ANEURYSM | clinical feature | cause | sign and symptoms| treatment

           ANEURYSM

An aneurysm occurs when an artery’s wall weakens and causes an abnormally large bulge. This bulge can rupture and cause internal bleeding. Although an aneurysm can occur in any part of your body, they’re most common in the:

Brain
Aorta
Legs
Spleen

*Types* 



*Abdominal aortic aneurysm*

An aortic aneurysm is a weakened or bulging area on the wall of the aorta. 
An abdominal aortic aneurysm occurs when the large blood vessel (the aorta) that supplies blood to the abdomen, pelvis and legs becomes abnormally large or balloons outward.
 This type of aneurysm is most often found in men over age 60 who have at least one or more risk factor, including emphysema, family history, high blood pressure, high cholesterol, obesity and smoking.
 The rupture of an abdominal aortic aneurysm is a medical emergency, and only about 20 percent of patients survive.



An aortic aneurysm is a weakened or bulging area on the wall of the aorta.

Symptoms of abdominal aortic aneurysm includes:

*.Chest pain and *.Jaw pain, are generally associated with a heart attack, but the sudden stabbing, radiating pain, fainting, difficulty breathing, and sometimes even sudden weakness on one side are also symptoms of an aortic event.

*Cerebral Aneurysm or Brain Aneurysm*

Cerebral aneurysms, which affect about 5 percent of the population, occur when the wall of a blood vessel in the brain becomes weakened and bulges or balloons out. 
There are many types of aneurysms. The most common, a “berry aneurysm,” is more common in adults. It can range in size from a few millimeters to more than a centimeter. 
A family history of multiple berry aneurysms may increase  risk.



*.Conditions that injure or weaken the walls of the blood vessel, including atherosclerosis, trauma or infection, may also cause cerebral aneurysms. Other risk factors include medical conditions such as polycystic kidney disease, narrowing of the aorta and endocarditis. Like other types of aneurysm, cerebral aneurysms may not have any symptoms. 

Symptoms may include:

*.Severe headache
*.Double vision
*.Loss of vision
*.Headaches
*.Eye pain
*.Neck pain
*.Stiff neck
*.Thoracic Aortic *.Aneurysm
*.A thoracic aortic aneurysm is an abnormal bulging or ballooning of the portion of the aorta that passes through the chest.



The most common cause is atherosclerosis, or hardening of the arteries. Other risk factors include:

*.Aging
*.Genetic conditions, such as Marfan syndrome
*.Inflammation of the aorta
*.Injury from falls or other trauma
*.Syphilis
A patient with an aneurysm may not experience any symptoms until the aneurysm begins to “leak” blood into nearby tissue or expand. *.Symptoms of a thoracic aortic aneurysm may include:

*.Hoarseness
*.Swallowing problems
*.High-pitched breathing
*.Swelling in the neck
*.Chest or upper back pain
*.Clammy skin
*.Nausea and vomiting
*.Rapid heart rate
*.Sense of impending doom

*Causes*


A person may inherit the tendency to form aneurysms, or aneurysms may develop because of hardening of the arteries (atherosclerosis) and aging. 
The following risk factors may increase  risk for an aneurysm or, if  already have an aneurysm, may increase  risk of it rupturing:

*Family history.*
 People who have a family history of aneurysms are more likely to have an aneurysm than those who don’t.
*.Hardening of the arteries (atherosclerosis).*.
Atherosclerosis occurs when fat and other substances build up on the lining of a blood vessel. 
This condition may increase  risk of an aneurysm.
High blood pressure. 
The risk of subarachnoid hemorrhage is greater in people who have a history of high blood pressure.

*Blood vessel diseases in the aorta.*
 Abdominal aortic aneurysms can be caused by diseases that cause blood vessels to become inflamed.

Trauma, such as being in a car accident, can cause abdominal aortic aneurysms.

*Infection in the aorta.*
 Infections, such as a bacterial or fungal infection, may rarely cause abdominal aortic aneurysms.

In addition to being a cause of high blood pressure, the use of cigarettes may greatly increase the chances of a brain aneurysm rupturing.

*Diagnosis* 

*Computed tomography (CT) scan.*
 A CT scan can help identify bleeding in the brain. Sometimes a lumbar puncture may be used if suspects that  have a ruptured cerebral aneurysm with a subarachnoid hemorrhage.

*Computed tomography angiogram (CTA) scan.*
 CTA is a more precise method of evaluating blood vessels than a standard CT scan. CTA uses a combination of CT scanning, special computer techniques, and contrast material (dye) injected into the blood to produce images of blood vessels.

*Magnetic resonance angiography (MRA).*
 Similar to a CTA, MRA uses a magnetic field and pulses of radio wave energy to provide pictures of blood vessels inside the body. As with CTA and cerebral angiography, a dye is often used during MRA to make blood vessels show up more clearly.

*Cerebral angiogram.*
 During this X-ray test, a catheter is inserted through a blood vessel in the groin or arm and moved up through the vessel into the brain. A dye is then injected into the cerebral artery. As with the above tests, the dye allows any problems in the artery, including aneurysms, to be seen on the X-ray. 
Although this test is more invasive and carries more risk than the above tests, it is the best way to locate small (less than 5 mm) brain aneurysms.

*Abdominal ultrasound.*
 This test is most commonly used to diagnose abdominal aortic aneurysms. During this painless exam,  lie on  back on an examination table and a small amount of warm gel is applied to  abdomen.
 The gel helps eliminate the formation of air pockets between  body and the instrument the technician uses to see  aorta, called a transducer. The technician presses the transducer against skin over  abdomen, moving from one area to another. 
The transducer sends images to a computer screen that the technician monitors to check for a potential aneurysm.

*Treatment* 

Aortic aneurysms are treated with medicines and surgery. 
Small aneurysms that are found early and aren’t causing symptoms may not need treatment. Other aneurysms need to be treated. The goals of treatment may include:

*.Preventing the aneurysm from growing
*.Preventing or reversing damage to other body structures
*.Preventing or treating a rupture or dissection
*.Allowing  to continue doing normal daily activities
Treatment for an aortic aneurysm is based on its size.
 may recommend routine testing to make sure an aneurysm isn’t getting bigger. 
This method usually is used for aneurysms that are smaller than 5 centimeters (about 2 inches) across.

*Medicines*

If  have an aortic aneurysm, may prescribe medicines before surgery or instead of surgery.
 *.Medicines are used to lower blood pressure, relax blood vessels, and lower the risk that the aneurysm will 
rupture (burst). 
*.Beta blockers and calcium channel blockers are the medicines most commonly used.

*Surgery*

*Open Abdominal or Open Chest Repair:*
 The standard and most common type of surgery for aortic aneurysms is open abdominal or open chest repair. This surgery involves a major incision (cut) in the abdomen or chest.

*Endovascular Repair:*
 In endovascular repair, the aneurysm isn’t removed. Instead, a graft is inserted into the aorta to strengthen it.
 Surgeons do this type of surgery using catheters (tubes) inserted into the arteries; it doesn’t require surgically opening the chest or abdomen. 
General anesthesia is used during this procedure.
The surgeon first inserts a catheter into an artery in the groin (upper thigh) and threads it to the aneurysm. Then, using an x ray to see the artery, the surgeon threads the graft (also called a stent graft) into the aorta to the aneurysm.
 The graft is then expanded inside the aorta and fastened in place to form a stable channel for blood flow. 
The graft reinforces the weakened section of the aorta. This helps prevent the aneurysm from rupturing.



*Surgical clipping.*
 This surgery involves placing a small metal clip around the base of the aneurysm to isolate it from normal blood circulation. 
This decreases the pressure on the aneurysm and prevents it from rupturing. 
Whether this surgery can be done depends on the location of the aneurysm

*Complications*

*Thromboembolism –*
 depending on where the clot has traveled to, thromboembolism can cause pain in the extremities or the abdomen. 
If a clot travels to the brain, it can cause a stroke
*Dissection of the aorta –*
 People who have an aortic dissection often describe a tearing or ripping pain in the chest that is abrupt and excruciating, and the pain can travel as the dissection progresses along the aorta. The pain can radiate toward the back.

*Severe chest and/or back pain –*
 If a silent or diagnosed aortic aneurysm in the chest ruptures, severe chest or back pain may arise. 
Such symptoms may help hospital medical staff diagnose an aneurysm.
*Angina –*
 Certain types of aneurysm can lead to angina, another type of chest pain; the pain is related to narrowed arteries supplying the heart itself (causing myocardial ischemia and possibly heart attack).
*Sudden extreme headache –*
 If a brain aneurysm leads to subarachnoid hemorrhage (a kind of stroke), the main symptom is sudden extreme headache; often so severe that it is unlike any previous experience of head pain.


