the allergic response. Up to 30% of Americans at times suffer from allergic rhinitis. A person is programmed to be allergic by his/her genetic makeup and is destined to be allergic from birth. Approximately one in four people with allergic rhinitis also has asthma.

ELISA Tests

What is ELISA?

ELISA is an abbreviation for "enzyme-linked immunosorbent assay."

What is an ELISA test?

An ELISA test uses components of the immune system and chemicals to detect immune responses in the body (for example, to infectious microbes). The ELISA test involves an enzyme (a protein that catalyzes a biochemical reaction). It also involves an antibody or antigen (immunologic molecules).

What is the use of an ELISA test?

ELISA tests are widely utilized to detect substances that have antigenic properties, primarily proteins (as opposed to small molecules and ions such as glucose and potassium). The substances detected by ELISA tests include hormones, bacterial antigens and antibodies.

How does an ELISA test work?

There are variations of the ELISA test, but the most basic type consists of an antibody attached to a solid surface. This antibody has affinity for (will latch on to) the substance of interest, for example, human chorionic gonadotropin (HCG), the commonly measured protein which indicates pregnancy. A mixture of purified HCG linked (coupled) to an enzyme and the test sample (blood, urine, etc) are added to the test system. If no HCG is present in the test sample, then only HCG with linked enzyme will bind. The more HCG which is present in the test sample, the less enzyme linked HCG will bind. The substance the enzyme acts on is then added, and the amount of product measured in some way, such as a change in color of the solution.

What are the advantages of ELISA?

ELISA tests are generally relatively accurate tests. They are considered highly sensitive and specific and compare favorably with other methods used to detect substances in the body, such as radioimmune assay (RIA) tests. They have the added advantages of not needing radioisotopes (radioactive substances) or a costly radiation counter (a radiation-counting apparatus).

Hydrocephalus

What is hydrocephalus?

The term hydrocephalus is derived from the Greek words "hydro" meaning water and "cephalus" meaning head. As the name implies, it is a condition in which the primary characteristic is excessive accumulation of fluid in the brain. Although hydrocephalus was once known as "water on the brain," the "water" is actually cerebrospinal fluid (CSF) — a clear fluid that surrounds the brain and spinal cord. The excessive accumulation of CSF results in an abnormal widening of spaces in the brain called ventricles. This widening creates potentially harmful pressure on the tissues of the brain.

The ventricular system is made up of four ventricles connected by narrow passages.. Normally, CSF flows through the ventricles, exits into cisterns (closed spaces that serve as reservoirs) at the base of the brain, bathes the surfaces of the brain and spinal cord, and then reabsorbs into the bloodstream.

CSF has three important life-sustaining functions: 1) to keep the brain tissue buoyant, acting as a cushion or "shock absorber"; 2) to act as the vehicle for delivering nutrients to the brain and removing waste; and 3) to flow between the cranium and spine and compensate for changes in intracranial blood volume (the amount of blood within the brain).

What are the different types of hydrocephalus?

Hydrocephalus may be congenital or acquired. Congenital hydrocephalus is present at birth and may be caused by either events or influences that occur during fetal development, or genetic abnormalities. Acquired hydrocephalus develops at the time of birth or at some point afterward. This type of hydrocephalus can affect individuals of all ages and may be caused by injury or disease.Hydrocephalus may also be communicating or non-communicating. Communicating hydrocephalus occurs when the flow of CSF is blocked after it exits the ventricles. This form is called communicating because the CSF can still flow between the ventricles, which remain open. Non-communicating hydrocephalus - also called "obstructive" hydrocephalus - occurs when the flow of CSF is blocked along one or more of the narrow passages connecting the ventricles. One of the most common causes of hydrocephalus is "aqueductal stenosis." In this case, hydrocephalus results from a narrowing of the aqueduct of Sylvius, a small passage between the third and fourth ventricles in the middle of the brain.

There are two other forms of hydrocephalus which do not fit exactly into the categories mentioned above and primarily affect adults: hydrocephalus ex-vacuo and normal pressure hydrocephalus.

Hydrocephalus ex-vacuo occurs when stroke or traumatic injury cause damage to the brain. In these cases, brain tissue may actually shrink. Normal pressure hydrocephalus can happen to people at any age, but it is most common among the elderly. It may result from a subarachnoid hemorrhage, head trauma, infection, tumor, or complications of surgery. However, many people develop normal pressure hydrocephalus even when none of these factors are present for reasons that are unknown.

Who gets this hydrocephalus?

The number of people who develop hydrocephalus or who are currently living with it is difficult to establish since there is no national registry or database of people with the condition. However, experts estimate that hydrocephalus affects approximately 1 in every 500 children.

What causes hydrocephalus?

The causes of hydrocephalus are still not well understood. Hydrocephalus may result from inherited genetic abnormalities (such as the genetic defect that causes aqueductal stenosis) or developmental disorders (such as those associated with neural tube defects including spina bifida and encephalocele). Other possible causes include complications of premature birth such as intraventricular hemorrhage, diseases such as meningitis, tumors, traumatic head injury, or subarachnoid hemorrhage, which block the exit of CSF from the ventricles to the cisterns or eliminate the passageway for CSF into the cisterns.

