Pearls in Medicine for Students PDF

Pearls in Medicine for Students “Great things are not done by impulse, but by a series of small things brought together” —Vincent van Gogh (1853 – 1890) By the Same Author: ————————————————————————————————————————————— Bedside Clinics in Medicine, Part I & Part II Multiple Choice Questions in Medicine and A Section on Online Appendix of “Kumar & Clark’s” Textbook, ‘Clinical Medicine’, 6th edition Pearls in Medicine for Students A Treasure Island in Medicine for Undergraduate and Postgraduate Students Arup Kumar Kundu MD FICP MNAS Associate Professor Department of Medicine and In-charge, Division of Rheumatology Nil Ratan Sircar Medical College Kolkata, West Bengal India ® JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD New Delhi Ahmedabad Bengaluru Chennai Hyderabad Kochi Kolkata Lucknow Mumbai Nagpur Published by Jitendar P Vij Jaypee Brothers Medical Publishers (P) Ltd B-3 EMCA House, 23/23B Ansari Road, Daryaganj, New Delhi 110 002 India Phones: +91-11-23272143, +91-11-23272703, +91-11-23282021, +91-11-23245672 Rel: +91-11-32558559 Fax: +91-11-23276490 +91-11-23245683 e-mail: [email protected], Visit our website: www.jaypeebrothers.com Branches 2/B, Akruti Society, Jodhpur Gam Road Satellite, Ahmedabad 380 015 Phones: +91-79-26926233, Rel: +91-79-32988717, Fax: +91-79-26927094 e-mail: [email protected] 202 Batavia Chambers, 8 Kumara Krupa Road, Kumara Park East, Bengaluru 560 001 Phones: +91-80-22285971, +91-80-22382956, +91-80-22372664, Rel: +91-80-32714073 Fax: +91-80-22281761, e-mail: [email protected] 282 IIIrd Floor, Khaleel Shirazi Estate, Fountain Plaza, Pantheon Road, Chennai 600 008 Phones: +91-44-28193265, +91-44-28194897, Rel: +91-44-32972089 Fax: +91-44-28193231, e-mail:[email protected] 4-2-1067/1-3, 1st Floor, Balaji Building, Ramkote, Cross Road, Hyderabad 500 095 Phones: +91-40-66610020, +91-40-24758498, Rel: +91-40-32940929 Fax:+91-40-24758499, e-mail: [email protected] Kuruvi Building, 1st Floor, Plot/Door No. 41/3098, B & B1, St. Vincent Road Kochi 682 018 Kerala, Phones: +91-484-4036109, +91-484-2395739 Fax: +91-484-2395740, e-mail: [email protected] 1-A Indian Mirror Street, Wellington Square Kolkata 700 013 Phones: +91-33-22651926, +91-33-22276404, +91-33-22276415, Rel: +91-33-32901926 Fax: +91-33-22656075 e-mail: [email protected] Lekhraj Market III, B-2, Sector-4, Faizabad Road, Indira Nagar, Lucknow 226 016 Phones: +91-522-3040553, +91-522-3040554, e-mail: [email protected] 106 Amit Industrial Estate, 61 Dr SS Rao Road, Near MGM Hospital, Parel Mumbai 400 012 Phones: +91-22-24124863, +91-22-24104532, Rel: +91-22-32926896 Fax: +91-22-24160828, e-mail: [email protected] “KAMALPUSHPA” 38, Reshimbag, Opp. Mohota Science College Umred Road, Nagpur 440 009 Phone: Rel: +91-712-3245220 Fax: +91-712-2704275 e-mail: [email protected] Pearls in Medicine for Students © 2008, Jaypee Brothers Medical Publishers All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the author and the publisher. This book has been published in good faith that the material provided by author is original. Every effort is made to ensure accuracy of material, but the publisher, printer and author will not be held responsible for any inadvertent error(s). In case of any dispute, all legal matters are to be settled under Delhi jurisdiction only. First Edition: 2008 ISBN 978-81-8448-269-0 Typeset at JPBMP typesetting unit Printed at Ajanta Offset to My daughter Ushasi My son Abhishek My beloved students for their constant inspiration and moral support and to my sick patients who have taught me the beauty of Medicine Preface I think myself a student even after learning medicine for more than two and half decades. Teaching a large number of students made me realize the need for such kind of book which deals with common medical presentations, and is lucid, handy, concise, updated as well as truly student-oriented. The aim of this book is to provide guidance for under- graduate and postgraduate students, and young physicians doing private practice or serving villages. This book is a distillation of my experience while answering questions for patients and health professionals over 25 years of practice. The manual consists of short descriptions of facts frequently encountered at the bedside, and I do believe that the cumulative symptomatology with differential diagnoses give a glimpse of real-life story of our day to day clinical practice. There are altogether 75 chapters in the book and each chapter may be regarded as a window of medicine; individual chapter also contains many jig-saw puzzles. The contents are arranged alphabetically while the index gives a wider idea about the matters or topics present in the book. To write a book as a single- handed author is a challenging task, and I am fully aware of this. ‘Pearls’ help us to crystallize knowledge in our memory very easily. I hope as well as expect that the book will be used as a quick-reference ready- reckoner handbook and a learning-revision tool to increase the core knowledge during early years of medical training. The problem-solving attitude will help the students in their theoretical as well as practical examination, and also in their professional life in future. I hope the extensive and beautiful colour photographs will boost the students while confronting with the patients at the bedside. This work would not have been possible without the constant support and encouragement from my family members, especially to speak of my wife Bijoya Kundu, my daughter Ushasi and son Abhishek, which ultimately made the book a reality. I would like to appreciate the attitude of my colleagues Dr SK Pal, Associate Professor and Dr P Chattopadhyay, Assistant Professor who helped by giving some interesting clinical viii Pearls in Medicine for Students photographs for presentation in the book. I am grateful to all my patients whose photographs are printed here, and to the MSVP, N.R.S. Medical College and Hospital for permitting me to take the photographs. I would also like to record my appreciation for Mr. Sandip Gupta, General Manager (Sales) and Mr. Sushil Shaw, Branch in-charge of Kolkata office for extending their cooperation in every step. My sincere thanks are extended to Shri JP Vij, CMD and Mr. Tarun Duneja, General Manager (Publishing), of M/S Jaypee Brothers Medical Publishers (P) Ltd, who have helped me throughout and also taken immense pain in publishing this book. I welcome healthy suggestions and constructive criticisms from the thoughtful readers through e-mail to me ([email protected]) or the publishers. Arup Kumar Kundu Contents 1. Abnormal Sweating............................................................................. 1 2. Alopecia.................................................................................................. 5 3. Alteration of Facial Contour.............................................................. 9 4. Angular Stomatitis............................................................................. 12 5. Aseptic Fever....................................................................................... 14 6. Bald Tongue........................................................................................ 18 7. Blackish Urine..................................................................................... 22 8. Blue Fingers/Toes............................................................................... 24 9. Blue Sclera........................................................................................... 28 10. Bull-neck............................................................................................... 32 11. Bruxism (Teeth Grinding)................................................................ 35 12. Claw Foot............................................................................................. 38 13. Coprolalia............................................................................................. 43 14. Cough.................................................................................................... 45 15. Cramp.................................................................................................... 52 16. Depressed Bridge of the Nose........................................................ 56 17. Diffuse Aches and Pains.................................................................. 61 18. Diplopia................................................................................................ 64 19. Discoloured Teeth.............................................................................. 67 20. Drop Attacks........................................................................................ 