*Prevention*

The best way to prevent an aortic aneurysm is to avoid the factors that put  at higher risk for one.
 They are as follows:

*.Smoking is a greater risk factor for aneurysm than it is for atherosclerosis, the cardiovascular disease where fatty deposits accumulate on the arterial wall and which can weaken artery walls.
*.A healthy diet includes a variety of fruits, vegetables, and whole grains. It also includes lean meats, poultry, fish, beans, and fat-free or low-fat milk or milk products. 
A healthy diet is low in saturated fat, Tran’s fat, cholesterol, sodium (salt), and added sugar.

MUMPS:


Mumps is an infection caused by a type of virus called a paramyxovirus.
 It is very contagious and spread in saliva, the same way as a cold or flu.
 This means it can be caught from an infected person coughing, sneezing, etc.
It can also be caught from touching infected objects – for example, door handles.

 

Mumps virions are pleomorphic particles ranging from 100 to 600 nm in size, consisting of a helical ribonucleoprotein (RNP) core surrounded by a host cell–derived lipid envelope.
 The RNP consists of a single-stranded RNA (ssRNA) molecule coated by the viral nucleoprotein.
 The RNP appears to be a hollow tube with a unit length of approximately 1 mm, a diameter of 17 to 20 nm, and a central core of 5 to 6 nm.
 The viral host cell–derived envelope contains the viral glycoproteins that project 12 to 15 nm from the virion surface.

*Causes*



Mumps is due to an infection by the mumps virus.
 It can be transmitted by respiratory secretions (e.g. saliva) from a person already affected with the condition.
When contracting mumps, the virus travels from the respiratory tract to the salivary glands and reproduces, causing the glands to swell.


Examples of how mumps can be spread include:

*.Sneezing or coughing.
*.Using the same cutlery and plates as an infected person.
*.Sharing food and drink with someone who is infected.
*.An infected person touching their nose or mouth and then passing it onto a surface that someone else may touch.
*.Individuals infected with the mumps virus are contagious for approximately 15 days (6 days before the symptoms start to show, and up to 9 days after .

 *Risk factors*

*.Failure to vaccinate completely (two separate doses) with exposure to those with mumps

*Age:* The highest risk of contracting mumps is to a child between 2-12 years of age.

*Season:* Outbreaks of mumps were most likely during the winter/spring seasons.

*Travel to high-risk regions of the world:*
 Africa, general Indian subcontinent region, and Southeast Asia. These areas have a very low rate of immunization.

*Weakening immune system:*
 either due to diseases (for example, HIV/AIDS, cancer) or medication (oral steroid use for more than two weeks, chemotherapy).

*Born before 1956:*
 Generally, these individuals are believed to have experienced mumps infection in childhood. However, if they did not, they are at risk for adult mumps disease.

*Symptoms*


The most common symptoms include:

*.Fever
*.Headache
*.Muscle aches
*.Tiredness
*.Loss of appetite
*.Swollen and tender salivary glands under the ears on one or both sides (parotitis)
*.Symptoms typically appear 16-18 days after infection, but this period can range from 12-25 days after infection. *.Some people who get mumps have very mild or no symptoms, and often they do not know they have the disease. Most people with mumps recover completely in a few weeks.

*Sign*

*.Swelling that lasts longer than seven days
*.Headaches not relieved with medication
*.Ongoing fever
*.Nausea and vomiting
*.Swelling accompanied by redness or warmth
*.Decreased hearing
*.Neck stiffness
*.Pain or swelling in testicles (male)
*.Abdominal Pain

*Diagnosis*



Normally, mumps can be diagnosed by its symptoms alone, especially by examining the facial swelling.

*.Check inside the mouth to see the position of the tonsils – when infected with mumps, a person’s tonsils can get pushed to the side.

*.Take the patient’s temperature.
*.Take a sample of blood, urine, or saliva to confirm diagnosis.
*.Take a sample of CSF (cerebrospinal fluid) from the spine for testing – this is usually only in severe cases.

*Treatment

Because mumps is viral, antibiotics cannot be used to treat it, and at present, there are no anti-viral medications that can treat mumps.

*.Current treatment can only help relieve the symptoms until the infection has run its course and the body has built up an immunity, much like a cold. In most cases, people recover from mumps within 2 weeks.

*.Due to the viral nature of mumps, treatment focuses on decreasing symptoms.

*.Eat soft, bland foods that do not require much chewing. Examples include oatmeal, bananas, pasta, potatoes, eggs, gelatin, cooked vegetables, applesauce and tender cooked meats.
*.Avoid tart drinks and sour foods since they can irritate the swelling and cause pain. *.Examples of these include orange juice, salad dressing, and pickles.
*.Apply heat or cold packs to the cheeks. Some people find warm compresses to be more soothing while others from cold compresses provide more pain relief.
*.Use over-the-counter medication such as acetaminophen or ibuprofen to reduce fever and pain.
*.Get extra rest and stay well hydrated with plenty of fluids such as water, *.Sprite, bouillon, milk and popsicles.
*.If orchitis develops, treat this with bed rest, ice packs, ibuprofen and provide support to inflamed testicles by wearing tight fitting underwear or an athletic supporter.

*Complications*

Complications are more frequent in adults than children, the most common are:

*Orchitis* –
 testicles swell and become painful, this happens to 1 in 5 adult males with mumps. The swelling normally goes down within 1 week; tenderness can last longer than that. This rarely results in infertility.

*Oophoritis* – ovaries swell and are painful; it occurs in 1 in 20 adult females. The swelling will subside as the immune system fights off the virus. This rarely results in infertility.

*Viral meningitis* –
this is one of the rarest of the common complications. It happens when the virus spreads through the bloodstream and infects the body’s central nervous system (brain and spinal cord).

*Inflamed pancreas (pancreatitis) –*
 pain will be experienced in the upper abdomen; this occurs in 1 out of 20 cases and is usually mild.

Electrocardiogram changes compatible with myocarditis are seen in 3%–15% of patients with mumps, but symptomatic involvement is rare. Complete recovery is the rule, but deaths have been reported.
If a pregnant woman contracts mumps in the first 12-16 weeks of her pregnancy, she will have a slightly increased risk of miscarriage.

Rarer complications of mumps include:

*Encephalitis –*
 the brain swells causing neurological issues. In some cases, this can be fatal. This is a very rare risk factor and affects just 1 in 6,000 cases.

*Hearing loss –*
 this is the rarest of all the complications affecting just 1 in 15,000.
Other less common complications of mumps include arthralgia, arthritis, and nephritis.

*Prevention*

*.Immunisation given on-time is the best method of preventing mumps.
*.The measles, mumps, rubella vaccine (MMR) is given as part of the immunisation schedule at 15 months and 4 years of age.
*.No mumps-only vaccine is available in New Zealand.
*.People with mumps are excluded from early childhood education, school and work until nine days after the appearance of swollen salivary glands to protect others from infection.
* Contacts of mumps cases, who are not immune to mumps e.g. those who are unvaccinated, are excluded from early childhood education, school and work until 25 days after the appearance of swollen glands in the last case they were in contact with.
*.Anyone born after the 1990s would most probably have been given the MMR vaccine but, if unsure.
*.MMR vaccine side effects
Most people given the MMR vaccine do not suffer side effects, and the disease itself cannot be contracted from the vaccine.
*.A small percentage might develop a rash or fever and possibly aches in their joints.

*.Preventing the spread of mumps*

*.There are a number of precautions that help prevent the spread of infection; these are:

*.Washing hands with water and soap frequently.

*.Not going into work/school until 5 days after the symptoms start.
*.Covering the nose and mouth with a tissue when sneezing or coughing.

