Bird's Beak Sign On Barium Enema

A patient presents to the emergency room with abdominal pain. An abdominal series shows a “bird’s beak” sign.

The most likely diagnosis is

A) Intussusception
B) Volvulus
C) Pyloric stenosis
D) Malrotation
E) Acute appendicitis

Answer and Discussion
The answer is B.

Sigmoid volvulus is a rare problem seen in children and adolescents. Volvulus occurs when a floppy sigmoid loop rotates around its base, producing arterial and venous obstruction of the affected segment, followed by rapid distention of the closed loop. Because the consequences can be life-threatening, sigmoid volvulus should be included in the differential diagnosis of acute and recurrent episodes of abdominal pain or bowel obstruction in children, especially if colonic dilation is seen on
radiographs.

Ludwig’s angina

Which of the following best describes Ludwig’s angina?

A) Substernal chest pain that radiates to the right arm.
B) An infection involving the sublingual and submaxillary space.
C) Abdominal pain secondary to an enlarging AAA.
D) A tonsillar infection that leads to chronic abscess formation.
E) Ischemic pain related to insufficient blood flow to an extremity.

Answer and Discussion
The answer is B. ( An infection involving the sublingual and submaxillary space.)

Ludwig’s angina usually develops from a periodontal or dental infection and is one of the most common neck space infections.

The condition is usually a rapidly developing, bilateral cellulitis that affects the sublingual and submaxillary space, without involvement of the lymph nodes or formation of abscesses.
The infection usually rapidly arises from the second and third mandibular molars as a result of poor dental hygiene, tooth extraction, or trauma.

Symptoms include:

Acute Subdural Hematoma

A 34-year-old driver was hit from behind at approximately 25 mph. He hit his head, but did not lose consciousness and did not seek care. Approximately 12 hours later, he developed a headache and confusion, and was taken to the emergency department by a family member. He was found to have an acute subdural hematoma . (Picture shown below). He was hospitalized, and a neurosurgeon was consulted for surgical management.

CT scan of an acute subdural hematoma (arrow) seen as a hyperdense clot with an irregular border. There is a midline shift from the mass effect of the accumulated blood.

Case Discussion

Subdural hematomas (SHs) can occur at any age, but are most common in infants and older adults. Most SHs are caused by trauma.

A Brief Summary Of Hand Deformities

Deformities of hand can be congenital or acquired due to trauma or an underlying medical condition.
A brief description is given below:

Congenital : The deformity is usually recognizable at birth and may be associated with congenital anomalies elsewhere in the body. These include:

• Absent digit
• Extra digit
• Fusion of digits ( Syndactyly)
• Primary muscle contractures.

Cleft hand with ring and small finger fusion (syndactyly) 

Amniotic construction band of the hand with deformity of index finger

Thumb deformity and absent digits. 

Acquired: It may be due to:

1. Trauma: A clinical history of trauma will be present and the deformity depends on the extent of trauma and resulting amputation or surgery. 

Cauliflower Ear.

Medical students are examining a patient in the medical ward admitted with the diagnosis of pneumonia. While doing a general physical examination a deformity is observed in his ear. The patient mentions that he got it after a trauma few years ago.

This deformity is known as Cauliflower Ear.

Case discussion:

Cauliflower Ear: It refers to a deformity of the ear that is caused by a blunt trauma or an injury to the ear. Initially there is bruising and swelling due to subperichondral hematoma. If the swelling is not drained or repeted trauma occurs, this leads to a deformity known as Cauliflower ear.
It is often seen in boxers, wrestlers and rugby players.

Charcot Arthropathy

A 62-year-old man with type 2 diabetes for 15 years presents with history of erythematous, hot, swollen right foot for 2 weeks. Picture shown below:

 He is on multiple medications for management of his diabetes, but it is not successfully controlled. The patient does not recall any trauma to the foot. Three days ago, he noticed pain in his foot. He denies fever or chills.
The radiograph of his foot shows midfoot osteopenia, an early sign of acute Charcot arthropathy.

Case Discussion.

Charcot Arthropathy: 

Charcot arthropathy is an uncommon foot complication in patients with neuropathy. Patients often present with pain, swelling, and erythema, similar to the presentation with a foot infection. Patients
may have a rockerbottom foot deformity. Radiographs confirm the diagnosis.

The incidence of Charcot arthropathy in diabetes ranges from 0.1% to 5%.