Leiomyoma vs Adenomyosis - USMLE

Enlarged Uterus

Leiomyoma and Adenomyosis (Non-Pregnant) 

Urinary Incontinence and its types (Stress , Urge , Overflow , Bypass & Irritative)

Difference Between Osler's Node and Janeway Lesions (Infective Endocarditis)

INFECTIVE ENDOCARDITIS 

Osler's Nodes : Painful Nodules on Finger tip and Toes (Immunologic phenomena)

Janeway Lesions : Macular Erythematous non tender lesion on Palms and Soles . (Vascular phenomena)

Hepatitis C associated problems

Extrinsic intrinsic pathway coagulation (Easy to memorize)

Skin conditions and important associations

Acanthosis nigricans -- Insulin resistance (Polycystic Ovarian Syndrome), Gastrointestinal malignancy

Multiple skin tags   -- Insulin resistance , Pregnancy and Crohn disease (perianal)

Porphyria cutanea tarda
Cutaneous leukocytoclastic vasculitis (palpable purpura) secondary to cryoglobulinemia, Lichen planus --
Hepatitis C

Dermatitis herpetiformis  -- Celiac disease

Sudden-onset severe psoriasis 
Recurrent herpes zoster 
Disseminated molluscum contagiosum   -- HIV infection

Severe seborrheic dermatitis  -- HIV infection and Parkinson disease

Explosive onset of multiple itchy seborrheic keratosis -- GI malignancy

Pyoderma gangrenosum -- IBD (inflammatory bowel disease)

Vitiligo -- other autoimmune conditions such as Celiac disease, Pernicious anemia , autoimmune thyroid disease, type 1 diabetes mellitus, primary adrenal insufficiency, hypopituitarism, and alopecia areata.

Amyloidosis

Epidemiology

• Extracellular deposit of insoluble polymeric protein fibrils in tissue & organs
• Can be primary (AL type) or secondary (AA) to chronic inflammatory conditions such as:
• Inflammatory arthritis (e.g RA)
• Chronic infections (e.g bronchiectasis, tuberculosis, osteomyelitis)
• Inflammatory bowel disease (e.g Crohn's disease)
• Malignancy (e.g. lymphoma)
• Vasculitis

Clinical presentation

• Asymptomatic proteinuria or nephrotic syndrome 
• Restrictive cardiomyopathy
• Hepatomegaly
• Peripheral neuropathy &/or autonomic neuropathy
• Visible organ enlargement (e.g. macroglossia)
• Bleeding diathesis
• Waxy thickening, easy bruising of skin

Diagnosis 

• Tissue biopsy (e.g. abdominal fat pad)

Congo red stain shows amyloid deposits within vessel walls. 

Congo red stain shows apple green birefringence under polarized light.

List of Granulomatous diseases

• Bartonella henselae(cat scratch disease)
• Berylliosis
• Churg-Strauss syndrome
• Crohn disease
• Francisella tularensis
• Fungal infections (e.g., histoplasmosis, 
• blastomycosis)
• Granulomatosis with polyangiitis (Wegener)
• Listeria monocytogenes(granulomatosis 
• infantiseptica)
• M. leprae(leprosy; Hansen disease)
• M. tuberculosis
• Treponema pallidum(tertiary syphilis)
• Sarcoidosis 
• Schistosomiasis

Th1cells secrete γ-interferon, activating macrophages. TNF-αfrom macrophages 

induce and maintain granuloma formation. Anti-TNF drugs can, as a side effect, cause 

sequestering granulomas to breakdown, leading to disseminated disease. Always test for 

latent TB before starting anti-TNF therapy.