Drug of choice | DOC

drug of choice
1. Enuresis      = imipramine
2. Rheumatic fever =penicillin
3. Paracetamol poisoning- :- - acetyl cysteine
4. acute bronchial- asthma :- salbutamol
5. acute gout :- NSAIDS
6. acute hyperkalemia:- calcium gluconate
7. severe DIGITALIS toxicity :-DIGIBIND
8. acute migraine :- sumatriptan
9. cheese reaction :- phentolamine
10. atropine poisoning :- physostigmine
11. cyanide poisoning :- amyl nitrite
12. benzodiazepine poisoning:- flumazenil
13. cholera :- tetracycline
14. KALA-AZAR :- lipozomal amphotericin- B
15. iron poisoning :- desferrioxamine 
16. MRSA :- vancomycin
17. VRSA :- LINEZOLID
18. warfarin overdose :- vitamin-K (NIPER- 2009)
19. OCD -  fluoxetine
20. alcohol poisoning :- fomepizole
21. epilepsy in pregnency :- phenobarbitone
22. anaphylactic shock :- Adrenaline
23. Malaria in Pregnancy-Chloroquine
24. Whooping Cough or Perteusis- Erythromycin
25. Kawasaki disease-IV Ig
26. Heparin Overdose-Protamine
27. Hairy Cell Leukemia-Cladirabine
28. Multiple Myeloma- Melphalan
29. CML-Imatinib
30. Wegner's granulomatosis-Cyclophosphamide
31. HOCM- Propranolol
32. Delirium Tremens-Diazepam
33. Drug Induced Parkinsonism-Benzhexol
34. Diacumarol Poisoning-Vit-K
35. Type-1 Lepra Reaction-Steroids
36. Type- 2 Lepra Reaction-Thalidomide
37.  Allergic Contect Dermatitis-Steroids
38. PSVT- 1st-Adenosine, 2nd-Verapamil, 3rd-Digoxin
39.  Z-E Syndrome- Proton Pump Inhibitor
40. Chancroid-Cotrimoxazole
41. Dermatitis Herpetiformis-Dapsone
42. Spastic Type of Cerebral Palsy-Diazepam
43. Herpis Simplex Keratitis-Trifluridine
44. Herpes Simplex Orolabialis-Pancyclovir
45. Neonatal Herpes Simplex-Acyclovir
46. Pneumocystis carinii Pneumonia-
47. Cotrimoxazole   -  Nodulo .
48. Trigeminal Neuralgia-Carbamezapine
49. Actinomycosis-Penicillin
50. Plague- Streptomycin
51. Opioid Withdrawal- Methadone 2nd-Clonidine
52.  Alcohol Withdrawal- Chlordiazepoxide 2nd Diazepam
53. Post Herpetic Neuralgia- Fluphenazine
54. WEST Syndrome-ACTH
55. Diabetic Diarrhoea- Clonidine
56. Lithium Induced Neuropathy-Amiloride Communicable Disease:
57. Tetanus: PEN G Na; TETRACYCLINE; (DIAZEPAM
58. Diphteria: PEN G K; ERYTHROMYCIN
59. Pertusis: ERYTHROMYCIN; AMPICILLIN
60. Meningitis: MANNITOL (osmotic diuretic); DEXAMETHASONE (anti-inflammatory); DILANTIN/PHENYTOIN (anti-convulsive); PYRETINOL/ENCEPHABO L (CNS stimulant)
61. Amoebic Dysentery: METRONIDAZOLE
62. Shigellosis: CO-TRIMOXAZOLE
63. Typhoid: CHLORAMPHENICOL
64. Rabies: LYSSAVAC, VERORAB
65. Immunoglobulins: ERIG or HRIg
66. Malaria: CHLOROQUINE
67. Schistosomiasis: PRAZIQUANTEL
68. Felariasis: DIETHYLCARBAMAZINE CITRATE
69. Scabies: EURAX/ CROTAMITON
70. Chicken pox: ACYCLOVIR/ZOVIRAX
71. Leptospirosis: PENICILLIN; TETRACYCLINE; ERYTHROMYCIN
72. Leprosy: DAPSONE, RIFAMPICIN
73. Anthrax: PENICILLIN
74. Tuberculosis: R.I.P.E.S.
75. Pneumonia: COTRIMOXAZOLE; Procaine Penicillin
76. Helminths: MEBENDAZOLE; PYRANTEL PAMOATE
77. Syphilis: PENICILLIN
78. Gonorrhea: PENICILLIN
79. Cystic Acne  -Retinoic aciddrug of choice 
1. Enuresis      = imipramine
2. Rheumatic fever =penicillin
3. Paracetamol poisoning- :- - acetyl cysteine
4. acute bronchial- asthma :- salbutamol
5. acute gout :- NSAIDS
6. acute hyperkalemia:- calcium gluconate
7. severe DIGITALIS toxicity :-DIGIBIND
8. acute migraine :- sumatriptan
9. cheese reaction :- phentolamine
10. atropine poisoning :- physostigmine
11. cyanide poisoning :- amyl nitrite
12. benzodiazepine poisoning:- flumazenil
13. cholera :- tetracycline
14. KALA-AZAR :- lipozomal amphotericin- B
15. iron poisoning :- desferrioxamine 
16. MRSA :- vancomycin
17. VRSA :- LINEZOLID
18. warfarin overdose :- vitamin-K (NIPER- 2009)
19. OCD -  fluoxetine
20. alcohol poisoning :- fomepizole
21. epilepsy in pregnency :- phenobarbitone
22. anaphylactic shock :- Adrenaline
23. Malaria in Pregnancy-Chloroquine
24. Whooping Cough or Perteusis- Erythromycin
25. Kawasaki disease-IV Ig
26. Heparin Overdose-Protamine
27. Hairy Cell Leukemia-Cladirabine
28. Multiple Myeloma- Melphalan
29. CML-Imatinib
30. Wegner's granulomatosis-Cyclophosphamide
31. HOCM- Propranolol
32. Delirium Tremens-Diazepam
33. Drug Induced Parkinsonism-Benzhexol
34. Diacumarol Poisoning-Vit-K
35. Type-1 Lepra Reaction-Steroids
36. Type- 2 Lepra Reaction-Thalidomide
37.  Allergic Contect Dermatitis-Steroids
38. PSVT- 1st-Adenosine, 2nd-Verapamil, 3rd-Digoxin
39.  Z-E Syndrome- Proton Pump Inhibitor
40. Chancroid-Cotrimoxazole
41. Dermatitis Herpetiformis-Dapsone
42. Spastic Type of Cerebral Palsy-Diazepam
43. Herpis Simplex Keratitis-Trifluridine
44. Herpes Simplex Orolabialis-Pancyclovir
45. Neonatal Herpes Simplex-Acyclovir
46. Pneumocystis carinii Pneumonia-
47. Cotrimoxazole   -  Nodulo .
48. Trigeminal Neuralgia-Carbamezapine
49. Actinomycosis-Penicillin
50. Plague- Streptomycin
51. Opioid Withdrawal- Methadone 2nd-Clonidine
52.  Alcohol Withdrawal- Chlordiazepoxide 2nd Diazepam
53. Post Herpetic Neuralgia- Fluphenazine
54. WEST Syndrome-ACTH
55. Diabetic Diarrhoea- Clonidine
56. Lithium Induced Neuropathy-Amiloride Communicable Disease:
57. Tetanus: PEN G Na; TETRACYCLINE; (DIAZEPAM
58. Diphteria: PEN G K; ERYTHROMYCIN
59. Pertusis: ERYTHROMYCIN; AMPICILLIN
60. Meningitis: MANNITOL (osmotic diuretic); DEXAMETHASONE (anti-inflammatory); DILANTIN/PHENYTOIN (anti-convulsive); PYRETINOL/ENCEPHABO L (CNS stimulant)
61. Amoebic Dysentery: METRONIDAZOLE
62. Shigellosis: CO-TRIMOXAZOLE
63. Typhoid: CHLORAMPHENICOL
64. Rabies: LYSSAVAC, VERORAB
65. Immunoglobulins: ERIG or HRIg
66. Malaria: CHLOROQUINE
67. Schistosomiasis: PRAZIQUANTEL
68. Felariasis: DIETHYLCARBAMAZINE CITRATE
69. Scabies: EURAX/ CROTAMITON
70. Chicken pox: ACYCLOVIR/ZOVIRAX
71. Leptospirosis: PENICILLIN; TETRACYCLINE; ERYTHROMYCIN
72. Leprosy: DAPSONE, RIFAMPICIN
73. Anthrax: PENICILLIN
74. Tuberculosis: R.I.P.E.S.
75. Pneumonia: COTRIMOXAZOLE; Procaine Penicillin
76. Helminths: MEBENDAZOLE; PYRANTEL PAMOATE
77. Syphilis: PENICILLIN
78. Gonorrhea: PENICILLIN
79. Cystic Acne  -Retinoic acid

National medical commission (MNC) | National medical commission act

Cabinet approves the National Medical Commission (NMC) Bill The Cabinet today approved the National Medical Commission Bill which seeks to replace existing apex regulator of medical education, MCI by a new advisory body called the National Medical Commission (NMC). The bill now will be tabled in Parliament for approval by the Loksabha and the Rajyasabha in upcoming sessions. Some of the salient features of the NMC Bill are: 1. The NMC, which would replace the MCI, will have four autonomous boards tasked with conducting undergraduate and postgraduate education, assessing and rating medical institutions, registering practitioners and enforcing medical ethics. 2. Unlike MCI where all members were elected, only five members of the NMC will be elected while the others will be nominated by the government. The government will be the second appellate authority in case disputes arise. 3. The NMC shall comprise a chair person, 9 ex-officio members and 10 part time members. 4. All doctors must be registered in the National Register to practice in the country. 5. An exit examination, called National Licentiate Examination, is compulsory for all MBBS graduates to clear for the purpose of grant of a licence to practice and enrolment in Medical Register(s). This exam will also be used as the entrance examination for post graduate admissions.

