deja.vu_internal_medicine

MICKEY MOUSE SIGN :
represent the normal anatomy of the common femoral artery, common femoral vein and great saphenous vein on ultrasound at the level just inferior the inguinal crease. !
One way of screening for deep vein thrombosis, is by checking the compressibility of these veins...
Lower extremity US should include compression, color and spectral Doppler sonography with assessment of phasicity and venous flow augmentation...

Whenever you come across a patient with unequal blood pressure readings in both arms ...or extremity claudication or headache,malaise etc ...look for the presence of carotid bruit or abdominal bruit.... Takayasu arteritis is a large vessel vasculitis ..most common in young females and asians ..the picture above is an angiography showing multiple stenosis in the branches of aorta secondary to Takayasu... It can also be associated with Renal artery stenosis , where fibromuscular dysplasia should then be on top of your dd list ...Management includes STEROIDS...

Quite a few findings..
1. Straight line - fluid level and air above suggestive of hydropneumothorax
2. Collapsed left lung
3. Compensatory hyperinflation of right lung
4. Bowel loop under the left diaphragm...something like a chiladiti sign....

Overwhelming responses ..The majority got it right....
Serotonin syndrome is a potentially life-threatening syndrome that is precipitated by the use of serotonergic drugs and overactivation of both the peripheral and central postsynaptic 5HT-1A and, most notably, 5HT-2A receptors.
In mild cases, the predominating features are mild hypertension and tachycardia, mydriasis, diaphoresis, shivering, tremor, myoclonus, and hyperreflexia. Patients with a mild syndrome are usually afebrile. Patients with a moderate syndrome usually have the above symptoms plus hyperthermia (40°C), hyperactive bowel sounds, horizontal ocular clonus, mild agitation, hypervigilance, and pressured speech.
In severe cases, patients have all of the above symptoms plus hyperthermia greater than 41.1°C, dramatic swings in pulse rate and blood pressure, delirium, and muscle rigidity. Severe cases may result in complications, such as seizures, rhabdomyolysis, myoglobinuria, metabolic acidosis, renal failure, acute respiratory distress syndrome, respiratory failure, diffuse intravascular clotting, coma, and death. The symptoms of hyperreflexia, rigidity, and clonus tend to be more prominent in the lower extremities.
The keys to management are discontinuing all serotonergic agents, providing supportive care via stabilizing vital signs, giving oxygen to keep oxygen saturation greater than 93%, administering intravenous fluids, providing continuous cardiac monitoring, sedating with benzodiazepines, and possibly administering serotonin antagonists.
Cyproheptadine is the more potent 5HT-2A receptor antagonist and therefore may be more effective than chlorpromazine.
Several case reports have shown that cyproheptadine provides symptomatic relief in mild to moderate cases of serotonin syndrome, but its efficacy in severe cases has yet to be studied. Also, cyproheptadine does not shorten the time course of serotonin syndrome.
The recommended dose of cyproheptadine is an initial dose of 12 mg, with the addition of 2 mg every 2 hours if symptoms persist. A maintenance dose of 8 mg should be used every 6 hours once the patient is stabilized.

Some tips to keep in mind while treating osteoporotic fractures .. if your DEXA scan shows a T Score of less than -2.5 , your patient needs treatment. Remember fracture in a patient who is older than 75 years, you do not have to do a DEXA scan, you can treat the patient.
All should recieve Vitamin D and Calcium unless you feel that they have sufficient levels.
Bisphosphonates are very useful. Consider Alendronate and if not tolerating then try Zoledronic acid . Still having problems consider Strontium or Raloxefene (many contraindications beware)
Denosumab (promising drug) , hormone replacement and Teriparatide can be considered but have their own pros and cons.
Image above : MRI showing fractures and

Syndesmophytes are due to ossification of outer fibres of annulus fibrosus....
This is an x-ray spine of a young male patient who has lower back pain imrpoving on rest and NSAID...Typical of Ankylosing spondylitis..the bamboo spine is actually a late and uncommon feature although pathognomic. Sacroilitis is relatively more common in these patients. .

Posting something about HANTA virus today... We may have forgotten.....the common Hanta virus subtypes and also the key clinical differences between the Hemorrhagic Fever with Renal Syndrome (HFRS) and Hanta Pulmonary Syndrome (HPS) ...