Features of constrictive pericarditis

Features of constrictive pericarditis

Etiology 

• Idiopathic or viral pericarditis
• Cardiac surgery or radiation therapy
• Tuberculous pericarditis (in endemic areas)

Clinical presentation

• Fatigue and dyspnea on exertion
• Peripheral edema and ascites
• Increased JVP
• Pericardial knock may be heard
• Pulsus paradoxus
• Kussmaul's sign

Diagnostic findings

• ECG may be nonspecific or show atrial fibrillation or low voltage QRS complex
• Imaging shows pericardial thickening and calcification
• Jugular venous pulse tracing shows prominent x and y decents.

Findings of Cor pulmonale

Characteristic findings of Cor pulmonale

Common etiologies :

• COPD
• Interstitial lung disease
• Pulmonary vascular disease (eg, thromboembolic)
• Obstructive sleep apnea

Symptoms :

• Dyspnea on exertion, fatigue, lethargy
• Exertional syncope (due to decreased CO)
• Exertional angina (due to increased myocardial demand)

Examination : 

1. Peripheral edema
2. Increased Jugular venous pressure with prominent a wave
3. Loud S2
4. Right sided heave
5. Pulsatile liver from congestion
6. Tricuspid regurgitation murmur

Imaging :

• EKG : partial or complete RBBB , right axis deviation, right ventricular hypertrophy right ventricular enlargement

• Echocardiogram : Pulmonary hypertension, dilated right ventricle, tricuspid regurgitation

Right heart catheterization: Gold standard for Dx showing right ventricular dysfunction, pulmonary HTN and no left heart disease.

Spinal Cord Lesions - USMLE high yield concepts

Common Antibodies and Their Disease Associations

Common Antibodies and Their Disease Associations

ANTIBODY  DISEASE ASSOCIATION

1. ANA  SLE 
2. Anti-CCP  RA 
3. Anti  centromere  CREST  syndrome 
4. Anti-dsDNA  SLE 
5. Anti  histone  Drug-induced  SLE 
6. Anti-Jo- 1  Polymyositis/dermatomyositis 
7. Anti  mitochondrial  Primary biliary cirrhosis 
8. Antinuclear  Scleroderma 
9. Anti-Scl-70  Scleroderma 
10. Anti-Sm  SLE 
11. Anti-smooth muscle  Autoimmune hepatitis 
12. Antitopoisomerase I  Scleroderma 
13. Anti-TSHR  Graves'  disease 
14. c-ANCA  Vasculitis, especially Wegener's 
15. p-ANCA  Vasculitis,  microscopic polyangiitis 
16. Rheumatoid factor  RA 
17. Ul  RNP antibody  Mixed connective tissue disease

Common AIDS-defining illnesses and Opportunistic infections

Common AIDS-defining illnesses:

• Esophageal candidiasis 
• CMV retinitis 
• Kaposi's sarcoma 
• CNS  lymphoma, toxoplasmosis, PML 
• P jiroveci pneumonia  or  recurrent bacterial  pneumonia 
• HIV encephalopathy 
• Disseminated  mycobacterial or fungal infection 
• Invasive cervical cancer

Thyrotoxicosis with low radioactive iodine

The most important cause of thyrotoxicosis with low radioactive iodine uptake include:

1.Subacute painless thyroiditis
2.subacute granulomatous thyroiditis
3.iodine induced thyroid toxicosis
4.levothyroxine overdose
5.Struma ovarii

Vascular and immunologic manifestations of infective endocarditis

Vascular & immunologic manifestations of infective endocarditis:

Duke Criteria

Vascular phenomena:

• Systemic arterial emboli (focal neurologic deficits, renal or splenic infarcts)
• Septic pulmonary infarcts
• Mycotic aneurysm
• Conjunctival hemorrhages
• Janeway lesions- Macular, erythematous, non-tender lesions on the palms and soles.

Immunologic phenomena:

• Osler's nodes- Painful, violaceous nodules seen on the fingertips & toes.
• Roth spots- Edematous and hemorrhagic lesions of the retina.
• Glomerulonephritis
• Arthritis or positive rheumatoid factor.