What are the symptoms of hydrocephalus?

Symptoms of hydrocephalus vary with age, disease progression, and individual differences in tolerance to the condition. For example, an infant's ability to compensate for increased CSF pressure and enlargement of the ventricles differs from an adult's. The infant skull can expand to accommodate the buildup of CSF because the sutures (the fibrous joints that connect the bones of the skull) have not yet closed.

In infancy, the most obvious indication of hydrocephalus is often a rapid increase in head circumference or an unusually large head size. Other symptoms may include vomiting, sleepiness, irritability, downward deviation of the eyes (also called "sunsetting"), and seizures.

Older children and adults may experience different symptoms because their skulls cannot expand to accommodate the buildup of CSF. Symptoms may include headache followed by vomiting, nausea, papilledema (swelling of the optic disk which is part of the optic nerve), blurred or double vision, sunsetting of the eyes, problems with balance, poor coordination, gait disturbance, urinary incontinence, slowing or loss of developmental progress, lethargy, drowsiness, irritability, or other changes in personality or cognition including memory loss.

Symptoms of normal pressure hydrocephalus include, problems with walking, impaired bladder control leading to urinary frequency and/or incontinence, and progressive mental impairment and dementia. An individual with this type of hydrocephalus may have a general slowing of movements or may complain that his or her feet feel "stuck." Because some of these symptoms may also be experienced in other disorders such as Alzheimer's disease, Parkinson's disease, and Creutzfeldt-Jakob disease, normal pressure hydrocephalus is often incorrectly diagnosed and never properly treated. Doctors may use a variety of tests, including brain scans (CT and/or MRI), a spinal tap or lumbar catheter, intracranial pressure monitoring, and neuropsychological tests, to help them accurately diagnose normal pressure hydrocephalus and rule out any other conditions.

How is hydrocephalus diagnosed?

Hydrocephalus is diagnosed through clinical neurological evaluation and by using cranial imaging techniques such as ultrasonography, computed tomography (CT), magnetic resonance imaging (MRI), or pressure-monitoring techniques. A physician selects the appropriate diagnostic tool based on an individual's age, clinical presentation, and the presence of known or suspected abnormalities of the brain or spinal cord. top

What is the current treatment for hydrocephalus?

Hydrocephalus is most often treated by surgically inserting a shunt system. This system diverts the flow of CSF from the CNS to another area of the body where it can be absorbed as part of the normal circulatory process.

Leukoplakia

Introduction

Leukoplakia is a white or gray patch that develops on the tongue or the inside of the cheek. It is the mouth's reaction to chronic irritation of the mucous membranes of the mouth. Leukoplakia patches can also develop on the female genital area; however, the cause of this is unknown.

The growth can occur at any time in your life, but it is most common in the elderly.

"Hairy" leukoplakia of the mouth is an unusual form of leukoplakia that is seen only in people who are infected with HIV, have AIDS, or AIDS-related complex. It consists of fuzzy, hence the name "hairy," white patches on the tongue and less frequently elsewhere in the mouth. It may resemble thrush, an infection caused by the fungus Candida which, in adults, usually occurs if your immune system is not working properly, and may be one of the first signs of infection with the HIV virus.

What Causes Leukoplakia?

• Irritation from rough teeth, fillings, or crowns, or ill-fitting dentures that rub against your cheek or gum
• Chronic smoking, pipe smoking, or other tobacco use
• Sun exposure to the lips
• Oral cancer, although rare
• HIV or AIDS

What Are the Symptoms?

The presence of white or gray colored patches on your tongue, gums, roof of your mouth, or the inside of the cheeks of your mouth may be a sign of leukoplakia. The patch may have developed slowly over weeks to months and be thick, slightly raised, and may eventually take on a hardened and rough texture. It usually is painless, but may be sensitive to touch, heat, spicy foods, or other irritation.

How Is Leukoplakia Diagnosed?

Your dentist may suspect leukoplakia upon examination; however, a biopsy will likely be taken to rule out other causes, such as oral cancer. During the biopsy, a small piece of tissue from the lesion will be removed to be examined in a lab. A numbing agent will be used so that you will not feel any pain.

How Is Leukoplakia Treated?

Treatment, if needed, involves removing the source of irritation. For example, if leukoplakia is caused by a rough tooth or an irregular surface on a denture or filling the tooth will be smoothed and dental appliances repaired. If leukoplakia is caused by smoking, you will be asked to minimize or stop smoking or using other tobacco products.

Leukoplakia is usually harmless, and lesions usually clear in a few weeks or months after the source of irritation is removed. If eliminating the source of irritation is ineffective in reducing leukoplakia, the lesion may need to be surgically removed. The lesion can be removed either by your general dentist or by an oral surgeon in their office under local anesthesia.

Hairy leukoplakia requires treatment with an antiviral medication.