IMPORTANT POINTS for PG

#IMPORTANT_POINTS...
1. PAP smear - cervical cancer
2. Serum amylase - pancreas
3. Painful menstruation - Dysmenorrhoea
4. Natural method of FP - colender method
5. Longest portion of FT - Ampulla
6. Killed vaccine except - BCG
7. >100 pulse rate - tachycardia
8. Drug in anaphylaxis - adrenaline
9. TB spread by - droplet
10. Uterus above symphysis - 14 wk
11. Hydrocele - scrotum
12. Decrease platelets in - dangue fever
13. B.P. - sphignomenometer
14. Male sex hormone - testosterone
15. Myopia - concave lense
16. Duration of pregnancy - 280 days
17. Ripeness of cervix - Bishop score
18. Chief regulator of immune cell - Heller T
cell
19. Hydronephrosis - Dilatation of kidney
20. Isotonic - 0.9%
21. PPH - >500ml
22. Dangue - Adese species
23. M/C/C of blindness in India - cataract
24. Central incisior - 6 month
25. Pulse rate increase in sleeping -
Hyperthyroidism
26. Organ in ECG - Heart
27. BMI Obase - >30
28. PH of blood - 7.4
29. Nutrition provide by - placenta
30. Pasteurization - milk
31. NFWP - 1952
32. TB - Rifampicine
33. Distal blood vessels - dorsalis pedis
34. Insuline - SC
35. Second stage of labour - expulsion of fetus
36. Pacemaker - S.A. node
37. Plasma protein oncotic pressure -
Albumine
38. Chief site of ectopic pregnancy - Tubal
39. JVP point - suprasternal notch
40. Weaning - 6 M
41. Fern Test - Ovulation
42. Chief sourse of progesterone - Ovary /
adrenal cortex
43. Bartholine gland - Vagina
44. Bleeding Disorder - Hemophilia
45. Confirm pregnancy hormone - HCG
46. Main muscles of inspiration - Diaphragm
47. TORCH except - Tetanus
48. ORS mainly contain - sodium & glucose
49. 70 kg total body water - 42 lit.
50. Eradicate disease - small pox
51. Position in perineal operation - lithotomy
52. Neonate peroid - up to 28 days
53. Hypothyroidism - critinism
54. Wt. increase in pregnancy - 12 - 13 kg
55. Bitot spot - Vit A
56. Neutralize bad odor - deodorant
57. Epistaxis - Nose
58. Base of brain gland - pituitary gland

Ventilator

What Is a Ventilator?

A ventilator (VEN-til-a-tor) is a machine that supports breathing. These machines mainly are used in hospitals. Ventilators:

what is purpose of ventilator ?
1.Get oxygen into the lungs.
2.Remove carbon dioxide from the body.
3.Help people breathe easier.
4.Breathe for people who have lost all ability to breathe on their own.
5.A ventilator often is used for short periods, such as during surgery when you're under general anesthesia.
6.A ventilator also may be used during treatment for a serious lung disease or other condition that affects normal breathing.

A ventilator doesn't treat a disease or condition. It's used only for life support.

Other Names for a Ventilator?
1.Mechanical ventilator
2.Respirator
3.Breathing machine

How Does a Ventilator Work?

1.Ventilators blow air—or air with extra oxygen—into the airways and then the lungs. The airways are pipes that carry oxygen-rich air to your lungs. They also carry carbon dioxide, a waste gas, out of your lungs.
2.The Breathing Tube
A ventilator blows air into your airways through a breathing tube. One end of the tube is inserted into your windpipe and the other end is attached to the ventilator. The breathing tube serves as an airway by letting air and oxygen from the ventilator flow into the lungs.
3.The Ventilator
A ventilator uses pressure to blow air or a mixture of gases (like oxygen and air) into the lungs. This pressure is known as positive pressure. You usually exhale (breathe out) the air on your own, but sometimes the ventilator does this for you too.
A ventilator can be set to "breathe" a set number of times a minute. Sometimes it's set so that you can trigger the machine to blow air into your lungs. But, if you fail to trigger it within a certain amount of time, the machine automatically blows air to keep you breathing.

MODE of ventilator

1 Volume controlled continuous mandatory ventilation
2 Volume controlled intermittent mandatory ventilation
3 Pressure controlled continuous mandatory ventilation
4 Pressure controlled intermittent mandatory ventilation
5 Continuous spontaneous ventilation


1.Volume controlled continuous mandatory ventilation
(I).....Volume controlled continuous mandatory ventilation (VC-CMV -        formerly known as assist control)
Continuous mandatory ventilation — (CMV) is a mode of mechanical ventilation where breaths are delivered based on set variables. In previous nomenclature CMV referred to "controlled mechanical ventilation", a mode of ventilation characterized by a ventilator that makes no effort to sense patient effort. In continuous mandatory ventilation CMV the ventilator can be triggered by the patient or mechanically by the ventilator. The ventilator is set to deliver a breath according to parameters selected by the operator. CMV may be uncomfortable for the patient. "Assist control" or "controlled mechanical ventilation" are outdated terms for CMV, which is now accepted standard nomenclature.
Volume-controlled CMV,
Limits in VC-CMV may be set and pressure based. The ventilator will attempt to deliver the set tidal volume utilizing whatever pressure is required to reach its setting. A pressure limit may be added to limit damage to the lungs (barotrauma).

2.Volume controlled intermittent mandatory ventilation
(I) ...Synchronized intermittent mechanical ventilation (SIMV)

Intermittent Mandatory Ventilation (IMV) refers to any mode of mechanical ventilation where a regular series of breaths are scheduled but the ventilator senses patient effort and reschedules mandatory breaths based on the calculated need of the patient. Similar to continuous mandatory ventilation in parameters set for the patients pressures and volumes but distinct in its ability to support a patient by either supporting their own effort or providing support when patient effort is not sensed. IMV is frequently paired with additional strategies to improve weaning from ventilator support or to improve cardiovascular stability in patients who may need full life support.

(II) ...Mandatory minute ventilation (MMV)
Mandatory minute ventilation (MMV) (also called minimum minute ventilation) is a mode of mechanical ventilation which requires the operator to determine what the appropriate minute ventilation for the patient should be and the ventilator then monitors the patient's ability to generate this volume. If the calculation suggests the volume target will not be met, supplemental breaths are delivered at the targeted volume to achieve the desired minute ventilation.
3.Pressure controlled continuous mandatory ventilation
 (I).... Pressure controlled continuous mandatory ventilation (PC-CMV)   formerly known as simply pressure control ventilation.
Continuous mandatory ventilation — (CMV) is a mode of mechanical ventilation where breaths are delivered based on set variables. In previous nomenclature CMV referred to "controlled mechanical ventilation", a mode of ventilation characterized by a ventilator that makes no effort to sense patient effort. In continuous mandatory ventilation CMV the ventilator can be triggered by the patient or mechanically by the ventilator. The ventilator is set to deliver a breath according to parameters selected by the operator. CMV may be uncomfortable for the patient. "Assist control" or "controlled mechanical ventilation" are outdated terms for CMV, which is now accepted standard nomenclature.
4.Pressure controlled intermittent mandatory ventilation
 (I)....Airway pressure release ventilation (APRV)
Airway pressure release ventilation (APRV) is a pressure control mode of mechanical ventilation that utilizes an inverse ratio ventilation strategy. APRV is an applied continuous positive airway pressure (CPAP) that at a set timed interval releases the applied pressure. Depending on the ventilator manufacturer, it may be referred to as BiVent. This is just as appropriate to use, since the only difference is that the term APRV is copyrighted.