69 21. Erectile Dysfunction (Impotence)................................................... 72 22. Eyes: a Clue to Diagnosis................................................................ 77 23. Face Reading....................................................................................... 82 24. Facial Pain............................................................................................ 93 25. Fatigue................................................................................................... 97 x Pearls in Medicine for Students 26. Flushing of Face............................................................................... 100 27. Foul Breath......................................................................................... 103 28. Genital Ulcer..................................................................................... 106 29. Gingival Bleeding............................................................................ 110 30. Gum Hypertrophy............................................................................ 113 31. Hardness (Thickening) of Skin..................................................... 115 32. Head-nodding.................................................................................... 118 33. Heel Pain............................................................................................ 120 34. Herpes Labialis................................................................................. 123 35. Hiccough............................................................................................. 127 36. Hirsutism............................................................................................ 130 37. Hoarseness of Voice........................................................................ 135 38. Hyperkeratosis of Palms................................................................. 139 39. Hypertelorism.................................................................................... 142 40. Indigestion (Dyspepsia).................................................................. 144 41. Intermittent Claudication............................................................... 148 42. Joint Pain............................................................................................ 152 43. Leg Ulceration................................................................................... 160 44. Lock Jaw............................................................................................. 163 45. Lump in Right Iliac Fossa.............................................................. 165 46. Macroglossia...................................................................................... 170 47. Nerve Thickening............................................................................. 174 48. Night Blindness................................................................................ 177 49. Nocturnal Enuresis........................................................................... 180 50. Pallor................................................................................................... 186 51. Parotid Swelling............................................................................... 188 52. Patch Tonsil....................................................................................... 191 53. Photosensitivity................................................................................. 193 54. Polycythemia..................................................................................... 197 55. Pruritus............................................................................................... 201 Contents xi 56. Ptosis................................................................................................... 206 57. Purpuric Spots................................................................................... 210 58. Purse-lip Respiration....................................................................... 215 59. Rectal Bleeding................................................................................. 219 60. Recurrent Oral Ulcers...................................................................... 222 61. Red Urine........................................................................................... 226 62. Rings around Cornea....................................................................... 230 63. Shake Hands with the Patient...................................................... 233 64. Sneezing, Yawning and Snoring.................................................. 237 65. Splinter Haemorrhage..................................................................... 241 66. Spoon-shaped Nails......................................................................... 247 67. Sternal (Bone) Tenderness............................................................. 250 68. Sudden Cardiac Death (SCD)........................................................ 252 69. Swollen Legs..................................................................................... 254 70. Tongue: a Clue to Many Diseases............................................... 260 71. Weight Gain/Loss............................................................................. 264 72. Wheeze/Stridor.................................................................................. 269 73. White Nails........................................................................................ 271 74. White (Milky) Urine........................................................................ 274 75. Yellowish Palms/Soles.................................................................... 276 Index..................................................................................................... 279 CHAPTER 1......................... Abnormal Sweating PROLOGUE The sweat glands are divided into two classes: a. Eccrine, and b. Apocrine gland. The eccrine glands are the major sweat glands in the body and are generally found throughout the surface. The glands present on palms and soles do not respond to temperature but secrete at the time of emotional stress. The apocrine glands are larger sweat glands and are found in axilla, areola of the nipples, mons pubis, labia majora, ear, eyelid and mammary gland. The eccrine glands are supplied anatomically by sympathetic fibres, yet they are functionally cholinergic (e.g. pilocarpine increases the flow of sweat and atropine abolishes sweating). The apocrine sweat glands respond to circulating adrenaline (these glands are of sexual significance and remain inactive until puberty). The daily total amount of sweat secreted by a human is approximately 480-600 ml, which may even rise to 10 litres in extremely hot weather. TYPES a. Sensible: When sweating is increased and evaporation stopped, drops of sweat appear on skin surface. b. Insensible (approximately 500 ml/day): The loss of water from skin surface is neither visible nor perceptible; it is not due to active secretion but occurs as a result of passage of water by diffusion of tissue fluid through the epidermis. 2 Pearls in Medicine for Students SWEATING MAY BE CLASSIFIED INTO (NORMAL PHYSIOLOGICAL RESPONSE) a. Thermal sweating → due to rise of external temperature and is controlled by thermoregulatory centre at hypothalamus. b. Emotional (mental) sweating → chiefly palms, soles and axillae are involved. c. Sweating due to muscular exercise/exertion → factors involved are thermal sweating + emotional sweating. d. Gustatory sweating → eating of spicy food may stimulate sweating in head and neck region. e. Miscellaneous → as a result of sympathetic overactivity, nausea/ vomiting, syncopal attack, hypoglycaemia and asphyxia. COMPOSITION OF HUMAN SWEAT A clear colourless fluid Specific gravity: 1.001 - 1.006; pH 3.8 to 6.5 Contains mainly water Solid present in sweat are lactic acid, carbolic acid, urea, creatinine, sugar, uric acid, nitrogen and non-protein nitrogen, calcium, iodine, iron, sulphur, copper, amino acids, sodium, chloride, potassium and others Sodium: 24-312 mg/dl and Chloride: 36-468 mg/dl HYPERHIDROSIS (GENERALISED) 1. Exercise, anxiety, pyrexia, hot climate. 2. Thyrotoxicosis, hyperpituitarism, acromegaly, carcinoid syndrome, pheochromocytoma, menopause, pregnancy, obesity. 3. Hypoglycaemia. 4. Acute myocardial infarction, heart failure, shock. 5. Tuberculosis, other infections/pyrogens, lymphoma, malignancy, rheumatoid arthritis. 6. Alcohol intoxication, antidepressant drugs, pilocarpine, opiates. 7. Intense pain, syncope. 8. Rickets, infantile scurvy. 