Cor-pulmonale

Cor-pulmonale is a term for right-sided heart failure most commonly due to pulmonary disease. Signs of right-sided heart failure include

• JVD
• right sided S3
• right ventricular heave
• hepatomegaly
• Ascites 
• Dependent edema

Allergic Interstitial Nephritis

Allergic Interstitial Nephritis

Etiology :

70 % of cases due to adverse effect to medications

Drugs

1.Penicillins
2.Cephalosporins
3.Sulfa drugs
4.Allopurinol
5.Rifampin
6.Quinolones.

it happens from the first dose.As compared to Aminoglycosides take 5-10 days.
Infections (viruses,bacteria or fungi).Most common causes includes

1.Leptospirosis
2.Legionella
3.CMV
4.Rickettsia
5.Streptococci

Autoimmune disease

1.SLE
2.Sjogren syndrome
3.Sarcoidosis
4.Cryoglobulinemia

Dx: 

1.Rash
2.Fever
3.Joint pain
4.Eosinophilia
5.Increased serum IgE

Best initial test-urinalysis

1.Eosinophiluria (Wright or Giemsa stain)
2.Hematuria
3.Proteinuria (<2g hrs="" p="">
Most accurate test

1.Biopsy
2.Rarely performed

Rx
1.Stop the offending agent
2.+/- corticosteroids

Smoking and Chest diseases in Pakistan

Asthma Severity and Treatment

Asthma management

The Gallbladder and bile ducts

Gallbladder

• The gallbladder is a pear-shaped reservoir in continuity with the common hepatic and common bile ducts through the cystic duct.
•  It is usually 7.5 to 12cm in length, is 3 to 5 cm in diameter, and has a capacity of 35 to 50 mL.
•  The gallbladder lies on the inferior surface of the liver partially enveloped in a layer of peritoneum.
•  The gallbladder is anatomically divided into the fundus, body, infundibulum, and neck, which empties into the cystic duct.
•  Both the gallbladder neck and the cystic duct contain spirally oriented mucosal folds known as the valves of Heister. 
• The valves prevent the passage of gallstones and excessive distention or collapse of the cystic duct, despite variations in ductal pressure. 

The Hepatic Duct (ductus hepaticus)

• Two main trunks of nearly equal size. Arising from the liver at the porta. one from the right, the other from the left lobe.
• The common hepatic duct is less than 2.5cm long  and is formed by the union of the right  and left hepatic ducts.
• It passes downward and to the right for about 4 cm.
• Joined at an acute angle by the cystic duct to form the common bile duct. Lies between  the layers of the lesser omentum.
• Is accompanied by the hepatic artery and portal vein. 

Cystic duct

The cystic duct varies in length from 1 to 5 cm and in diameter from 1 to 3 mm; it usually joins the common hepatic duct at an acute angle.

The Common Bile Duct 

The common bile duct is formed by the junction of the cystic and hepatic ducts.

• Length: It is about 7.5 cm. long.
• Diameter: That of a  goose-quill.

• Course and extent : It descends along the right free margin  of the lesser omentum along with   portal vein ( which is behind it ) , and to the right of the hepatic artery. 
• Then behind the superior portion of the duodenum,
• After crossing the duodenum, it runs on the posterior surface of the head of the pancreas, and in front of IVC. 
• Occasionally completely imbedded in the pancreatic substance. 
• At its termination it lies for a short distance along the right side of the terminal part of the pancreatic duct and passes with it obliquely between the mucous and muscular coats. 
• The two ducts unite and open by a common orifice upon the summit of the duodenal papilla, situated at the medial side of the descending portion of the duodenum, a little below its middle and about 7 to 10 cm. from the pylorus. The short tube formed by the union of the two ducts is dilated into an ampulla, the ampulla of Vater. 

Blood supply

• Gall bladder is supplied by Cystic artery, a branch of right hepatic artery.
• The blood supply to the common hepatic duct, cystic duct and common bile duct comes from the gastroduodenal, retroduodenal, postero-superior pacreatico duodenal arteries. 