 (II).....Pressure regulated volume control (PRVC)
Dual-control modes of ventilation are auto-regulated pressure-controlled modes of mechanical ventilation with a user-selected tidal volume target. The ventilator adjusts the pressure limit of the next breath as necessary according to the previous breath's measured exhaled tidal volume. Peak airway pressure varies from breath to breath according to changes in the patient's airway resistance and lung compliance.
The pressure waveform is square, and the flow waveform is decelerating. This mode is a form of continuous mandatory ventilation as a minimum number of passive breaths will be time-triggered, and patient-initiated breaths are time-cycled and regulated according to operator-set tidal volume.
The first few breaths are delivered to the patient according to the ventilator manufacturer's particular algorithm for determining the patient's resistance and compliance. These are 'test breaths' that the ventilator can then use to calculate the optimal pressures for the next, regulated breaths. The pressure is constant during the set inspiratory time as with pressure-controlled CMV. The ventilator will use the exhaled tidal volume measured at the end of that breath's expiratory phase to calculate the pressure of the next breath. If the exhaled tidal volume is lower than the software threshold, the next breath will be delivered at a higher pressure, and if the exhaled tidal volume is higher than the software threshold, the next breath will be delivered at a lower pressure.


(III).....Proportional assist ventilation (PAV)

Intermittent Mandatory Ventilation (IMV) refers to any mode of mechanical ventilation where a regular series of breaths are scheduled but the ventilator senses patient effort and reschedules mandatory breaths based on the calculated need of the patient. Similar to continuous mandatory ventilation in parameters set for the patients pressures and volumes but distinct in its ability to support a patient by either supporting their own effort or providing support when patient effort is not sensed. IMV is frequently paired with additional strategies to improve weaning from ventilator support or to improve cardiovascular stability in patients who may need full life support.

(IV)....Adaptive support ventilation (ASV)

5.Continuous spontaneous ventilation

(I),,,,,Continuous positive pressure ventilation (CPPV or sometimes Cpap.

Continuous spontaneous ventilation is any mode of mechanical ventilation where every breath is spontaneous (i.e., patient triggered and patient cycled).

Dependent modes
Some modes of mechanical ventilation require spontaneous ventilation, some of these include:
Bilevel positive airway pressure (BPAP, BiPAP®)
Continuous positive airway pressure (CPAP)
Airway pressure release ventilation[1] (APRV,
 (II)...Bilevel positive pressure ventilation (BPAP or sometimes, though unrecommended "BiPap"
Continuous spontaneous ventilation is any mode of mechanical ventilation where every breath is spontaneous (i.e., patient triggered and patient cycled).

Dependent modes
Some modes of mechanical ventilation require spontaneous ventilation, some of these include:

Bilevel positive airway pressure (BPAP, BiPAP®)
Continuous positive airway pressure (CPAP)
Airway pressure release ventilation[1] (APRV,

What Are the Risks of Being on a Ventilator?
1.Infections
2.Pneumothorax
3.Lung damage
4.Oxygen toxicity

MECONIUM ASPIRATIONS SYNDROME

      MECONIUM ASPIRATIONS                                 SYNDROME          


The Meconium aspiration syndrome is a respiratory disorder occurring in the newborn babies.
 MAS develops when the meconium is inhaled by the babies when they are in the womb or during the labor.
 Due to which meconium is trapped in the airways and lungs that causes suffocation during respiration.

*Meconium* is a sterile fecal material dark green in color that is produced in the intestine of the fetus before the labor.
It consists of intestinal epithelial cells, mucus, lanugo, and intestinal secretions such as bile.

Usually, the meconium is expelled out after 1-2 days when the mother starts feeding the baby.
 In some cases, it comes out from the intestine into the amniotic fluid before the delivery of a baby due to intrauterine stress.
 In such situation, the meconium-stained amniotic fluid (MSAF) is aspirated by the fetus into the airways of the lungs.
This is known as Meconium aspiration syndrome (MAS).
 MAS makes the baby suffer from difficulty breathing.
It affects the surfactants in alveoli and causes collapsed airways finally leads to respiratory distress.

*Causes*


*.Aging of the placenta if the labor happens far the due date
*.Prolonged labor
*.Umbilical cord compression due to changing position of baby
* Shortage in oxygen supply to the fetus in the womb due to cord compression
*.Decreased oxygen supply in babies increase the intestinal activity and cause relaxation of the anal sphincter
* Overdue date or postmaturity
* Underdeveloped circulatory system or abnormal blood pressure in the fetus
* Difficult labor
* Uterine stress
* Chronic respiratory condition in the pregnant woman

*Risk factors*

*.Placental insufficiency
* Maternal hypertension
* Drug abuse, especially tobacco and cocaine during pregnancy
* Preeclampsia
*.Oligohydramnios
*.Uterine infections
* Acidosis
* Maternal diabetes

*Symptoms*

* Before or at the time of birth  notice the common symptoms and signs of MAS includes:

*.Dark green streaks or stains or meconium appears in the amniotic fluid
*.Baby’s skin colour changes into blue (cyanosis) or green due to the staining of meconium
*.Breathing problems such as fast breathing (tachypnea), labored (difficulty) breathing, or breath apnea
*.Before birth, baby’s heart rate will be low
* Limpness in the baby
*.Staining of Amniotic fluid as greenish yellow
* Baby shows low Apgar score. This indicates the severe stress during the birth process


*Complications*

The possible complications associated with Meconium Aspiration Syndrome include:

*.Chronic lung disease in babies who are severely affected with MAS
*.Some babies who are affected severely with MAS may lose their sense of hearing or they may have developmental abnormalities such as bronchopulmonary dysplasia, cerebral palsy, seizures and hypoxic brain damage.
*.Brain damage may occur if oxygen supply is cut off for too long time
*.Neurological damage
*.Baby’s breath may affect because of irritation to the lung tissue.
It is due to the blockage of meconium in the airway or by infection. This leads to the inactivation of lung surfactant ( the natural substance that filled in the lungs to keep the air sacs open)
*.Collapsed lungs


*.Diagnosis:-

*.Diagnosis for MAS is conducted through the following tests such as follows:

*.Blood gas analysis test to know the enough supply of oxygen to baby
*.The chest X-ray to see the streaky or patches which show meconium entered in the baby’s lungs
*.May use a stethoscope on baby’s chest to listen the abnormal breath sounds mainly coarse and crackly sounds
*.The Laryngoscope is inserted into the throat to observe the vocal cords and to see the meconium stain in the vocal cords.

*Treatment*


*.After birth, if the baby is active and crying, no treatment is needed.
*.There skilled physician should be available to review infants during delivery to check whether the meconium is found in amniotic fluid.

*.If the baby is not active and not crying, the suction tube is inserted into the trachea and it is suctioned until the meconium content is not seen in suction tube.

*.If the baby is not breathing properly or heart rate is low, the skilled team will help the baby to breath by placing a face mask that is attached to a bag and an oxygen mixture which will inflate the baby’s lung.

* The baby is kept in special care in neonatal intensive care (NICU) for a few days to monitor and to treat.

*Other treatments may include*

*.Antibiotics (ampicillin and gentamycin) are given to get away from infections
*.IV to support nutritional requirements
*.Breathing support using ventilator is to keep the baby’s lungs inflated
*.Radiant warmers to keep control body temperature
*.In case the above machines fails the Extra Corporeal
Membrane Oxygen (ECMO) is used as an artificial heart and lung machine to support delivery of oxygen to new born.

*Prevention*

Preventive methods are as follows

*.Intrapartum suctioning ( After head delivered, immediately suctioning has to be carried out)

*.Antenatal monitoring of the fetus and placenta in post-maturity births

*.Tracheal intubation and suctioning in severe respiratory distress

ASTIGMATISM

                       ASTIGMATISM


Astigmatism is the defects in the curvature of the cornea.
If the curvature of the cornea and lens is mismatched, this will allow the light inside eye in different angles.
 This condition leads eye discomfort, headaches and blurred or fuzzy vision.

*Types*

There are several types but three most common types are as follows:

*Myopic:*
 The one or two principal medians are near sighted.
Should both the meridians be near sighted, they are myopic in changing degree.

*Hyperopic:*
 one or two principal medians are far sighted. Should both the meridians be farsighted, they are hyperopic in changing degree.

*Mixed:*
 One principal meridian is near sighted and the other is farsighted.

*Risk factors*


It occurs in both children and adults.
Risk may be higher if a person has any of the following:

*.Family history of astigmatism and eye disorders such as keratoconus
Thinning or cone shaped of your cornea
*.Excessive near sightedness, which creates blurry vision at a distance
*.Excessive farsightedness, which creates blurry close-up vision
*.A history of eye surgery, such as cataract surgery (surgical removal of a clouded lens)

*Causes*

It is mainly caused by the irregular shape of the cornea, which is called corneal astigmatism.
 It might be from the birth or later in life due to injury, disease and surgery in the eye.
The exact cause is unknown. In a few cases, it is caused by the shape of the lens inside the eye which is called *lenticular astigmatism.*


*.In rare cases the astigmatism is caused by a rare condition called keratoconus in which the cornea become thinner and cone shaped.
 This leads to loss of vision that cannot be corrected with eyeglasses.
 Usually keratoconus condition needs contact lenses to get clear vision and may need a corneal transplant.