9. Neurological lesions of cerebral cortex, basal ganglia, spinal cord and sympathetic nervous system; familial dysautonomia. Abnormal Sweating 3 LOCALISED HYPERHIDROSIS 1. Organic neurological lesions–brain tumour, spinal cord injury (may help to localise site of lesion), syringomyelia. 2. Localised sweating of palms, soles and axillae–hot weather, anxiety, psychoneurosis and embarrassment. 3. Dermatological disorders–dyshidrotic eczema, vitiligo, epidermolysis bullosa, palmo-plantar keratoderma, nail-patella syndrome. 4. Pachydermoperiostitis (or primary hypertrophic osteoarthropathy with grade IV clubbing + leonine face)–affects skinfolds of forehead and extremities. 5. Granulosis rubra nasi–rare genetic disorder; sweating of tip of the nose with a diffuse erythema associated with. ANHIDROSIS/HYPOHIDROSIS (GENERALISED) It is less common than hyperhidrosis. 1. Heat stroke 2. Ectodermal dysplasia 3. Scleroderma 4. Organic brain damage, especially of the hypothalamus 5. Ichthyosis 6. Anderson-Fabry’s disease 7. Miscellaneous: myxoedema, atopic eczema, psoriasis, lichen planus. ANHIDROSIS/HYPOHIDROSIS (LOCALISED) 1. Horner’s syndrome (involves half of the face, neck, front and back of upper chest, arm) 2. Diabetic or leprosy neuropathy * Autonomic neuropathy may lead to anhidrosis and/or gustatory sweating. COLD AND CLAMMY SKIN A classical physical finding in shock, and is due to sweating associated with cutaneous vasoconstriction; commonly found in: Hypoglycaemia Acute myocardial infarction Shock and syncopal states Alcohol withdrawal Dumping syndrome * First two conditions give rise to drenching perspiration. 4 Pearls in Medicine for Students ‘NIGHT SWEATS’ IN CLINICAL MEDICINE 1. Tuberculosis 2. Lymphoma 3. Chronic myeloid leukaemia 4. Brucellosis 5. Giant cell arteritis 6. AIDS 7. Nocturnal (sleeping) hypoglycaemia 8. Rheumatoid arthritis (rare). OSMIDROSIS (FOUL SMELLING SWEAT) The personal body odour is basically determined by apocrine gland secretion. Eccrine sweat is usually odourless. 1. Substances excreted in the sweat, e.g. garlic, drugs like dimethyl sulphoxide, arsenic, urea in renal failure (urhidrosis). 2. Hyperhidrosis of sole, complicated by bacterial overgrowth may give rise to foul odour in some persons. 3. Imaginary foul odour is perceived in paranoid delusion. 4. Others (as a result of bacterial overgrowth after sweat excretion): acute rheumatic fever, scurvy, gout, diabetes mellitus, pneumonia, enteric fever. CHROMHIDROSIS (COLOURED SWEAT) 1. Pigment produced by chromogenic bacteria. 2. 10% of normal people may have coloured apocrine sweat (yellow/ green/blue)–due to the pigment ‘lipofuscins’. 3. Drugs excreted through sweat, e.g. rifampicin. MILIARIA These are vesicles (sudmina)/papules (prickly heat) resulting from blockage and rupture of sweat ducts. These are commonly seen in tropical conditions of heat and high humidity. The clear vesicles contain sweat and are often found on the trunk during febrile illness (especially, when the body is covered by blanket during pyrexia), and is known as ‘sudaminal rash’. SWEAT TEST Pilocarpine iontophoresis test–done to diagnose cystic fibrosis by giving inj. pilocarpine to the patient with measuring the chloride concentration of the sweat → which is very high ( > 60 mEq/L) in cystic fibrosis. –––– o –––– CHAPTER 2......................... Chapter 5 Alopecia FIGUER 2.1: Chemotherapy-induced non-scarring alopecia (temporary relief of symptoms at the cost of hairs!) SYNONYM Loss of hair TYPES Two a. Scarring or cicatrical—permanent loss of hair follicle with replacement by scar tissue. b. Non-scarring—temporary loss of hair follicle and the scalp skin looks normal. 6 Pearls in Medicine for Students BASICS ‘Hair growth’ is influenced by → genetic, racial, nutritional and hormonal factors. ‘Hair loss’ may result from → changes in hair follicle due to follicular destruction/dysfunction or fracture of fibres. CAUSES Scarring or Cicatrical Discoid lupus erythematosus (DLE) Tinea capitis with inflammation (kerion) Lichen planus Imflammatory: bacterial folliculitis Idiopathic: ‘pseudopelade’ Folliculitis decalvans Scleroderma X-irradiation Trauma or chemical damage Neoplasm Congenital (aplasia cutis). Non-scarring Androgenetic alopecia (male-pattern baldness) Alopecia areata Telogen effluvium Traction alopecia Tinea capitis Trichotilomania (self-induced hair-pulling) Lymphoma, leukaemias Cosmetic treatment Bullous pemphigoid Metabolic: iron deficiency anaemia, hypothyroidism, diabetes mellitus Drugs: anticancer chemotherapy, oral contraceptive pills, heparin, isotretinoin. TRACTION ALOPECIA ‘Mechanical damage’ type of hair loss; from repeated tugging and pulling of the hair back into a bun or tight plating, and is usually caused by hair dressing styles or special headgear (e.g. turban wearing sikhs). Alopecia 7 PSEUDOPELADE No cause known. Atrophic, adherent, depressed scarred areas or irregular plaques are seen; stray hair present without any sign of inflammation → may gradually enlarge leaving a shiny scalp without any visible follicular orifice. TRICHOTILOMANIA (HAIR PULLING TICS) Unconscious twisting and pulling of scalp hair; partially alopecic area is formed with irregularly broken, twisted hair growing in different directions. TELOGEN EFFLUVIUM Diffuse hair loss occurring 3 months after pregnancy or a severe illness (e.g. septicaemia, typhoid meningism) → due to ‘stress’, putting all the hairs into the telogen phase of hair shedding at the same time. Full recovery with normal hair growth within a few months. ALOPECIA AREATA Localised or patchy hair loss which is sharply defined; immune-mediated → commonly seen in children or young adults with patches of baldness → broken ‘exclamation mark’ hair (i.e. narrow at the scalp, and wider and more pigmented at the tip) seen at the periphery of bald area is diagnostic → rare progression to total scalp (alopecia totalis) or the entire body (alopecia universalis). Regrowth may occur which is initially replaced by white hairs and may take months to cover the patchy area of baldness in alopecia areata. MALE-PATTERN BALDNESS Hair loss is seen primarily at vertex and bi-temporal region of scalp. The thinning of the hair is asymptomatic and gradual. This type of baldness is seen in females after menopause. MANAGEMENT 1. Reassurance as alopecia puts the person under social and psychological stress. 2. Wig, camouflage, creative hair style or hair prosthesis, autologous hair transplantation or hair grafting may be of help. 8 Pearls in Medicine for Students 3. Topical immunotherapy: allergic contact sensitization with dinitro- chlorbenzene (DNCB), diphencyprone or PUVA may be beneficial. 4. Steroids: topical steroids or intra-lesional injection of steroids (e.g. triamcinolone in alopecia areata) may be given. 5. Topical 2% minoxidil application or systemic finasteride may be of some help in androgenetic alopecia. –––– o –––– CHAPTER 3......................... Chapter 9 Alteration of Facial Contour FIGURE 3.1: Facial hemiatrophy (right): A patient of Parry-Romberg syndrome ASYMMETRY OF FACE 1. Hemiatrophy (e.g. linear scleroderma–en-coup de sabre) 2. Hemihypertrophy 3. Residual Bell’s palsy 4. Lipodystrophy 5. Unilateral facial oedema (angioneurotic oedema, postural) 6. Paget’s disease (osteitis deformans)–face seems to be an inverted triangle 10 Pearls in Medicine for Students FIGURE 3.2: Hypertrophied, deformed and asymmetrical left lower extremity (congenital) – unilateral macrosomia 7. Fibrous dysplasia 8. Absence of condyle of mandible (congenital) 9. Massive swelling of parotid gland (e.g. mixed parotid tumour, Mikulicz’s syndrome) 10. Acromegaly 11. Micrognathia (small mandible or receding chin)–e.g. Pierre Robin’s syndrome 12. Hemifacial spasm (irregular, painless, clonic contraction involving one half of face, and is commonly due to sequelae of Bell’s palsy, compressive lesion of facial nerve, trauma or demyelination) 13. Plexiform neurofibromatosis 14. Absence of teeth or bad (ill-fitted) dentures. * In Parry–Romberg syndrome, the facial hemiatrophy may be associated with atrophy of skin, tongue, gingiva, soft palate, subcutaneous fat, muscle, bone and cartilage of nose/ear; it is a variety of lipodystrophy. COMMON CAUSES OF BILATERAL FACIAL PALSY OF LMN TYPE (FACIAL DIPLEGIA) 1. Acute infective polyneuritis (Guillain-Barré syndrome) 2. Leprosy 3. Sarcoidosis 4. Forceps delivery 5. Leukaemia or lymphoma (deposits in parotids) Alteration of Facial Contour 11 6. Bilateral Bell’s palsy 7. Bilateral otitis media 8. Diphtheria * Myasthenia gravis and myopathy develop into facial weakness; there is no involvement of facial nerve. PROGNATHISM (BULL-DOG JAW OR LANTERN JAW) It is the prominence of mandible, and is diagnosed clinically by inspection and observing the lower incisors (mandible) protruding