Monday, March 6, 2017

Uncal Herniation Syndrome After Severe Head Injuries

Severe head injury can result in extra-axial hematoma, cerebral contusion, or diffuse cerebral edema which, in turn, may cause one of five brain herniation syndromes:

  1. uncal, 
  2. central
  3. transtentorial, 
  4. cerebellotonsillar, 
  5. subfalcine, and external.

Uncal herniation occurs when the uncus of the temporal lobe is displaced inferiorly through the medial edge of the tentorium.
Compression of cranial nerve III can cause an ipsilateral dilated pupil. Typically, patients with uncal herniation are unconscious and require intubation. A contusion to the eye may also result in a dilated, non responsive pupil and arouse suspicion for severe head injury and uncal herniation
but typically these patients will be alert.

                                         Ipsilateral Dilated Pupil due to Uncal Herniation.
      ( CT revealed an epidural hematoma and unilateral effacement of the quadrigeminal cistern. )

Management: Intubate unconscious head trauma patients with a unilateral dilated pupil and transfer them immediately to a facility capable of caring for traumatic brain injury. A noncontrasted head CT scan can identify a subdural or epidural hematoma, diffuse edema, or temporal lobe contusion. These conditions often cause midline shift of cerebral structures and compression of the quadrigeminal cistern. Unilateral effacement of the quadrigeminal cistern confirms uncal herniation.

Wednesday, February 15, 2017

A 19 Year Old Woman With Fever And Sore Throat

A 19-yr-old woman presents with a severe sore throat, fever and malaise. She has marked cervical lymphadenopathy, gross splenomegaly and scattered petechiae on the soft palate, with enlarged tonsils covered by a confluent white exudate.

Her White cell count is mildly elevated, her serum ALT and AST concentrations are twice normal and her ALP is slightly elevated.
Which one of the following investigations is most likely to help guide your management?
A. FNA of a LN
B. HBsAg
D. Heterophilic antibodies
E. HIV test


Tuesday, February 14, 2017

Acute Right Ventricular Myocardial Infarction - ECG

Right Ventricular Myocardial Infarction. This ECG was obtained with right-sided lead placement.

ECG Findings
• ST elevation in right-sided V leads (V4R, V5R).
• ST elevation greater in lead III than lead II suggests RV MI.
• ST elevation in the normally obtained V1 also strongly suggests RV MI.

• Often associated with inferior MI and/or posterior MI.

ST elevation in V4R and V5R (arrows), with the V4 and V5 leads placed in their mirror-image locations on the right side of the chest. Any ST elevation seen in the right-sided precordial leads is significant.

Important Points: 
1. The smaller muscle mass of the right ventricle produces a less intense injury pattern that is

A 55-year-old woman complains of generalized fatigue, weakness and a rash.....

A 55-year-old woman complains of generalized fatigue, weakness, inability to climb stairs, arthralgias, and dysphagia.
Physical examination reveals definite proximal muscle weakness, a periorbital heliotrope rash, and skin findings associated with the hands (shown here).

The most likely diagnosis is
A) Lupus erythematosus
B) Sarcoidosis
C) Sj√∂gren’s disease
D) Dermatomyositis
E) Polymyalgia rheumatica


Chondrodermatitis nodularis helicis

Chondrodermatitis nodularis helicis (CNH) is a common and benign condition characterised by the development of a painful nodule on the ear.

Causes: It is thought to be caused by factors such as persistent pressure on the ear (e.g. secondary to sleep, headsets), trauma or cold. CNH is more common in men and with increasing age.

Clinical Presentation: The classic presentation of chondrodermatitis nodularis chronica helicis (CNH) is a middle-aged to elderly man with a spontaneously appearing painful nodule on the helix or antihelix. The nodule usually enlarges rapidly to its maximum size and remains stable. Onset may be precipitated by pressure, trauma, or cold. When asked, the patient usually admits to sleeping on the affected side.

On Examination: Nodules are firm, tender, well demarcated, and round to oval with a raised, rolled edge and central ulcer or crust. Removal of the crust often reveals a small channel. Color is similar to that of the surrounding skin, although a thin rim of erythema may be noted.

Pleural effusion On Chest X ray

A 28 years old male came to radiology department for X-ray chest with history of breathlessness on exertion since 10 days.
X-ray chest  shows a large pleural effusion on left side, the trachea and mediastinum are pushed to the right, right lung field is clear.

Pleural effusion is the accumulation of fluid in the pleural space, i.e. between the visceral and parietal layers of pleura.
The fluid may be transude, exudate, blood, chyle or rarely bile.
Pleural fluid casts a shadow of the density of water on the chest radiograph. The most dependent recess of the pleura is the posterior costophrenic angle. A small effusion will, therefore, tend to collect posteriorly; however, a lateral decubitus view is the most sensitive film to detect small quantity of free pleural effusion (as small as 50 ml). 100–200 ml of pleural fluid is required to be seen above the dome of the diaphragm on frontal chest radiograph. As more fluid is accumulated, a homogeneous opacity spreads upwards, obscuring the lung base. Typically this opacity has a fairly well-defined, concave upper edge , which is higher laterally and obscures the diaphragmatic shadow. Frequently the fluid will track into the pleural fissures.
A massive effusion may cause complete radiopacity of a hemithorax. The underlying lung will retract
towards its hilum, and the space occupying effect of the effusion will push the mediastinum towards the opposite side.