*Symptoms*


Symptoms include:

*.Blurred or distorted vision
*.Eyestrain or discomfort
*.Headaches
*.Difficulty with night vision
*.Squinting


*Diagnosis*

*.Astigmatism is commonly diagnosed by comprehensive eye examination.
*.This examination undergoes for measuring how the eyes focus light and it determines the power of the lenses required for better vision.
*The tests may include:*

*Visual acuity test:*

This assessment text will be conducted by asking the patient to read the letter from the chart at a particular distance to examine how well patient can see the letters.

*Keratometry:*

It is the instrument used to measure the curvature of the cornea by focusing the light on the cornea and it calculates the reflection of the light.
From the results of reflection, it is possible to determine the curvature of the cornea surface.
These measurements are used to determine the proper fit for the contact lenses.

*Refraction:*

For refraction test the instrument called refractor is used.
  This machine contains multiple corrective glass lenses of different strengths.
To conduct the test patient should read a chart through the lenses which having different strengths on the optical refractor.
 At the end of the test will finds a lens that fits the patient’s vision.


*Treatment*


There are some several options available to get back clear visions.

*Contact lenses:*

Some people will get better vision with contact lenses rather than eyeglasses.
It provides cleaner vision and a broader view.
Though it is wears directly on eyes it needs proper care and cleaning of the lens to keep eyes safe.

*Eyeglasses:*

*.Mostly people use eyeglasses to improve their vision.
*.The cylindrical lens which is present in the eyeglasses will compensate astigmatism.
*.It provides additional power to the certain parts of the lens.

*Orthokeratology (Ortho k):*

*.It involves fitting the suitable lenses to reshape the cornea.
*. The patient wears contact lenses for a short period of time and removes after overnight.
*.People with moderate astigmatism will get a temporary clear vision in their daily activities.
*. Orthokeratology doesn’t give permanent cure.
*. If the patient stops wearing lenses, they may get back into their original condition.

*Laser and other refractive surgery procedures:*

*.Astigmatism can also be treated by reshaping the cornea by using two techniques such as LASIK (laser in situ keratomileusis) it removes tissue only from the inner layer of the cornea or PRK (photorefractive keratectomy).
*. It removes tissue from the superficial and inner layers of the cornea.

*Prevention*

*.There is no prevention for astigmatism.
But the regular preventive care will detect the problem early and keep the corrective lenses up to date.

*Adults should undergo periodic eye tests:*

*.Every 2-4 years between ages 40 and 55
*.Every 1-3 years from 55-65
*.Every 1-2 years after 65

Acanthosis Nigricans

Acanthosis Nigricans

Acanthosis nigricans is a condition characterized by abnormal thickening and darkening of the skin, especially in the armpit and around the groin and neck. It is most commonly associated with obesity or polycystic ovarian disease in women, though acanthosis nigricans can occasionally be found in people who have more serious underlying health problems or who are taking certain medications. Treatment of the underlying medical condition usually resolves the skin lesions.

*Who's at risk?*

Acanthosis nigricans can affect individuals of any age, including children and those of any ethnic background. However, it is more common in adults and in people with darker skin. Males and females are affected equally.

Groups of people who commonly develop acanthosis nigricans:

Overweight or obese personsPeople with endocrine (glandular) abnormalitiesPersons taking certain medications (for example, oral contraceptives, niacinamide, corticosteroids)Kidney transplant patientsPeople with internal malignancy, especially stomach cancer (very rare cause of acanthosis nigricans)

*What causes acanthosis nigricans?*

Acanthosis nigricans sometimes occurs in people who are otherwise in good health, particularly dark-skinned people of African descent. However, in most cases it's a sign of an underlying problem or condition such as obesity, diabetes or abnormal hormone levels. Some of the main causes of acanthosis nigricans are outlined below.

*Obesity*

Acanthosis nigricans is usually the result of obesity. This is known as obesity-associated acanthosis nigricans.

It occurs because obesity can cause insulin resistance (when the body is unable to properly use the hormone insulin), which may lead to high levels of insulin in the blood, affecting the skin cells.

Insulin resistance can also cause type 2 diabetes, so acanthosis nigricans can be an early sign that you have diabetes or are at risk of developing the condition

*Syndromes and hormone problems*

Acanthosis nigricans is sometimes associated with an underlying syndrome or hormone problem, such as:

polycystic ovary syndrome - a condition that affects how a woman's ovaries work, which can cause excessive body hair, irregular periods, infertility, acne and weight gainCushing's syndrome -symptoms such as weight gain, bruising and stretch marks caused by very high levels of the hormone cortisol in the bodyacromegaly -where the body produces too much growth hormone, leading to the excess growth of body tissues over timeunderactive thyroid (hypothyroidism) -where your thyroid gland does not produce enough hormones, causing symptoms such as tiredness and weight gainThis type of acanthosis nigricans is known as syndromic acanthosis nigricans.

*Medication*

Acanthosis nigricans is sometimes triggered by medicines, including insulin, corticosteroids, and hormone treatments such as human growth hormone or the contraceptive pill. This is known as drug-induced or medication-associated acanthosis nigricans.

*Genes*

In rare cases, acanthosis nigricans can be caused by a faulty gene inherited directly from your parents. This is known as familial or benign genetic acanthosis nigricans.

This type is usually passed on in an autosomal dominant pattern, which means it can be passed on if only one of your parents carries the faulty gene.

*Cancer*

If the dark skin patches come on suddenly and spread quickly, it may be a sign you have cancer (usually stomach cancer). This is known as malignant acanthosis nigricans. This is a rare condition that tends to affect middle-aged or elderly people, regardless of their weight or ethnic background. The patches are more severe and the mouth, tongue and lips may also be affected. The skin may also become irritated and itchy.

*Signs and Symptoms*

Dark, velvety patches

If you have acanthosis nigricans, you'll have thickened, brownish-grey or black patches of skin. 

The patches will be dry and rough, feeling similar to velvet. They may also be itchy. 

These patches may occur anywhere, but are usually seen around the neck, in the armpit, around the groin and sometimes in other skin folds. Occasionally, the skin over the joints of the fingers and toes may be affected, as well as the lips, palms of the hands and soles of the feet. 

The patches usually develop slowly over time. Patches that grow and spread quickly are more likely to be associated with cancer. In these cases, the mouth, tongue, throat, nose and windpipe may also be affected.

*Tiny growths on the skin*

You may also have lots of tiny finger-like growths from the patches. This is known as papillomatosis.

There may also be skin tags around the affected area. These are small flesh-coloured or pigmented growths that hang off the skin and look a bit like warts.

*Self-Care Guidelines*

Because most people who develop acanthosis nigricans are overweight, their skin lesions can improve dramatically and even resolve with weight loss. Other underlying medical conditions should be treated as well. 

*Other treatments that might help include:*

Weight loss by changing dietary and exercise habits.Over-the-counter preparations containing alpha-hydroxy acids, such as glycolic acid or lactic acid.Over-the-counter lotions containing salicylic acid.Over-the-counter creams containing urea.Over-the-counter cortisone cream (if the areas are itchy).

*When to Seek Medical Care*

If you notice thickening and darkening of the skin folds, it is probably a good idea to see your primary care provider. If the acanthosis nigricans is due to obesity, then you can have medical assistance developing healthy strategies to attain your weight goals. 

The sudden development of widespread acanthosis nigricans (involving the skin folds as well as the palms of the hands, the lips, and other, less typical areas) should prompt immediate medical attention. The doctor may be able to diagnose and treat a more serious underlying medical condition that is causing the acanthosis nigricans.

*Treatment*

The doctor will certainly try to establish the underlying cause of the acanthosis nigricans. If it is due to obesity, then assistance with weight loss may be in order. If obesity is not a factor, the physician may try to determine an underlying cause by ordering blood work, X-rays, or other diagnostic tests. 

Once the underlying medical condition has been established and is being treated, your physician may recommend a topical cream or lotion containing the following:

Prescription-strength alpha- or beta-hydroxy acids (glycolic acid, lactic acid, salicylic acid)Prescription-strength ureaA retinoid such as tretinoin, tazarotene, or adapaleneFor more severe, stubborn acanthosis nigricans, oral treatments may include:Dietary fish oilsIsotretinoin, a very strong medication with many potential side effects, usually used in the treatment of severe, scarring acneNot usually covered by insurance, some procedures to treat acanthosis nigricans include:Dermabrasion, a mechanical process of controlled, surgical scraping of the skinLasers that thin the skin by destroying the uppermost layers

*Outlook*

Most cases of acanthosis nigricans are harmless and not a sign of anything serious. The skin patches often fade with time as the underlying condition is treated. 