in front of the upper incisors (maxilla); it is seen in: 1. Acromegaly 2. Fragile-X syndrome 3. Nemaline myopathy 4. A particular variety of osteopetrosis. LIMB LENGTH INEQUALITY 1. Achondroplasia 2. Fibrous dysplasia 3. Congenital asymmetry (coxa vara, short femur/tibia) 4. Epiphyseal trauma 5. Dislocation of hip joint 6. Osteitis. UNILATERAL HEMIHYPERTROPHY Commonly known as Klippel-Trenaunay syndrome which is internally associated with a spinal cord vascular malformation and externally featured by haemangioma of the trunk or upper or lower extremity + hypertrophy of haemangiomatous limb. The cord lesion may bleed and leads to spinal sensorimotor paralysis. –––– o –––– 12 4......................... Pearls in Medicine for Students CHAPTER Angular Stomatitis DEFINITION Cracking with inflammation of the skin at the angle or corner of mouth. To start with, there is redness → fissuring → crusting. CLINICAL ASSOCIATIONS Excessive use of betel-leaf, tobacco, alcohol or chewing masala Improperly-fitted denture Iron deficiency anaemia (associated with glossitis and koilonychia) Riboflavin, nicotinic acid, folic acid or pyridoxine deficiency Starvation or malnutrition Herpes labialis, candidiasis or streptococcal infection at the angle of mouth Habitual lip-licking, especially in children * Angular stomatitis: leaves no scar on healing. PERLECHE Painful small fissures at the angle of mouth (angular cheilitis) Often covered with yellow crusts Associated with candidiasis or secondary syphilis. RHAGADES Linear scars at the angles of mouth and nose Commonly seen in congenital syphilis. Angular Stomatitis 13 SWOLLEN LIPS Injury Angioneurotic oedema Herpetic infection Urticarial rash Acromegaly. –––– o –––– 14 5......................... Pearls in Medicine for Students CHAPTER Aseptic Fever NON-INFECTIVE CAUSES OF FEVER 1. Drug fever–virtually any drug may produce unexplained pyrexia but the main drugs in the list are rifampicin, sulphonamides, methyldopa, procainamide, different vaccines, following anticancer chemotherapy 2. Connective tissue diseases, e.g. SLE, rheumatoid arthritis, poly- myalgia rheumatica, temporal arteritis, polyarteritis nodosa 3. Malignancies: Carcinomas (especially of lung, liver, and kidney) Lymphomas Leukaemias and other haematological malignancies 4. Thyroid storm 5. Pontine heamorrhage 6. Heat stroke 7. Crush injury 8. Over-atropinisation or dhatura poisoning 9. Acute myocardial infarction 10. Gout 11. Radiation sickness 12. Malignant hyperthermia (halothane-induced) or neuroleptic malignant syndrome (haloperidol-induced). FEVER ASSOCIATED WITH MACULO-PAPULAR RASH 1. Measles: Usually appears on the fourth day of illness, maculo-papular in type. Rash first appears at the back of the ears, and at the junction of skin and hair on the forehead; ultimately face, neck, trunk, limbs upto palms and soles may be affected. The density of rash is greatest Aseptic Fever 15 on the forehead. They are discrete, pink, and blanch on pressure. Later, the rashes become confluent and give rise to characteristic blotchy appearance (morbilliform rash). 2. Infectious mononucleosis: Rash in this disease usually follows the administration of penicillin or ampicillin for a presumed pharyngitis. Associated suggestive features are generalised lymphadenopathy along with splenomegaly. 3. Meningococcaemia: Usually the rash is haemorrhagic but for the first 12-24 hours it may occasionally be erythematous and maculo-papular simulating rash of measles. Usually it is a disease of children and young adults with characteristic short prodrome (unlike measles and scarlet fever), a rapidly changing rash, pallor and toxicity. 4. Toxic shock syndrome: This is a disease of females with staphylo- coccal infection, commonly associated with use of tampons. The patient is acutely ill with vomiting and diarrhoea, headache, and myalgia which progresses towards shock and rapidly developing maculo-erythematous rash. 5. Scarlet fever: The rash first appears behind the ears on the second day and rapidly becomes a generalised punctate erythema which is mostly abundant in flexures of the arms and legs. The affected children usually have a flushed face due to fever; the rash does not affect face. 6. Rubella: The rash (pink macules) usually begins on the second or third day on face and neck (like measles) but progresses much more rapidly than measles, and become generalised within 24-48 hours. Postauricular and occipital lymphadenopathy are characteristic. 7. Enteric fever: Rose spots are sparse, small rose-red, blanching, slightly raised macules mainly present over upper abdomen and chest during the end of the first week of illness. It is usually visible only on fair- skinned persons. Rarely, these rashes can evolve into non-blanching small haemorrhages. 8. Dengue: Primary rashes appear on the 3rd day of illness, which are erythematous (diffuse flushing) and present over face, neck and shoulder. Secondary or true rash are measly or morbilliform which appears on the 6th day of illness and is usually present over the dosrum of hands and feet. Ultimately, the rash becomes generalised (mostly over the trunk) except the face. The rash may persist from two hours to several days and terminates by desquamation. Classically, there is associated ‘saddle-back’ pyrexia. 16 Pearls in Medicine for Students 9. AIDS: A mononucleosis-like syndrome may be seen 2-6 weeks after acquisition of HIV infection. The rash (occurs in 50% patients) is macular, erythematous, and predominantly affects the trunk. The illness is associated with pyrexia, perspiration, lethargy, arthralgia, myalgia and generalised lymphadenopathy. 10. Typhus: Different varieties of typhus like epidemic and endemic typhus, Rocky Mountain spotted fever, scrub typhus and rickettsialpox are associated with pyrexia and rash. 11. Kawasaki disease: The affected children may have a polymorphous rash along with fever, conjunctivitis, red lips and red tongue, red indurated hands and cervical lymphadenopathy. PYREXIA OF UNKNOWN ORIGIN (PUO) Definition (by Petersdorf and Beeson, 1961): 1. Fever > 101°F on several occasions. 2. A duration of fever > 3 weeks. 3. Failure to reach a provisional diagnosis after one week of inpatient investigations or by three outpatient visits. Recently PUO has been classified into 4 different types (Durack and Street, 1991): 1. Classic PUO (as previous definition). 2. Nosocomial PUO (hospital-acquired). 3. Neutropenic PUO (when neutrophil count is ≤ 500/mm3). 4. HIV-associated PUO (e.g. tuberculosis, NHL, drug fever). CLINICAL EXAMINATION OF PUO WHICH NEEDS SPECIAL ATTENTION 1. Oral cavity: Teeth and gum for sepsis. 2. Thyroid: Enlargement and tenderness → thyroiditis. 3. Eye: Phlyctenular conjunctivitis and other manifestations of systemic disease. 4. Lymph nodes: With special attention to cervical and epitrochlear nodes. 5. Bone: Sternal tenderness, gibbus with tenderness. 6. Musculoskeletal system–Still’s disease, systemic onset juvenile idiopathic arthritis. 7. Skin: Rashes and nodules. 8. Blood vessels: Evidences of vasculitis/arteritis (temporal arteritis). Aseptic fever 17 9. CVS: Murmurs and pericardial rub. 10. Respiratory system: Pleural rub, basal pneumonia. 11. GI tract: Enlargement of liver, spleen or kidney; tenderness of renal angle. 12. Intercostal tenderness: Amoebic liver abscess/empyema thoracis. 13. Genitalia: Phimosis, discharge per urethra, any swelling, epididymitis (filarial/tubercular). 14. Per rectal or vaginal examination: Abscess, tumours. 15. Fundoscopy: Choroid tubercles. 16. Covered area, if any: Breast abscess, any sepsis under bandages/ plasters. POSSIBILITIES IN COMBINATION WITH ARTHRITIS, FEVER, AND RASH Viral infections (rubella, parvovirus B-19) Gonococcaemia or meningococcaemia Periodic fever syndrome Acute rheumatic fever Adult Still’s disease Sarcoidosis Serum sickness Secondary syphilis Familial Mediterranean fever Vasculitis Lyme diaease –––– o –––– 18 6......................... Pearls in Medicine for Students CHAPTER Bald Tongue FIGURE: 6.1: Bald tongue developing from iron deficiency anaemia DEFINITION Total loss or atrophy of the papillae resulting in a smooth or plane dorsum of the tongue. Bald Tongue 19 CLUE TO DIAGNOSIS 1. Iron deficiency anaemia (most common cause) ↓ H/O bleeding piles, menorrhagia or melaena; intake of NSAIDs; dietary history is important; enquire H/O ‘pica’ (eating of strange substances like mud, ice etc); working bare-footed (hookworm infestation)? ↓ Look for anaemia, glossitis, angular stomatitis, cheilosis, koilonychia, mild splenomegaly (rarely found) ↓ Enquire for dysphagia, specially in middle-aged women (Plummer- Vinson syndrome or Paterson-Kelly syndrome) ↓ Investigate: Blood for Hb%, peripheral smear, RBC morphology, colour index, serum Fe, TIBC, plus Stool for occult blood and hookworm ova ↓ Examine: Per rectally or per vaginally, associated with upper and lower GI endoscopy in search of a carcinoma of large gut/fibroid of uterus or peptic ulcer. 