lateral winging of scapula

 Lateral winging of scapula

Lateral winging → lateral border of scapula protrudes

• Cause: paralysis of trapezius (due to spinal accessory nerve injury, CN XI).

• Also from rhomboid paralysis (dorsal scapular nerve),

• Scapula drifts laterally and downward, shoulder droops, difficulty elevating arm above head.

• Bedside evaluation - Ask the patient to push against a wall

• Causes of lateral winging -

Neck dissection / lymph node biopsy (iatrogenic CN XI injury).

Trauma to posterior triangle of neck.

SYMPTOMS OF GASTROINTESTINAL SYSTEM

SYMPTOMS OF GASTROINTESTINAL SYSTEM

1)Dysphagia and odynophagia.

2)Heartburn and reflux

3)Indigestion

4)Flatulence

5)Vomiting

6)Anorexia

7)Constipation

8)Diarrhea

9)Alternation of bowel pattern

10)Abdominal pain

11)Abdominal distention

12)Weight loss

13)Hematemesis

14)Rectal bleeding

15)Malena

16)Jaundice

17)Itching

18)Urinary symptoms

Ref :Hutchison's clinical methods 24th edition

Dog related infections of the lung

Dog related infections of the lung

• PARASITIC INFECTIONS - 

1.  Echinococcus granulosus (hydatid disease) - Dogs are definitive hosts.
2. Toxocara canis (dog roundworm)

      

•  BACTERIAL INFECTIONS -

      1.Capnocytophaga - 

• Capnocytophaga canimorsus is a gram-negative bacterium, which is found in the normal flora of the oropharyngeal tract of dogs and cats.

• Transmitted to human by dogs bite and causes an overwhelming sepsis, particularly in elderly, immunocompromised or asplenic patients  

• Causes meningitis, osteomyelitis, arthritis, lung abscess or empyema and endocarditis,  thrombotic thrombocytopenic purpura and hemolytic uremic syndrome

      2.Bordetella bronchiseptica  - 

• A gram-negative rod bacterium , normally lives in the upper respiratory tract of the mammals such as dogs and cats and is transmitted to humans by aerosol.  

• Human infection with B. bronchiseptica is very rare; however, it can also cause pneumonia and upper respiratory tract infection in dog owners.

      3.Pasteurella multocida

• From dog bites, licks, or close contact.

• Can cause pneumonia, empyema, or lung abscess, especially in people with chronic lung disease.

      4.Coxiella burnetii - causes Q fever in humans. The pathogen normally infects individuals via aerosol and direct contact with the body fluids of the infected animals.

      5. Leptospira  - L. interrogans is an aerobic spirochete

• Rodents are the major reservoirs for Leptospirosis; however, domestic animals including dogs can play an important role in leptospirosis transmission in endemic regions.

• Fungal (less common)

• Blastomycosis, Histoplasmosis, Cryptococcus

       

Berryliosis

 Berylliosis- causes

-Inhalation of dust or fumes of beryllium

Occupational risk in :

1)primary beryllium factory workers 2)workersprocessing beryllium (foundry workers, furnace tenders, machinists, welders)

 3)Individuals working with beryllium products (dental technicians, golf club manufacturers, bike parts manufacturers), 4)select industries (e.g., aerospace, automotive, defense, electronics, energy, telecommunications)

-Genetic predisposition with HLA DP1 gene

Orthostatic Hypotension

Orthostasis is the presence of at least one of the following: a decrease in systolic blood pressure by ≥20 mm Hg, a decrease in diastolic blood pressure by ≥10 mm Hg present within 3 minutes of standing or a head up tilt table at 60⁰.According to European society of cardiology.

Clinical features of different stages of syphilis

Clinical features of different stages of syphilis

Primary syphilis: The primary lesion or chancre develops at the site of infection, usually in the genital area. A dull red macule develops, becomes papular and then erodes to form an indurated, painless ulcer (chancre) with associated inguinal lymphadenopathy. Without treatment, the chancre will resolve to leave a thin, atrophic scar. 

Secondary syphilis: Constitutional features such as mild fever, malaise and headache are seen. Maculopapular rash on the trunk and limbs that may later involve the palms and soles. Generalised nontender lymphadenopathy. Mucous patches, may affect the genitalia, mouth, pharynx or larynx, and are essentially modified papules, which become eroded. Rarely, confluence produces characteristic ‘snail track ulcers’ in the mouth.

 Tertiary syphilis: The characteristic feature is a chronic granulomatous lesion called a gumma, which may be single or multiple and can affect skin, mucosa, bone, muscles or viscera. After several years, cardiovascular syphilis, particularly aortitis with aortic incompetence, angina and aneurysm, and neurosyphilis, with meningovascular disease, tabes dorsalis or general paralysis of the insane, may develop

Overcrowding

 Overcrowding is the situation in which the dwelling is occupied by a greater number of persons than is deemed consistent with the maintenance of health, efficiency, and general well-being of the occupants.

Room Standard –

Two persons of opposite sex over 9 years of age, not being husband and wife, should not sleep in the same room.

Cubic Space Standard (air space):

Minimum 500 cubic feet of air space per person should be available

Air space per person=

Length × Breadth × Height of the room divided by number of person

Reference - PARK

Post tussive suction

It is seen in patients with lung cavity after coughing. Coughing causes the cavity to collapse due to forceful expiration and during inspiration, air rushes into the cavity causing a hissing sound known as the post-tussive suction.

Source- MacLeod's clinical examination 14th edition

Conditions causing Concave st segment elevation

1. Acute Pericarditis

2. Benign early repolarization 

3. Left ventricular strain pattern in LVH

Source - ECG made easy by John Hampton 9E

Symptoms and signs of pulmonary hypertension

 Symptoms of pulmonary arterial hypertension (PAH)

•  Dyspnea on exertion (WHO - functional class)
• Fatigue and rapid exhaustion
• Dyspnea when bending forward (bendopnea)
• Palpitations
• Hemoptysis
• Exercise induced abdominal distension and nausea
• Weight gain due to fluid retention
• Syncope (during or after physical exertion)

Rare symptoms due to pulmonary artery dilation

• Exertional chest pain - dynamic compression of left main coronary artery
• Hoarseness (dysphonia) - compression of left recurrent laryngeal nerve (cardiovocal or ortner's syndrome)
• Shortness of breath, wheezing, cough, lower respiratory tract infections, atelectasis- compression of the bronchi

Signs of pulmonary hypertension 

• Central, peripheral or mixed cyanosis
• Accentuated pulmonary component of the second heart sound
• RV third heart syndrome
• Systolic murmur of tricuspid regurgitation 
• Diastolic murmur of pulmonary regurgitation 

Signs pointing towards underlying cause of PH

• Digital clubbing - cyanotic CHD, fibrotic lung disease, bronchiectasis, PVOD, or liver disease
• Differential clubbing/cyanosis - PDA/ eisenmenger's syndrome
• Auscultatory findings (crackles or wheezing or murmurs) - lung or heart disease
• Sequelae of DVT, venous insufficiency - CTEPH
• Telengiectasia - HHT or SSc
• Sclerodactyly, raynaud's phenomenon, digital clubbing, GERD - SSc

Signs of RV backward failure

• Distended and pulsating jugular veins
• Abdominal distension 
• Hepatomegaly
• Ascites
• Peripheral edema

Signs of RV forward failure

• Peripheral cyanosis(blue lips and tips)
• Dizziness
• Pallor
• Cool extremities
• Prolonged capillary refill

Ref - ERS/ESC 2022 guidelines