If you have inherited acanthosis nigricans from your parents, your patches may gradually get bigger before staying the same or eventually fading on their own. 

Only in cases where there is underlying cancer is the situation very serious. If the tumour is successfully treated, the condition may disappear, but unfortunately the types of cancer that cause acanthosis nigricans tend to spread quickly and a cure is often not possible.

IMPORTANT BODIES

IMPORTANT BODIES

Aschoff Bodies - rheumatic fever
Asteroid body - sporotrichosis
BABES - ERNST Bodies - metachromatic granules
BALBIANI'S Bodies – yolk nucleus
Bamboo bodies - asbestosis
Bodies OF ARANTIUS - aortic valve nodules
BODY OF HIGHMORE - mediastinum testis
Bollinger bodies - fowlpox
Brassy body – dark shrunken blood corpuscle
found in malaria
Call exners bodies – granulosa theca cell tumour
Chromatid bodies - entamoeba histolytica precyst
Citron bodies - cl. Septicum
Civatte bodies – lichen planus
Councilman bodies – hepatitis B
Coccoid X bodies – psittacosis
Creola bodies - asthma
Cystoid bodies – in degenerated retinal nerve
fibers ( seen in Cotton wool
spots)
Dohle bodies-sepsis,myelo dysplatic syndromes,chediak hegasi syndrome
Donnes bodies – colostrums corpuscles
Donovan bodies – granulose inguinale (LGV)
Dutchel bodies-multiple myeloma,intracellular IgG deposits
Ferruginous bodies – interstitial lung disease {asbestosis}
Gamma gandy bodies – congestive splenomegaly,CM
L,sickle cell sequestration crisis,liver cirrhosis
Guarnieri bodies - inclusion bodies of vaccinia
Henderson Peterson bodies - molluscum contagiosum
Harting bodies – calcospheritis in the cerebral capillaries
Heinz bodies – G 6 PD deficiency
Herring bodies –Normal-terminal ends of axons from hypothalamus-located in posterior pitutary
Heterophil antibodies – infectious mononucleosis
Hirano bodies – alzheimer’s disease
Howel jelly bodies-splenectomy,sickle cell anemia,megaloblastic anemia
Lewy bodies{ALPHA SYNOCLEIN] – parkinsonism
Levinthal coles lille bodies - psittacosis
Mallory bodies – alcoholic hepatitis
Masson bodies – rheumatic pneumonia
Michelis guttman bodies – malakoplakia
Mooser bodies – endemic typhus
Moot bodies – multiple myeloma
Negri bodies – rabies
Odland body – keratinosome
Oken’s body - mesonephros
Paschen bodies – vaccinia / variola
Pick bodies – picks disease
Psamomma bodies –1. papillary carcinoma of thyroid ,serous papillary carcinoma
of ovary.

SIALOLITHIASIS

SIALOLITHIASIS:-

Sialolithiasis or salivary stone or salivary calculi are a condition in which a mass of crystallized minerals are formed in the salivary ducts.
 Salivary duct stones can develop in all salivary glands, but most commonly in the submandibular glands, which are situated in the back of the mouth and both sides of the jaw.
There is a possibility of stone formation in the parotid gland but they are much rarer.
 Usually more than one stone is formed in the duct.



The size of the stone may range from a few mm to more than 2 cm and appears as round or oval rough or smooth solid masses. The color of the stone is usually yellowish or yellowish white.
As the saliva is rich in calcium, stones are typically made up of hydroxyapatite and calcium phosphate

CAUSE



The cause of sialolithiasis is still unknown, but there are some researchers suggest some factors that contribute to develop sialolith.
 Sialolithiasis may develop even  are in healthy person.

*.Dehydration can cause high viscosity and decreasing of water proportion in the saliva, which makes the calcium and phosphates present in the saliva to form a stone.
*.This stone obstructs the salivary duct and its gland.
* Yet there are some other factors that afford to this condition are as follows:

*.Salivary stagnation
*.Reduced food intake
*.Calcium salt precipitation
*.Epithelial injury near the salivary duct may create unwanted salivary stone
*.Less salivary secretion
*.Constant use of medications for anti-psychotic, anti-hypertensives and anti-histamine drugs which really affect the manufacture of saliva of the mouth.
*.Frequent use of diuretics and anticholinergics.
*.In some diseases like Sjorgen’s syndrome, lupus, and autoimmune disease attacks the salivary glands by the body’s own immune system.

Risk factors

*.Radiation therapy of the mouth
*.Trauma
*.Smoking
*.Gout
*.Hyperparathyrodism
*.Chronic periodontal disease

Clinical manifestations

*.People with salivary calculi tend to be asymptomatic however small segments have some symptoms.

*.Facial swelling
*.Swelling and pain around the jaw and ear
*.Painful lump under the tongue

*.Swelling of affected glands occurs while eating a food
*.Difficult in opening mouth
* Dry mouth
Bacterial infection occurs when the mouth glands are filled with stagnant saliva
*.Fever and chillness may associate with gland infections
*.Redness around the infected gland
*.Foul taste in the mouth

Diagnosis

 *.MAy ask for previous medical history.
Some infectious diseases such as mumps, Sjögren’s syndrome, sarcoidosis, or salivary gland tumour (unilateral swelling) might associate with sialolithiasis.

*.X-ray* –
The possible way to visualize the salivary stone is x-ray because the stone in the submandibular gland is rich in calcium phosphate as in bone. However, there are also other components in the salivary stone and is less likely to show the stones through X-ray.

*Sialography* –
 It is a technically superior to X-ray in identifying sialoliths. Sialography uses X-ray as similar to normal X-rays; however a contrast dye injected into the affected salivary gland         before the X-rays passed through. This dye is helpful in examining the anatomy of the salivary calculi.

*CT-Scan* –
 Computed tomography is used with a contrast dye injection before undergoing the scanning step.
 However CT is used in very rare cases having more than one stone in the duct.



Treatment:-

There are different options of treatment for sialolithiasis, which are dependent upon the size and location of the stones.
*.After the stones are diagnosed, the following home treatments are recommended initially.
 *.The goal of the treatment is to increase the salivary secretion and purge out the stones from the duct.


*Hydration* –
 Drinking plenty of water and sucking sugar free lemon drops.

*Warm compresses* –
 Applying heat on the stone

*Gland massage* –
Massaging the affected area
Use of antibiotics to stop the spread of infection
Surgery

Large salivary stones and deep located stones are difficult to force out from the duct by home treatments.
*. These stones are removed by cutting down the entire salivary gland, which is a traditional way of treating the sialolithiasis.
 May make enough spit (saliva) from remaining glands if one is removed. Later advances in the endoscopic techniques helped to treat the salivary stones in a less invasive ways.

*Therapeutic sialendoscopy.*

Endoscopy of salivary glands is also performed to remove the sialolith.
An endoscope with a camera and light, is inserted into the gland or duct and grabber tool is used to remove the stone from the duct. This procedure is performed by a doctor.
A local anesthetic is injected into the affected area.

*Extracorporeal Shock Wave Lithotripsy (ESWL)*


ESWL is an ultrasonic technique referred as ultrasonic lithotripsy, which uses ultrasound waves to break up the stone in the duct. The broken stones are allowed to pass through the same salivary gland. Since the effectiveness of this treatment is yet to be validated and so do not recommend often.

*Trans Oral Ductotomy*

This is the opening of the Wharton Duct for it to be cannulated and dilated so the stone can be completely removed through trans-oral approach.


Complications

*.Eating food is tedious work
*.Ulceration, fistula, and sinus tract in the affected area may develop a chronic form of sialolithiasis
*.Lobular fibrosis and necrosis of gland acini can occur which results in loss of salivary secretion in the glands.
* Acute suppurative sialoadenitis and duct narrowing (stricture)
*.Untreated sialolith for long term lead to painful infections, scarring, and forms abscess in the salivary gland.