2. Pellagra Dermatitis found in nicotinic acid deficiency Seen in exposed part with erythema and desquamation There may be roughening and pigmentation Dermatitis in the neck (Casal’s collar) is pathognomonic Associated cheilosis, angular stomatitis and raw-beefy tongue 3. Pernicious anaemia ↓ Strict vegan or H/O gastrectomy ↓ H/O glossitis, cheilitis, tingling and numbness or premature graying of hair ↓ M = F, around age of 60 years ↓ Investigate: Peripheral blood smear with MCV, MCHC, RBC morphology (it is the commonest cause of vit B12 ↓ in temperate climate); histamine-fast achlorhydria, plus +ve Schilling’s test 20 Pearls in Medicine for Students 4. Tropical sprue ↓ Residents or visitors to tropical regions ↓ H/O malabsorption ↓ C/F like anorexia, diarrhoea, ↓ weight, anaemia and features of different nutritional deficiency like glossitis, cheilosis ↓ ↓ of Fe, folic acid and vit B12 ↓ Investigate: ↑ faecal fat, and +ve d-xylose absorption test ↓ +ve jejunal biopsy with shortened and thickened villi, ↑ crypt depth, infiltration of mononuclear cells in lamina propria and epithelium. 5. Syphilis ↓ Young adult with H/O exposure ↓ C/F like skin rash, condyloma lata, lymphadenopathy and snail track ulcers in mouth ↓ Along with the bald tongue, mucous patches in lips, oral mucosa, palate, pharynx, vulva, vagina, glans penis or inner prepuce may be seen ↓ Investigate: VDRL, Kahn test, FTA-ABS (fluorescent treponemal antibody-absorption) or TPI (treponema pallidum immobilisation test) * In iron deficiency anaemia (microcytic-hypochromic anaemia) MCV, MCH and MCHC are low; serum Fe is low but TIBC is increased. Pernicious anaemia is a macrocytic anaemia with high MCV, MCH and MCHC. MESSAGE Treat bald tongue mainly with Fe and vitamin B-complex * For the causes of ‘dry tongue’, read dry mouth under ‘Parotid swelling’. Bald Tongue 21 WHITE PATCHES IN TONGUE 1. Leukoplakia of tongue: Look for sharp teeth, ill-fitting dentures, sepsis (chronic infection), H/O chewing tobacco or smoking or consuming alcohol, syphilis (rare, nowadays) Pre-malignant condition Superficial layer of tongue shows extensive keratinisation and cornification (causes whiteness of the patch) If non-responsive to conservative treatment, biopsy should be done to exclude malignancy 2. Hairy leukoplakia (serrated white areas in margins of tongue; painless and are due to Epstein-Barr virus infection in a patient of AIDS). 3. Candidiasis of tongue. 4. Severe and chronic iron deficiency anaemia. * Except in candidiasis, all the plaques are adherent to tongue ** 6 ‘S’ in leukoplakia are sharp teeth, sepsis, smoking, spirits, syphilis and spices –––– o –––– 22 7......................... Pearls in Medicine for Students CHAPTER Blackish Urine POSSIBILITIES Though very rare, black discolouration of urine often puzzles the clinicians. 1. Alkaptonuria: The urine becomes black on standing, often after voiding. If collected in a test tube, it starts blackening from above downwards. The urine blackens on alkalinization too. Confirmation of the diagnosis is done by chromatographic and spectophotometric study of urine which demonstrate presence of homogentisic acid. It is due to deficiency of homogenitisic acid oxidase in human body. The other name of the disease is ochronosis. The brown stain of the napkin of infants makes the parents suspicious of some serious illness; the child may have grey-brown sclera. The adults may present with arthritis of big joints while the roentgenography of spine may reveal calcification of intervertebral discs. 2. Tyrosinosis: An autosomal recessive disorder of tyrosine aminotransferase deficiency associated with hepatic and renal tubular dysfunction. 3. Melanuria: In disseminated melanoma, melanogen present in urine gives the black discolouration. 4. Poisoning with phenol or cresol–Addition of ferric chloride turns the urine into blue or violet colour. 5. Drugs: Quinine, methyldopa or porphyrin therapy. * Blackwater fever due to severe P. falciparum infection produces red urine Blackish Urine 23 TREATMENT Relieve anxiety. Reassurance Adequate fluid intake to prevent renal insufficiency in cases of drug- induced or poisoning-induced black urine Treatment of the specific cause. BLACK STOOL 1. Melaena (altered blood due to production of acid haematin). 2. Ingestion of iron as haematinic (produces hard stool in contrast to melaena which is semisolid in consistensy). 3. Ingestion of bismuth (used in treatment of duodenal ulcer). 4. Intake of liquorice, charcoal (used in treating poisoning) or black berries. * No (2), (3) and (4) are non-sticky, and often known as ‘pseudomelaena’. –––– o –––– 24 8......................... Pearls in Medicine for Students CHAPTER Blue Fingers/ Toes FIGURE 8.1: Digital infarction (cicatrical depression at fingertips) in progressive systemic sclerosis PROLOGUE Blue fingers or toes are seen in vasospasm due to any condition, commonly as a result of Raynaud’s phenomenon. True cyanosis (central or peripheral) is also responsible for blueness in finger/toetips and nail-beds. RAYNAUD’S PHENOMENON It is a vasospastic disorder (i.e. intense vasospasm of peripheral arteries), manifested clinically by the classical ‘triphasic colour response’ which is Blue Fingers/Toes 25 sequential development of digital blanching (pallor due to vasospasm), cyanosis (blue due to sluggish blood flow) and rubor (redness due to vasodilatation or reactive hyperaemia) of the fingers and toes following cold exposure and subsequent rewarming. Some patients may develop only pallor and cyanosis, while others may experience cyanosis only. The changes in the fingers and toes are often diagnosed by nail-fold capillography. The fingers are affected more commonly than the toes. The duration of the attack is variable but may last for hours. Numbness, burning or paraesthesia, and severe pain in the digits are common features. MECHANISM 1. Exaggerated reflex sympathetic vasoconstriction. 2. Enhanced digital vascular responsiveness to cold or to normal sympathetic stimuli Colour Mechanism Clinical features Pallor (White) Vasospasm (ischaemia) Pain and numbness Cyanosis (blue) Subsequent venular Pain and numbness spasm (stasis) Rubor (red) Vasodilatation Warmth, throbbing (reperfusion) pain COMMON CAUSES A. Primary Raynaud’s phenomenon: Raynaud’s disease (F > M, 15-30 years, bilateral and symmetrical, no cause found, fingers > toes; +ve family history may be there; over 50% of patients with Raynaud’s phenomenon have Raynaud’s disease. Rarely, the earlobes and the tip of the nose may be involved. The radial, ulnar and pedal pulses remain normal as it is a disease of arterioles; it does not progress to digital ulceration or infarction. Long-acting preparation of nifedipine may be of some help. B. Secondary Raynaud’s phenomenon: 1. Collagen vascular diseases: Scleroderma, SLE, dermatomyositis, CREST syndrome, MCTD, rheumatoid arthritis. 2. Obliterative arterial disease: Atherosclerosis, thoracic inlet syndrome, thromboangiitis obliterans. 3. Occupational: vibration tool injury, electric shock, exposure to cold (e.g. frost bite), piano playing, vinyl chloride, typing. 4. Blood dyscrasias: Myeloproliferative disorders, hyperviscosity syndromes, cryoglobulinaemia. 26 Pearls in Medicine for Students 5. Neurologic disorders: Syringomyelia, carpal tunnel syndrome, spinal cord tumours. 6. Drug-induced: Ergot derivatives, β-blockers, methysergide, vinblastin or bleomycin. 7. Miscellaneous—pulmonary hypertension, crutch pressure, carcinoid syndrome. OTHER VASOSPASTIC DISORDERS 1. Pernio (chilblains) → Swelling of tips of toes with ulceration, often associated with pruritus and burning sensation → associated with cold exposure. 2. Erythromelalgia → M > F, feet > hands with burning pain and erythema of the extremities → may precipitate from myeloproliferative disorders, or nifedipine/bromocriptine-induced → precipitated by warm exposure and relieved by exposing to cool air or elevation of the limb. 3. Livedo reticularis (read the section on ‘Purpuric spots’). 4. Frost bite. 5. Vasculitis due to any cause. 6. Acrocyanosis → persistent cyanosis of the hands, less frequently, the feet → resulting from arterial vasoconstriction and secondary dilatation of capillaries and venules → cold exposure increases the incidence. F > M and usually below 30 years of age. Asymptomatic with normal pulses and without any skin ulceration → D/D with Raynaud’s phenomenon (acrocyanosis is persistent and not episodic, and blanching does not occur). MANAGEMENT 1. Reassurance. Avoid unnecessary exposure to cold or trauma. To wear gloves and mittens, protect the body with warm clothing and abstain from tobacco smoking. 