Stoma

What are stomas? Check this out!

http://www.coloplast.de/Services/Downloads/Stomaversorgung/Documents/Sprachenbooklet_en.PDF

Varicose Veins Examination

Varicose vein examination:

Dilated, tortuous veins.

(Sapheno-femoral junction: 4cm inferolateral to pubic tubercle)

1)      Look at lower limbs of varicose veins:

a.       Distribution of short saphenous veins (post to lat. Malleolus over lat calf into popliteal fossa)

b.      Long saphneous vein (ant to medial maellolus, pass medial to knee and up medial calf to SF junction)

2)      Examine around the gaiter area for : VVV LAPS

a.       Varicose Veins (are blue, disappear when lie flat)

b.      Venous stars / spider veins

c.       Venous ulcer  (Sign of chronic venous insufficiency, medial gaiter area, maybe filled with granulation tissue at base, or slough)

d.      Lipodermatosclerosis (scarring of skin and fat. Acute & chronic phase. Acute = rbc rush into tissue, brown hemosiderin fills the space. Chronic = lots of hemosiderin, fibrin deposition, skin looks thick and shiny. Inverted champagne bottle seen)

e.      Atrophy blanche (active and healed ulcers leave a white patch)

f.        Pitting edema

g.       Scars

Inspect for PVD.

3)      Palpation:

a.       Temperature, Tenderness.

b.      Palpate along course of veins

c.       Offer to palpate pedal pulses

d.      Offer to palpate abdomen (may have mass compressing IVC / Illiac veins > venous hypertension)

e.      Cough impulse (Patient standing, locate SFJ, saphena varix which is a lump at growing where saphenous vein and femoral vein joins, smooth swelling and palpable thrill.)

4)      Tredelenburg / Torniquet test

a.       Elevate patient leg and slowly empty the veins

b.      Tie a torniquet on SFJ and ask patient to stand.

c.       Normal valve at torniquet site: blood slowly filling from below torniquet; Valvular incompetence of communicating veins: Superficial veins fill more rapidly.

d.      Remove torniquet :  Veins fill rapidly from above = SF junction incompetence.

e.      Repeat test at 3 positions : SJ junction, slightly above knee, and slightly above medial malleolus,.

5)      Modified Perthes’ test

a.       Walking with torniquet on SF Junction, normally gets better with walking; incompetent valves: no effect; DVT = painful when walk

b.      Calf pump function, making varicosities less.

6)      Doppler examination

a.       Doppler probe put at Sfjunction, calf is squeezed. Increase venous return = whoosh sound, followed by plop sound  = valve prevents regurgitation.

General considerations:

Causes:

-Primary: Idiopathic / Familial/hereditary (in teens)

- Secondary: Obstruction (pelvic mass), DVT, AV fistulae, Klippel Trenaunay Syndrome (congenital av fistalae), pregnancy (progesterone ~ collagen, increase pressure)

Presenting complains: *Saphena varix, varicosities, heaviness, tension, itching (after standing)

RF: Female, age, occupation, ethnicity, pregnancy, obesity, smoking. Previous Hx for abdominal cancer, DVT, other venous complaints

Veins: Deep and superficial vs long and short saphenous veins

Esophageal cancer

Symptoms always present late into disease, hence poor prognosis, surgical intervention : not effective.

Squamous – RF: Smoking, HPV

Adenocarcinoma – barett’s., gerd

Symptoms: Dysphagia. (increase salivation is experienced in clerked patient),

Investigation: Barium swallow, endoscopy US (most eff). To rule out metastasis: CT, bone scan, bronchoscopy, laparoscopy, thoracoscopy.

Associated signs:  -hoarseness of voice indicate involvement of recurrent laryngeal nerve, lymphadenopathy, bleeding, weight loss (2^nd most common symptom(), cough, RS involvement, hepatomegaly, pain in the epigastric region, bony structure (metastatic)

D/D: achalasia, gastric cancer, esophageal stricture

Rx:

Radiotherapy provide relieve to dysphagia in half of the patients. Chemotherapy not so well received. Medical treatment provided before surgery to reduce tumor size to ease resectibility.  PDT : photodynamic therapy (Drugs called photosensitisers that when exposed to light, kills nearby cells by releasing oxygen.

Surgical Rx: THE – transhiatal esophagectomy, TTE- transthoracic esophagectomy

c/I surgery: metastasis.

http://www.youtube.com/watch?v=oItauetshNQ

Naproxen sodium:
NSAID, relieves pain, for dysmenorrhea as well. :)
GI problems, ulcers / IBD c/i.
reduce efficiency of SSRI.

Gaiter area:

Atrophie blanche
Scar arising on the lower leg. Occurs after skin injury due to poor blood flow.
http://dermnetnz.org/vascular/atrophie-blanche.html

Luftsichel sign

Seen in some cases of left upper lobe collapse, it is due to hyperinflation of apical segment of left lower lobe, interposing itself between the mediastinum and the collapsed left upper lobe.

The right lung seemed to be hyperinflated as well. Left lung volume is smaller. Mediastinum shift is observed.

Ref: http://www.radiologywiki.org/
www.my-uni.net

More radiology slides

www.mypacs.net

Kerley Lines

Source of information: Catscanman.net

Chest Radiography: AP view

Kerley B lines (red arrows) are thickened horizontal linear opacities in the subpleural region, which meet the pleura at right angles.

Kerley A lines (yellow arrows) are longer lines coursing diagonally toward the hila in the inner half of the lungs. 

Other findings:

1) Pulmonary venous congestions : visible at first intercostal space, vessels are more than 3mm in diameter.

2) Loss of clarity of major vessels: Perihilar haze. Undefined outline of vessels 

This is due to leakage of fluid  into the interstitium from pulmonary veins. Lymphatics converge to hilar and absorb fluid.

3) Pleural Effusion may be visible.

Learn more about Recognising (Radiology) Congestive Heart Failure here.

Reference: my-uni.net

Awesome Links!

My-Uni.net
Medschool can never give enough lectures on radiology.
In this website you can find intepretations of chest x-rays, and some CT scans.
Watch all the videos and you will find yourself more confident the next time you encounter an x ray.



Learnerstv.com
Awesome site with lectures, with immunology, bacteriology and so forth.
If you are already in your clinical years I suggest visiting geriatric medicine.
Certain schools did not give enough emphasis on echocardiography, hence it's great to watch the clinical cardiology videos too.
Great for USMLE preparation. :)

The chosen path.

In our journey in pursuing medicine, we realised that medicine was not like what we imagined at all. If anything, it is only worse. Some may even say that doctors are glorified slaves.

But are we?
Will all medical students eventually become a competent doctor at the end of the day if we graduate? Or is it just another license to kill?

Three years into my medical education, and I still haven't quite figure out the answer.
But what I do know is, the more we know, the safer we will be.

Here is a place to share the knowledge that I  have gained, points of views, and also awesome websites to learn more things.

Hopefully we can be closer to ideal.