Lymphatics

• The lymphatics of gallbladder (subserosal and submucosal) drain into the cystic L/N of Lund.
• Small veins and lymphatics course between the gallbladder fossa and the gallbladder wall, connecting the lymphatic and venous drainage of the liver and gallbladder. These connections are the cause of the direct inflammatory and carcinomatous spread from the gallbladder into the liver.

Calot’s triangle

Formed by:

• Common hepatic duct to the left
• Cystic duct below and 
• inferior surface of the liver above.

Content:

• the cystic artery, 
• the right hepatic artery, and
• the cystic duct lymph node.

Functions of gall bladder

• Stores bile
• Concentrates bile
• Secretion of mucus

Embryology

• The hepatic diverticulum arises from the ventral wall of the foregut and elongates into a stalk to form the choledochous.
• A lateral bud is given off, which becomes the gall bladder and the cystic duct.

Congenital abnormalities

• Absence of the gall bladder
• The Phrygian cap
• Floating gall bladder
• Double gall bladder
• Absence of the cystic duct
• Low insertion of the cystic duct
• An accessory cholecystohepatic duct

Biliary atresia

It may be due to viral infection or defective embryogenesis resulting in the inflammatory destruction of extra- and intrahepatic biliary tree.
Incidence 1 in 12000 live births
Male and female equally affected.
It may be associated with: cardiac lesions, polysplenia, situs inversus, absent vena cava and a preduodenal portal vein.

Classification

Type I: atresia restricted to the common bile duct
Type II: atresia of the common hepatic duct
Type III: atresia of the right and left hepatic ducts

Clinical features

• Progressive jaundice in a new born.
• Steatorrhea
• Osteomalacia
• Biliary rickets
• Severe pruritus
• Clubbing and skin xanthomas

D/D

• Alpha 1-AT deficiency
• Cholestasis associated with i.v feeding
• Choledochal cyst
• Inspissated bile syndrome
• Neonatal hepatitis

Treatment
In correctable cases:
Roux-en-Y hepaticojejunostomy
In noncorrectable cases:
Hepaticoportojejunostomy (Kasai’s operation)
Radical excision of all bile duct tissue up to the liver capsule is performed.
A roux-en-Y loop of jejunum is anastomosed to the exposed area of liver capsule above the bifurcation of the portal vein creating a portoenterostomy

Liver transplantation: in case of unsuccessful

Caroli’s disease

It is a congenital, multiple, irregular dilatations of the intrahepatic ducts with stenotic segments in between.
Extrahepatic biliary system is normal.

Types :

Simple type
Presents later with episodes of aqbdominal pain and biliary sepsis

Associated with:
Congenital hepatic fibrosis
Polycystic liver
Cholangiocarcinoma
Periportal fibrotic type
Presents in childhood

Periportal fibrotic type is associated with:
Biliary stasis
Stone formation and
Cholangitis

T/T

• Antibiotics for chalangitis and removal of calculi.
• If limited to one lobe of liver- lobectomy

Choledochal cyst

Choledochal cysts are congenital dilations of the intra- and/or extrahepatic biliary system.

Classification (Todani)

Type Ia and b: diffuse cystic
Type II: diverticulum of the common bile duct
Type III: diverticulum within the pancreas
Type IV: extension into the liver
Type V: cystic dilatation only of the intrahepatic ducts

Clinical features

• Can occur in any age.
• Patients may present with jaundice, fever, abdominal pain.
• O/E right upper quadrant mass which is smooth, soft, not moving with respiration, not mobile and resonant.

Ix

Ultrasonography abdomen:
Confirms the presence of  abnormal cyst

MRI/MRCP:  
reveals anatomy. Esp. relationship between the lower end of the bile duct and the pancreatic duct.

CT: 
show the extent of intra- and extrahepatic dilatation.

Treatment
Radical excision of the cyst is the t/t of choice with reconstruction of the biliary tree using a RouX-en-Y loop of jejunum.