2. Drugs: reserved for severe cases. Nifedipine, amlodipine, diltiazem (calcium-channel blockers) Reserpine (adrenergic blocking agent) Prazosin, doxazocin, terazocin (∝1- adrenergic antagonist) Methyldopa, guanethidine, phenoxybenzamine (sympatholytics) Iloprost (prostacyclin analogue and an endogenous vasodilator) Pentoxyfylline, naftidrofuryl, inositol nicotinate Calcitonin gene-related peptide Blue Fingers/Toes 27 The phosphodiesterase inhibitor sildenafil and oral endothelin antagonist bosentan are currently being tried Surgical sympathectomy. ULCERS (DIGITAL) AT FINGER OR TOETIPS 1. Raynaud’s phenomenon, e.g. scleroderma 2. Thromboangiitis obliterans 3. Leprosy 4. Diabetes mellitus 5. Trauma 6. Vasculitis 7. Atherothrombosis. ERYTHEMA OF FINGERS 1. Dermatomyositis 2. Frost bite 3. Chilblains 4. SLE 5. Urticaria. REGIONAL CYANOSIS (BLUENESS) 1. One limb–Arterial embolism or phlebothrombosis of a large vein with little collaterals 2. Face and upper extremity–superior vena caval syndrome 3. Differential cyanosis: a. Blue feet–PDA with reversal of shunt b. Blue hands–Coarctation of aorta with transposition of great vessels 4. Acrocyanosis (see above) 5. Erythrocyanosis (young lady → with short skirts → exposure to cold). –––– o –––– 28 9......................... Pearls in Medicine for Students CHAPTER Blue Sclera FIGURE 9.1: Classical blue sclera in osteogenesis imperfecta CLINICAL INVESTIGATION Search for multiple fractures (generalised osteopenia makes the bone brittle), loose-jointedness and progressive deafness ↓ A case of osteogenesis imperfecta (commonest cause) ↓ Due to thinness of sclerae, the underneath choroid with its vessels gives rise to blue tinge in the eyes ↓ Blue Sclera 29 FIGURE 9.2: Scar marks for repair of repeated femur fracture in osteogenesis imperfecta FIGURE 9.3: Hyperextensible skin over face in Ehlers-Danlos syndrome 30 Pearls in Medicine for Students FIGURE 9.4: ‘Cigarette-paper’ scars over skin in Ehlers-Danlos syndrome Associated features: Pseudoarthrosis, sabre tibia, pectus excavatum or carinatum, blue-yellow teeth with dental abnormalities (dentinogenesis imperfecta), blue tympanic membrane, aortic imcompetence or mitral valve prolapse ↓ Four types (type I, II, III and IV) ↓ X-ray of skull reveals ‘Wormian bones’ (small irregular bones related to sutures), especially in parietal bones. D/D OF BLUE SCLERA 1. Marfan’s syndrome 2. Hypophosphatasia 3. Pseudohypoparathyroidism 4. Brittle corneal syndrome 5. Corneal encroachment of sclera 6. Staphyloma 7. Ehlers-Danlos syndrome 8. Pseudoxanthoma elasticum 9. Newborn baby (underlying uveal tissue is visible due to thinness and immaturity of scleral collagen fibres). Blue Sclera 31 D/D OF BLUISH DISCOLOURATION OF BODY 1. Cyanosis (cyanosed skin blanches on pressure). 2. Carbon monoxide poisoning: cherry-red flush due to formation of carboxyhaemoglobin. 3. Argyria: Deposition of silver salts in the skin due to silver poisoning. The skin does not blanch on pressure. 4. Amiodarone toxicity: The skin may take a bluish hue. –––– o –––– 32 Pearls in Medicine for Students CHAPTER 10....................... Bull-neck PROLOGUE The space between the mandibles and the clavicles bulges with enlarged lymph nodes and oedema; commonly from malignant diphtheria. CERVICAL LYMPHADENOPATHY 1. Infection, malignancy or ulcer within the oral cavity 2. Infection of ear, eye and nose 3. Scalp infection by louse or dandruff 4. Miliary tuberculosis 5. Lymphoma 6. Lymphatic leukaemia (acute and chronic) 7. Metastasis in lymph nodes 8. Infectious mononucleosis 9. Sarcoidosis 10. Rubella infection. LYMPHADENOPATHY WITH SINUS FORMATION 1. Tuberculosis 2. Malignancy 3. Actinomycosis. D/D OF BULL-NECK 1. Surgical emphysema (press the stethoscope over the swelling and listen the crepitus). 2. Enlarged submandibular glands (Mikulicz’s syndrome). 3. Ludwig’s angina. Blue-neck 33 AXILLARY LYMPHADENOPATHY 1. Infection of the upper extremity 2. Breast carcinoma 3. Lymphoma 4. Miliary tuberculosis 5. Brucellosis 6. Cat-scratch disease. EPITROCHLEAR LYMPHADENOPATHY 1. Hand infections 2. Lymphoma, especially NHL 3. Sarcoidosis 4. Secondary syphilis 5. Tularaemia 6. Infectious mononucleosis. INGUINAL LYMPHADENOPATHY 1. Infection or cellulitis of the lower limb 2. Filarisis 3. Syphilis 4. Metastasis from genital malignancy, pelvic carcinoma 5. Chancroid 6. Lymphoma 7. Miliary tuberculosis 8. Lymphatic leukaemia (acute and chronic) * The importance of epitrochlear lymphadenopathy is highest to a clinician in comparison to inguinal lymphadenopathy, which rates lowest. MATTING OF LYMPH NODES Signifies periadenitis Most commonly in tuberculosis; may be seen in chronic lymphadenitis, NHL CONSISTENCY OF LYMPH NODE SWELLING Stony hard → malignancy Elastic and rubbery → Hodgkin’s disease Variegated → NHL 34 Pearls in Medicine for Students Firm and shotty → secondary syphilis Soft and fluctuating → cold abscess, inflammatory abscess. PATHOLOGICAL SIGNIFICANCE OF ENLARGED NODES Nodes are pathologically significant, if: > 1cm in diameter Firm in consistency Tender on palpation Matted Following factors should always be kept in mind in assessing the pathological nature of nodes: Age of the patient The physical characteristics (described above) Anatomical sites involved The total clinical setting. VIRCHOW’S NODE Also known as Ewald’s node or sentinel node Position: Medial group of left sided supraclavicular nodes which lie in between two heads of left sternomastoid muscle; always palpated from back of the patient. Receive lymphatics from: Upper limb (left) Breast (left) Lung (left) Stomach (Troisier’s sign) Testes Bronchogenic carcinoma commonly produces ‘scalene node’ enlargement. –––– o –––– CHAPTER 11....................... Chapter 35 Bruxism (Teeth Grinding) WHAT IS BRUXISM ? It is an involuntary and forceful teeth grinding during sleep. The classical age of onset is 17-20 years though this may appear in childhood, and may affect 10-20% of the population. The person is usually unaware of the problem; M:F = 1:1, and the problem usually remits by the age 40. Dental examination may give a clue to diagnosis where the damage is minor. Night time bed partner primarily notices the situation. Usually no treatment is necessary but in severe cases, a rubber tooth guard is required to prevent disfiguring injury of teeth. Stress management, psychotherapy or benzodiazepines may be of some help. Contrary to common belief, bruxism has no relation with intestinal infestation with helminths. ‘Teeth chattering’ is usually associated with fever with chill and rigor, or with shivering due to exposure to very cold weather. SLEEP DISORDERS 1. Insomnia (most common complaint in general population and mental disorders). 2. Sleep-walking (somnambulism). 3. Sleep terrors (occurs during first several hours after onset of sleep). 4. Sleep-related epileptic seizures. 5. Bruxism. 6. Clusture headache (a variety of migraine). 7. Abnormal swallowing, coughing, chocking and aspiration of saliva. 36 Pearls in Medicine for Students 8. Sleep-related gastroesophageal reflux disease (GERD)–often associated with hiatal hernia. 9. Nocturnal angina. 10. Sleep enuresis (bedwetting). 11. Sleep-talking. 12. Nocturnal leg cramps. 13. Nocturnal paroxysmal dystonia. 14. Paroxysmal nocturnal haemoglobinuria (sleep related acidic reaction of the blood produces haemolysis, making the morning urine brownish red). 15. Sleep apnoea (respiratory dysfunction during sleep disturbing nocturnal sleep with excessive daytime somnolence). 16. Restless leg syndrome (or Ekbom’s syndrome; causes are idiopathic, peripheral neuropathy, iron deficiency, uraemia). 17. Periodic limb movement disorder (previously known as nocturnal myoclonus). 18. Sleep paralysis (totally unable to perform a voluntary movement despite remaining alert and aware). 19. Narcolepsy (periods of irresistible sleep) may coexist with cataplexy (sudden loss of lower limbs tone and falling with full awareness)– often accompanied by hypnagogic hallucinations (on falling asleep). EXCESSIVE DAYTIME SLEEPINESS (HYPERSOMNIA) 1. Chronic sleep disruption at night (insomnia). Inadequate night-time sleep due to fatigue/excessive consumption of caffeine or alcohol are very common causes of daytime sleepiness. 2. Narcolepsy (recurrent bouts of irresistible sleep). 3. Obstructive sleep apnoea syndrome. 4. Sleeping sickness (African trypanosomiasis by T. brucei complex). 5. Depressive illness. 6. Following infections, e.g. infectious mononucleosis. 