Source : .gov

This patient presented with acute tender swollen right knee.
Diagnosis ??
X-ray shows chondrocalcinosis (visible calcification of the cartilage), which is pathognomic of 💥PSEUDOGOUT💥
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💥M.C joints affected : knee , wrist , shoulder.
💥Joint aspirate will reveal a weakly positively birefringent rhomboid shaped crystals
💥X-ray : chondrocalcinosis
💥Rx : aspirate to rule out septic arthritis. : NSAIDs +/- steroids as like for GOUT.
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is a common complica of P*P (Pneumocystis Jirovecci Pneumonia) , commonly seen in HIV patients with CD4

is the commonest cause of adult onset epilepsy in the world. It is more frequently seen in Central and South America, Asia and Africa.
As we all know it comes from ingestion of the tapeworm Tenis solium (from Pork mainly , salads etc )
CT scan shows calcified nodules scattered throughout the cerebral hemispheres without surrounding edema. The features are consistent with the nodular calcified stage of Neurocysticercosis representing quiescent calcified cyst remnant.

Scanning electron microscope picture of
S.Aureus bacteremia needs atleast 2 weeks of antibiotics .Flucloxacillin or other drugs with staph cover should be used.
Usually skin and soft tissue infections , i.v line , bone and joint and cardiac infections.
High risk for MRSA should be treated with Vancomycin..Resistant bugs with Teicoplanin.

Patient presents with cough and hemoptysis. CXR shows a cavity in left upper zone containing aspergilloma... Previously existing cavity was probably after a cured TB a few years earlier. Aspergillus specific IgG and IgE were positive . Itraconazole to be started .
Role of Steroids ? Read up......

HIV patient with low CD4 count , presents with blurring of vison. This is the fundus picture - characteristic retinal Hemorrhages and necrosis - Pizza pie appearance .
Diagnosis : Cytomegalovirus Retinitis.
Rx : i.v gancyclovir or its prodrug oral valganciclovir .

For a second I thought this was miliary TB .... But this patient has h/o recent crops of varicella lesions.
This chest xray shows miliary opacities throughout both lungs , which are uniform in size and dense suggesting calcification.. there is no focal lung parenchymal mass or cavitatory lesion . The appearance is characteristic of
VARICELLA PNEUMONIA (Healed) .

Although complications of Chicken Pox are rare, important to note are : pneumonitis , encephalitis , disseminated hemorrhagic chickenpox , arthritis , nephritis and pancreatitis....

Clinical presentation :
Dysphagia and chest pain.
O/e : partial ptosis left side , double vision and sustained upward gaze exacerbates his ptosis .

CXR : suggestive of partially delineated mediastinal mass (anterior mediastinum) with regular borders , bulging the left upper mediastinal contour , consistent with THYMOMA... So why Ptosis ? The history is suggestive of Myesthenia gravis which is seen in one third of the patients with THYMOMA. The ptosis worsening with upward gaze , demonstrates fatigability.

Lady who is 16 week pregnant with dysuria and ge***al vescicular lesions. Clinical diagnosis of Herpes simplex.
This is a pap smear which shows the 3Ms : multinucleation , margination of chromatin and Molding of nuclei.
Rx with Acyclovir .
In pregnancy, elective LSCS can be planned if primary attack of herpes occurs at greater than 28 weeks gestation.
Acyclovir , although not licensed , does not have significant teratogenic effects documented and hence can be given in pregnancy.

appearance.....
Features of ONCHOCERCIASIS , a disease caused by filarial nematode O.Volvulus . River blindess , when the worms die in the cornea and prove chronic inflammation , leading to clouding of cornea. Inflammation in subcutaneous tissue leads to pruritic rash and formation of a leopard skin appearance. Skin snip biopsy is useful. Rx of choice is IVERMECTIN.
Do not use DEC , cos rapid death of worms can exacerbate damage to surrounding tissues and can even cause complete blindness.

Post renal transplant patient develops this skin lesion on his forearm. Think of SQUAMOUS CELL CARCINOMA, in this scenario of immunosuppression. Other risk factors include : excessive sun exposure, actinic keratosis , smoking , long standing marjolin / leg ulcers , and genetic conditions like xeroderma pigmentosum and oculocutaneous albinism.
Rx refer for surgical excision with marginal clearance of 4mm if the lesion is 2cm....

D/d sudden cardiac death in young... Let's read ECG like an intern now... ECG shows :
Calliberation : good
Rhythm : Sinus
Rate : 70 , regular
Axis : No deviation
Positive findings :
S depth in V1 + R height in V6 > 35mm , indicating LVH
Also deep ST depression and T inversions look like LV Strain pattern... ECHO : Mitral regurgitation , , systolic anterior motion of anterior mitral leaflet and asymmetric hypertrophy
Diagnosis : Hypertrophic Cardiomyopathy.