Triad in medical

1.CHARCOT TRIAD

fever
Right upper quadrant pain
Jaundice

2. Reynold's pentad

Charcots triad + hypotention + altered mental status

Both seen in cholangitis

3. SAINTS TRIAD

gall stones
Diverticulosis
Hiatus hernia

4. Triad of portal hypertension

Varices
Ascites
Splenomegaly

5.MACKLER'S TRIAD

vomiting
Chestpain
Subcutaneous emphysema

Seen in Boehaaves syndrome

6. Beck's Triad

Muffled heart sound
Distended neck veins
Hypotension

Seen in cardiac tamponade

7. Galezia triad

Dupuytrens contracture
Peyronie,s disease of penis
Retroperitoneal fibrosis

IMPORTANT Questions | golden points for PG | Important points for PG

# IMPORTANT Questions #

Q.1.antidote of heparin
 Ans.protamine sulphate
 Q.2.drugs use in second stage of labour to improve uterine contraction
 Ans.oxytocin
 Q.3.acute panciatitis is manifested by
 Ans.eleveted serum amylase level
 Q.4.which t.b. drugs may cause damage 8th cranial nerve
 Ans.streptomycin
 Q.5.management of hyperkalamia
 Ans.insulin with glucose
 Q.6.absence of bowel sound may indicate
 Ans.paralytic illius
 Q.7.the normal intra occular pressure iop
 Ans.10-21 mm of hg
 Q.8.allen test performe to determine patency of
 Ans .radial ulnar ciculation
 Q.9.the most common risk of sever depression
 Ans.sucide
 Q.10.dumping syndrome is a complication of
 Ans.sub total gastrectomy
 Q.11.antidote of organo phosporus poisoning
 Ans.atropine
 Q.12.diaphram of stethospoce put on chest when appical pulse asssessment
 Ans.mitral area
 Q.13.iv canula size use in neonate
 Ans..24 num
 Q.14.noramal serum potasium level
 Ans.3.5-5.1
 Q.15.bleeding from nose
 Ans.epistaxis
 Q.16.another name of burger disease
 Ans.thromboangitis oblitrans
 Q.17.advise given in burger disease
 Ans.stop smoking
 Q.18.position provide in N G tube insertion
 Ans.high fowlers
 Q.18.goniometer use in
 Ans.assess rage of motion of joints
 Q.19.causative organism of peptic ulcer
 Ans.helicobactor pylori
 Q.20.ast is done which route
 Ans.intradermal id
 Q.21.appropriate needle size use in insulin administration
 Ans. 25 gauze 5/8 lon

DRUG OF CHOICE:-

1. Enuresis      = imipramine
2. Rheumatic fever =penicillin
3. Paracetamol poisoning- :- - acetyl cysteine
4. acute bronchial- asthma :- salbutamol
5. acute gout :- NSAIDS
6. acute hyperkalemia:- calcium gluconate
7. severe DIGITALIS toxicity :-DIGIBIND
8. acute migraine :- sumatriptan
9. cheese reaction :- phentolamine
10. atropine poisoning :- physostigmine
11. cyanide poisoning :- amyl nitrite
12. benzodiazepine poisoning:- flumazenil
13. cholera :- tetracycline
14. KALA-AZAR :- lipozomal amphotericin- B
15. iron poisoning :- desferrioxamine
16. MRSA :- vancomycin
17. VRSA :- LINEZOLID
18. warfarin overdose :- vitamin-K (NIPER- 2009)
19. OCD -  fluoxetine
20. alcohol poisoning :- fomepizole
21. epilepsy in pregnency :- phenobarbitone
22. anaphylactic shock :- Adrenaline
23. Malaria in Pregnancy-Chloroquine
24. Whooping Cough or Perteusis- Erythromycin
25. Kawasaki disease-IV Ig
26. Heparin Overdose-Protamine
27. Hairy Cell Leukemia-Cladirabine
28. Multiple Myeloma- Melphalan
29. CML-Imatinib
30. Wegner's granulomatosis-Cyclophosphamide
31. HOCM- Propranolol
32. Delirium Tremens-Diazepam
33. Drug Induced Parkinsonism-Benzhexol
34. Diacumarol Poisoning-Vit-K
35. Type-1 Lepra Reaction-Steroids
36. Type- 2 Lepra Reaction-Thalidomide
37.  Allergic Contect Dermatitis-Steroids
38. PSVT- 1st-Adenosine, 2nd-Verapamil, 3rd-Digoxin
39.  Z-E Syndrome- Proton Pump Inhibitor
40. Chancroid-Cotrimoxazole
41. Dermatitis Herpetiformis-Dapsone
42. Spastic Type of Cerebral Palsy-Diazepam
43. Herpis Simplex Keratitis-Trifluridine
44. Herpes Simplex Orolabialis-Pancyclovir
45. Neonatal Herpes Simplex-Acyclovir
46. Pneumocystis carinii Pneumonia-
47. Cotrimoxazole   -  Nodulo .
48. Trigeminal Neuralgia-Ca gluconate

Common Signs and Symptoms:-

*.Pulmonary Tuberculosis (PTB)—low-gradeafternoon fever.
*.Pneumonia—rust-colored sputum.
*.Asthma—wheezing on expiration.
*.Emphysema—barrel chest.
*.Kawasaki Syndrome—strawberry tongue.
*.Pernicious Anemia—red beefy tongue.
*.Down syndrome—protruding tongue.
*.Cholera—rice-watery stool and washer woman’s hands (wrinkled hands from dehydration).
*.Malaria—stepladder like fever with chills.
*.Typhoid—rose spots in the abdomen.
*.Dengue—fever,rash, and headache. Positive Herman’s sign.
*.Diphtheria—pseudomembrane formation.
*.Measles—Koplik’s spots (clustered white lesions on buccal mucosa).
*.Systemic Lupus Erythematosus—butterfly rash.
*.Leprosy—leonine facies (thickened folded facial skin).
*.Bulimia—chipmunk facies (parotid gland swelling).
*.Appendicitis—rebound tenderness at McBurney’s point. Rovsing’s sign (palpation of LLQ elicits pain in RLQ). Psoas sign (pain from flexing the thigh to the hip).
*.Meningitis—Kernig’s sign (stiffness of hamstrings causing inability to straighten the leg when the hip is flexed to 90 degrees), Brudzinski’s sign (forced flexion of the neck elicits a reflex flexion of the hips).
*.Tetany—hypocalcemia, [+] Trousseau’s sign; Chvostek sign.
*.Tetanus— Risus sardonicus or rictus grin.
*.Pancreatitis—Cullen’s sign (ecchymosis of the umbilicus), Grey Turner’s sign (bruising of the flank).
*.Pyloric Stenosis—olive like mass.
*.Patent Ductus Arteriosus—washing machine-like murmur.
*.Addison’s disease—bronzelike skin pigmentation.
*.Cushing’s syndrome—moon face appearance and buffalo hump.
*.Grave’s Disease (Hyperthyroidism)—Exophthalmos(bulging of the eye out of the orbit).
*.Intussusception—Sausage-shaped mass.
*.Multiple Sclerosis—Charcot’s Triad: nystagmus, intention tremor, and dysarthria.
*.Myasthenia Gravis—descending muscle weakness, ptosis (drooping of eyelids).
*.Guillain-Barre Syndrome—ascending muscles weakness.
*.Deep vein thrombosis (DVT)—Homan’s Sign.
*.Angina—crushing, stabbing pain relieved by NTG.
*.Myocardial Infarction (MI)—crushing, stabbing pain radiating to left shoulder, neck, and arms. Unrelieved by NTG.
*.Parkinson’s disease—pill-rolling tremors.
*.Cytomegalovirus (CMV) infection—Owl’seye appearance of cells (huge nucleus in cells).
*.Glaucoma—tunnel vision.
*.Retinal Detachment—flashes of light, shadow with curtain across vision.
*.Basilar Skull Fracture—Raccoon eyes (periorbital ecchymosis) and Battle’s sign (mastoid ecchymosis).
*.Buerger’s Disease—intermittent claudication (pain at buttocks or legs from poor circulation resulting in impaired walking).
*.Diabetic Ketoacidosis—acetone breathe.
*.Pregnancy Induced Hypertension (PIH)—proteinuria, hypertension, edema.
*.Diabetes Mellitus—polydipsia, polyphagia, polyuria.
*.Gastroesophageal Reflux Disease (GERD)—heartburn.
*.Hirschsprung’s Disease (Toxic Megacolon)—ribbon-like stool.
*.Sexual Transmitted Infections:
*.Herpes Simplex Type II—painful vesicles on genitalia
*.Genital Warts—warts 1-2 mm in diameter.
*.Syphilis—painless chancres.
*.Chancroid—painful chancres.
*.Gonorrhea—green, creamy discharges and painful urination.
*.Chlamydia—milky discharge and painful urination.
*.Candidiasis—white cheesy odorless vaginal discharges.
*.Trichomoniasis—yellow, itchy, frothy, and foul-smelling