7. Symptomatic hypersomnia–organic brain diseases, e.g. encephalitis, toxic or metabolic encephalopathies; tumour, vascular or traumatic brain damage. 8. Neurotic hypersomnia–in hysterics or neuroasthenic individuals. 9. Drug-induced–sedatives, antiepileptics. 10. Kleine-Levin syndrome–episodic hypersomnolence and hyperphagia in adolescent boys; rare. 11. Idiopathic hypersomnia–hereditary with excessive night-time sleep; also known as ‘sleep drunkenness’. Bruxism (Teeth Grinding) 37 INSOMNIA It is the ‘difficulty in sleeping’ and in general 1/3rd of adults suffer from this ailment. It may be categorized by: 1. Early insomnia, i.e. difficulty in getting off to sleep (commonly due to anxiety, depression, mania and substance abuse). 2. Middle insomnia, i.e. waking up from sleep at mid-night (mostly due to sleep apnoea, polyuria or nocturia, and benign hypertrophy of prostate). 3. Late insomnia, i.e. early morning waking (commonly due to depression and malnutrition). * Hypocretin (orexin) neuropeptides are involved in sleep-waking cycle (present between cerebral cortex and reticular formation). ** Electrophysiologic parameters of sleep are recorded by ‘polysom- nography’ i.e. electroencephalogram (EEG) + electrooculogram (EOG → records eye-movements activity) + electromyogram (EMG → measured on chin and neck muscles). –––– o –––– 38 CHAPTER 12....................... Pearls in Medicine for Students Claw Foot FIGURE 12.1: Pes cavus (claw foot or high-arched foot) due to wasting of intrinsic muscles of foot in peroneal muscular atrophy SYNONYM Pes cavus DEFINITION A fixed deformity of foot where both feet are more or less symmetrically high-arched, i.e. there is gross exaggerbation of the medial longitudinal arch of the feet. It is just opposite to flat foot (pes planus) deformity. Claw Foot 39 FIGURE 12.2: Short neck and low hairline in cranio-vertebral anomaly (patient had quadruplegia) FIGURE 12.3: Pes planus (flat foot) 40 Pearls in Medicine for Students FIGURE 12.4: Mutilated hands with pulp atrophy, sclerodactyly, limitation of full extension of fingers with dry, coarse skin in scleroderma FIGURE 12.5: Short 4th metacarpals in pseudohypoparathyroidism–‘knuckle-knuckle dimple-dimple syndrome’ (the patient had peeling of skin of hands due to some drug reaction Claw Foot 41 CONDITIONS ASSOCIATED Familial Friedreich’s ataxia Peroneal muscular atrophy Spina bifida occulta Poliomyelitis Syringomyelia Cerebral palsy Refsum’s disease Idiopathic METHOD OF DEMONSTRATION Take a foot-print on a white paper after painting the feet by lac-dye, or after immersing the feet in water, ask the patient to walk barefooted in the floor → observe the foot-prints. GENU VARUM DEFORMITY ‘Bow legs‘ are seen in: Rickets or osteomalacia Achondroplasia Paget’s disease GENU VALGUM DEFORMITY ‘Knock knees’ are seen in: Rickets Congenital deformity SKELETAL DEFORMITIES PRESENT WITH NEUROLOGICAL DISORDERS 1. Kyphoscoliosis 2. Pes cavus 3. High-arched palate 4. Short neck (e.g. cranio-vertebral anomaly) 5. Various skull deformities, e.g. craniostenosis. HEEL PAD THICKNESS A lateral view of patient’s foot is taken by X-ray. The distance between the lower most point of calcaneum and the lower most point of the soft tissue shadow of heel is measured → ‘heel pad thickness’. 42 Pearls in Medicine for Students ↑ HEEL PAD THICKNESS > 18 mm in women and > 21 mm in men Conditions associated: 1. Acromegaly (commonest cause) 2. Obesity 3. Anasarca DEFORMED OR MUTILATED FINGERS/TOES Leprosy Scleroderma Buerger’s disease Congenital defects Diabetic foot Frost bite Syringomyelia Vasculitis Atherothrombosis Arthritis mutilans (psoriasis) Trauma Porphyria Amyloid neuropathy Lesch-Nyhan syndrome SHORT FOURTH METACARPALS Pseudohypoparathyroidism Down’s syndrome Myositis ossificans congenita * As the knuckles and dimples in closed fist of both hands are not symmetrical, presence of short fourth metacarpals is also known as knuckle-knuckle dimple-dimple syndrome (especially in pseudo- hypoparathyroidism). –––– o –––– CHAPTER 13....................... Chapter 43 Coprolalia DEFINITION Offensive utterance of obscene words. ASSOCIATIONS 1. Poisoning (e.g. organophosphorous) 2. Atropinisation or overdose of atropine 3. Hepatic pre-coma 4. Subdural haematoma 5. Uraemia 6. Tourette syndrome 7. Encephalitis or encephalopathy 8. Habitual (personality disorder). GILLES DE LA TOURETTE SYNDROME Inherited neuropsychiatric disorder characterised by multiple motor (e.g. blinking, grimacing, head jerking) and vocal (e.g. clearing the throat or coprolalia) tics. Compulsive utterances of coprolalia is one of the most recognizable and distressing symptom, which appears a few years after disease onset. The disease starts in childhood or adolescence; hyperactive, non-specific ECG abnormalities are seen in 50%; the cause is probably an inherited disorder of synaptic transmission. Treatment is done by haloperidol (drug of choice), clonidine, clonazepam, pimozide or tetrabenazine. 44 Pearls in Medicine for Students SPEECH DISORDER It is the symbolic expression of thought process in spoken or written words. Aphasia or dysphasia–unable to speak due to defect in higher centre (e.g. Broca’s or Wernicke’s area in brain) with difficulty in language function Dysarthria–defect in articulation, commonly due to neuromuscular or muscular disorders resulting in impaired coordination of facio-lingual muscles, e.g. slurring, stammering or mumbling Dysphonia–disorder of phonation where the defect lies in the vocal cord, e.g. hoarse voice, voice loss Echolalia–repetition of examiner’s word Palilalia–repetition of terminal words of own speech Jargon aphasia–neologisms (new words) making no sense at all Perseveration–repeated use of particular words or phrases * Last 4 are part of speech disorder due to defect in higher centres (e.g. cerebrovascular accidents). –––– o –––– CHAPTER 14....................... Chapter 45 Cough DEFINITION It is the reflex or voluntary expulsion of the inspired air by forced expiratory effort against a transitorily closed glottis. Cough is known to be one of the unique defensive reflex of human body designed to clear the tracheobronchial tree of secretion and foreign body. Though previously recognised as the ‘watch-dog’ (i.e. protective reflex) of the respiratory system, it may be regarded as a manifestation of diseases affecting many other systems including a major symptom of pulmonary diseases. MECHANISM It requires an intricate network of neurosensory-muscular coordination: a. Afferent pathway: it originates from the sensory receptors present in epithelium of the airways (larynx, trachea and major bronchus), and the afferent nerves involved are trigeminal, glossopharyngeal, superior laryngeal and vagus. b. Centre: cough centre is present in medulla oblongata. c. Efferent pathway: The efferent impulses reach the diaphragm, intercostal muscles, abdominal muscles, and to larynx through vagus, phrenic, recurrent laryngeal and spinal motor nerves which result in cough, while the laryngeal air velocities produced as a result of violent action of respiratory muscles make a sound. Cough is usually associated with mucus secretion, bronchoconstriction and transient rise in systemic BP. 46 Pearls in Medicine for Students THREE PHASES OF COUGH 1. Appropriate stimulus, i.e. mechanical (dust, mucus, foreign body), chemical (toxic gases, fumes, cigarette smoke), inflammatory (oedema and hyperaemia of respiratory mucous membrane) and thermal stimuli (inhalation of either very cold or hot) initiate deep inspiration. 2. Glottic closure + contraction of muscles of expiration including accessory muscles + relaxation of diaphragm → resulting in maximum intrathoracic pressure → narrowing of trachea. 3. Opening of glottis → high flow rate generated as a result of pressure diffenence between the airways and the atmosphere associated with trac- heal narrowing→ propels excessive mucus and foreign body outside. AETIOLOGY A. Respiratory tract–Acute and chronic infection/neoplasm of larynx or pharynx, post-nasal drip, acute tracheobronchitis, cigarette smoking, pulmonary tuberculosis, bronchial asthma, chronic bronchitis, bronchiectasis, emphysema, interstitial pulmonary fibrosis, pneumonia, lung abscess, bronchogenic carcinoma, sarcoidosis, tropical eosinophilia, pneumoconiosis, cystic fibrosis, cough variant asthma, pleurisy, pleural effusion, mediastinal mass. B. System of ear, nose and throat–Inhalation of toxic gases, fumes, cooking fuels, dust or foreign body; otitis media, wax impacted in external ear, laryngitis, tracheitis, allergic rhinitis, sinusitis (maxillary) and post- nasal drip. C. Cardiovascular system–Pulmonary oedema, pericardial effusion, aortic aneurysm, enlarged left atrium (from mitral stenosis commonly), left ventricular failure. D. GI tract–Gastroesophageal reflux disease (GERD), hiatus hernia, achalasia cardia, oesophageal diverticulum. E. Reflex–Happens to be due to irritation of vagus nerve and is commonly from wax impacted in external ear, otitis media, subdiaphragmatic abscess and acute distension of stomach. F. Drug-induced–ACE-inhibitors (due to accumulation of bradykinin, substance P and prostaglandin E 2), β-blockers (indirect effect of bronchoconstriction). G. Psychogenic–Found in adolescents and self-conscious adults; usually smasmodic and explosive in nature; often it is barking (or ‘honking’) and loud in character → may be seen as a part of obsessional neurosis or coordinated tics. H. Idiopathic Cough 47 CLASSIFICATION 1. Acute (< 3 weeks ) or chronic (> 3 weeks). 