Abdomen x-ray showing Nephrocalcinosis - a classical finding in type 1 RTA.
Type 1 Renal Tubular Acidosis:
The inability to generate acid urine in distal tubule.
Causes hypokalemia.
Common complications are renal stones and Nephrocalcinosis.
Causes : Idiopathic , rheumatoid arthritis , SLE , Sjogrens , Amphotericin B toxicity, Analgesic nephropathy.
ABG : NAGMA (Hyperchloremic metabolic acidosis )

COVID-19 CUTANEOUS MANIFESTATIONS.... 1. Pseudo Chillblains
2. Urticarial eruptions
3. Vescicular eruptions
4. Maculopapular rash
5. Purpuric lesions
Source: Pictures from Recent publication in British Journal of Dermatology, for educational purposes only.

This is a monoclonal antibody targeting interleukin 1beta.

It can be used for treatment of Acute Gout patients who have not responded adequately or intolerant to treatment with NSAIDs or Colchicine. Remember allopurinol is not given during the acute attack unless they are already on it prior to the current attack.
More studies on its use in periodic syndromes and other inflammatory conditions are ongoing and seems to be a promising drug .

A patient who presented with hypertension and hypokalemia. BP was uncontrolled despite three antihypertensives and as a part of workup of secondary hypertension ,
CT Abdomen shows a right sided adrenal adenoma , which can be seen just below the liver, seen as a round mass (just left of that vertebral body).. So this is a case of Conn's Syndrome or primary hyperaldosteronism.
Next step is to do a renin/aldosterone ratio which will show low renin and high Aldo levels .

COVID 19 . CHEST XRAY .

We all tend to ensure that our suspects have atleast a chest xray on admission. Although non specific, it is still worth taking as we could atleast use it as a baseline study or decide if CT is needed (image shows CT picks up findings better) However due to practical reasons like disinfection etc , these decisions are totally case based rather than guideline based.
Plain radiograph

Chest radiographs may be normal in early or mild disease. . Findings are most extensive about 10-12 days after symptom onset.
The most frequent findings that have been described in papers are airspace opacities, whether described as consolidation or, less commonly, GGO (Ground glass opacities). The distribution is most often bilateral, peripheral, and lower zone predominant.
In contrast to parenchymal abnormalities, pleural effusion is rare (3%).

Acromegaly patients are usually managed with surgery , but medical management includes Octreotide , somatostatin analougue which will directly inhibit GH secretion...sometimes when this fails , or as an adjunct to surgery or if unfit for surgery , this drug , PEGVISOMANT is given as a subcutaneous injection once daily. It is a GH Receptor antagonist and prevents dimerization of the GH Receptor. Decreaes IGF-1 levels quite efficiently but doesn't reduce the tumor volume therefore surgery may still need to be considered to prevent mass effects .

Patient with Polycystic Ovarian Syndrome (PCOS) , who has a BMI of 30 but her major concern in androgen effects like hirsutism and acne....She will benefit from CO-CYPRINDOL, which contains both cyproterone (anti androgen) as well as ethinylestradiol (synthetic oestrogen) , which significantly reduced the symptoms due to androgen excess. Clomifene will be the preferred option if your planning on inducing ovulation , whereas metformin can address insulin resistance and obesity . Weight loss and lifestyle management is always first line treatment.

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Look what I found in last night's duty....! Nurse @ 1 am : patient has not passed urine doc.. Me : let's use the Priveleges of Aster Med City 😛 get the USG machine sister...so what's this ? Bladder hematoma ! The most common reason for intraluminal urinary bladder hematoma is trauma. However in gynecological and pelvic malignancies, the pelvic irradiation can affect non targeted organs resulting in uroge***al complications like hematoma. Small size hematoma can be easily diagnosed in ultrasound.

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Initial phase of Dengue fever , the rash need not be purpuric spots.. As seen in this patient , there is usually a "BLANCHING" rash that we commonly observe in many patients... And after like 2-3 days only we may see , those classical "Islands of white in a sea of red" ! Red flag signs are important : recurrent vomiting , pain abdomen , minor bleeding , serositis with effusion , organomegaly and increased PCV . These patients invariably go into shock , if failed to be monitored properly ...which includes : vitals , urine output , HEMATOCRIT (before and after fluid replacement , then 6th hourly) and of course our usual daily labs.