2. Dry (upper respiratory tract infection, smoker’s cough, early stage of pulmonary tuberculosis) or wet (e.g. bronchiectasis). 3. Paroxysmal cough (usually lasts for 1-2 minutes): Whooping cough, tracheal obstruction, bronchial asthma, pulmonary oedema, foreign body inhalation. TYPES 1. Dry or non-productive–Acute laryngotracheobronchitis; acute dry pleurisy, smoker’s cough, early stage of pulmonary tuberculosis. 2. Wet, productive or moist–Sputum production may be due to lung abscess, bronchiectasis, resolution stage of pneumonia. 3. Bovine (laryngeal cough)–The explosive nature of cough is lost in recurrent laryngeal nerve palsy (commonly due to bronchogenic carcinoma). 4. Brassy (or metallic)—Dry cough with a metallic sound may be heard in carcinoma of larynx. 5. Whooping–There is rapid succession of dry cough which gradually gather speed and end in a deep inspiration when the characteristic ‘whoop’ is audible; found in pertussis. 6. Spluttering cough–In tracheo-oesophageal fistula (cough during swallowing). 7. Hacking (pharyngeal cough)–Dry and irritable cough in heavy smokers. 8. Barking–Harsh and loud cough; found in epiglottitis and hysteria. 9. Nocturnal–chronic bronchitis, LVF, tropical eosinophilia, post-nasal drip, aspiration (e.g. from GERD). 10. Nagging cough–Commonly after use of ACE-inhibitors. 11. ‘Croupy’ cough–laryngitis, especially in children. 12. Foetid cough–In bronchiectasis and lung abscess, there is cough with foul smelling expectoration. 13. Suppressed cough–Short spell of suppressed cough is found in pleurisy to avoid pain during coughing. FACTORS INFLUENCING COUGH 1. Cough started acutely–Foreign body aspiration, pulmonary thromboembolism (PTE), pulmonary oedema, acute exacerbation of bronchial asthma, inhalation of fumes. 48 Pearls in Medicine for Students 2. Cough with wheeze–Bronchial asthma, chronic bronchitis, pulmonary thromboembolism (PTE). 3. Related to meals–Hiatus hernia, oesopheageal diverticulum, tracheo- oesophageal fistula, neurogenic dysphagia (e.g. bulbar palsy). 4. Related to exertion–Early left ventricular decompensation, mitral stenosis, bronchial asthma. 5. Related to posture–Bronchiectasis and lung abscess (cough evoked after change of posture in bed), GERD (cough evoked while lying horizontally). 6. Related to seasonal variation–Bronchial asthma and chronic bronchitis become worse in winter. 7. Related to working hours–Byssinosis (triggered by cotton dust). 8. Induced after inhalation of cold air–bronchial asthma. 9. Predominantly nocturnal cough–tropical eosinophilia, bronchial asthma, LVF, oesophageal disorders. 10. Predominantly early morning cough–Post-nasal drip, chronic bronchitis, sinusitis. 11. Recurrent cough since childhood–Cystic fibrosis, childhood asthma, congenital heart disease, cystic disease of lung, hypogammaglo- bulinaemia. HOW SPUTUM OR EXPECTORATION IS ANALYSED? 1. Amount (profuse or not). 2. Character (serous, mucoid, purulent, mucopurulent). 3. Colour (yellow, green, black, pinkish, rusty). 4. Odour or taste (offensive or not). 5. Mixed with blood (haemoptysis) or not. 6. Sputum production influenced by change of posture (bronchiectasis, lung abscess) or not. * Profuse sputum means approximately a teacupful (> 100 ml) of sputum production per day. PROFUSE AND FOETID (FOUL-SMELLING) SPUTUM Bronchiectasis Lung abscess Infection with anaerobic organism Infected cavity or neoplasm Empyaema thoracis ruptured into bronchus Cough 49 DIFFERENT COLOURS OF SPUTUM 1. Red–Haemoptysis. 2. Black–Carbon particles from atmosphere, cough in coal-miners (benign in nature). 3. Green–Respiratory tract infection (verdoperoxidase from dead neutrophil turns yellow sputum to green), bronchial asthma (due to large number of eosinophils), pseudomonas infection. 4. Pink and frothy in acute pulmonary oedema. 5. Rusty or golden yellow–Pneumonia (pneumococcal). 6. Yellow–Respiratory tract infection (creamy). 7. Yellow (with sulphur granules)–Actinomycosis of lung. 8. Brown to red + tenacious–Klebsiella pneumoniae infection. 9. Anchovy-sauce like–Amoebic liver abscess ruptured into lung. 10. Mucoid–Chronic bronchitis, COPD, chronic bronchial asthma. 11. Frothy–Pulmonary oedema, bronchoalveolar carcinoma (serous and frothy). HOW COUGH IS ANALYSED AT THE BEDSIDE? 1. Duration (days/months/years); acute < 3 weeks, chronic > 3 weeks. 2. Variability (daytime/nocturnal/morning). 3. Precipitating factors (dust/fumes/pollen/cold air/lying down). 4. Seasonal variation? wheeze? 5. Types (dry/wet/bovine). 6. Haemoptysis, present or not. 7. Change of character of cough in a chronic heavy smoker (e.g. development of COPD or bronchogenic carcinoma). 8. Associated symptoms (port-nasal drip, GERD, occult asthma, fever, dyspnoea). 9. Chest pain (pleurisy) or breathlessness (COPD, pneumonia). 10 H/O drug intake–ACE-inhibitors or β-blockers. EVALUATION OF CHRONIC COUGH Common associations are: 1. Viral infection 2. GERD 3. Post-nasal drip 4. Cough variant asthma (present with cough in the absence of wheezing or breathlessness) 5. ACE-inhibitor induced. 50 Pearls in Medicine for Students POSSIBLE INVESTIGATIONS IN CHRONIC COUGH 1. Chest X-ray (PA and oblique view). 2. ENT check-up. 3. PNS X-ray and CT scan of sinus for post-nasal drip. 4. Lung function tests and histamine bronchial provocation testing for cough variant asthma. 5. CT scan of thorax (to exclude interstitial lung disease). 6. Radionuclide ventilation/perfusion (VA/Q) scan for recurrent PTE. 7. Fibreoptic bronchoscopy–to rule out inhaled foreign body or carcinoma of the bronchus. 8. Ambulatory oesophageal pH monitoring for GERD. 9. ECG, echocardiography (to exclude valvular lesion or LV dysfunction). COMPLICATIONS 1. Chest and abdominal wall soreness form harassing cough, exhaustion, loss of sleep. 2. Severe vomiting, rib fracture (especially in elderly with osteoporosis, multiple myeloma or osteolytic metastases), cough syncope (momentary unconsciousness due to raised intrathoracic pressure during coughing which impedes venous return to the heart and reduces cardiac output), spontaneous pneumothorax, subconjunctival haemorrhage, frenal ulcer (in tongue), urinary or faecal incontinence, prolapse of rectum/uterus/ hernia. 3. Postoperative wound dehiscence, rupture of rectus abdominis (rare), heart block (rare). MANAGEMENT Non-specific 1. Antitussive agents: a. Antihistaminics–chlorpheniramine, clemastine, cetrizine. b. Sympathomimetic decongestants–pseudoephedrine, oxymeta- zoline, phenylephrine. c. Demulcents–menthol, tea with honey. d. Others–narcotic and non-narcotic analgesics, bronchodilators in asthma. 2. Protussive agents (or cough enhancing agent) a. Expectorants–guaiphenesin. Cough 51 b. Mucolytics–bromhexine, carbocysteine, acetyl cysteine, dornase alpha, ambroxol (a metabolite of bromhexine). c. Hypertonic saline aerosol (for chronic bronchitis). Specific Cessation of smoking, application of antibiotics, stoppage of ACE- inhibitors, treatment of LVF. –––– o –––– 52 15....................... Pearls in Medicine for Students CHAPTER Cramp DEFINITION It is the painful, involuntary contractions of a single or a group of muscles. Cramps are seen in normal healthy persons or may be precipitated by voluntary movements. Cramps in the calf muscles are so common as to be regarded normal, but a more generalised cramps may be a sign of chronic disease of motor neurone. AETIOPATHOGENESIS Not truely known but may be due to: Overactivity of muscle/nerve membranes Electrolyte imbalance Pain associated with cramp is possibly due to: Focal ischaemia Accumulation of metabolites within the muscles * Pathological cramps may be due to an abnormality anywhere in the pathway including anterior horn cells, peripheral nerve, neuromuscular junction and muscle membrane. POSSIBLE CAUSES 1. Normally occurs in healthy individual at night. 2. Electrolyte imbalance (↓Ca, ↓Mg, ↓Na, ↓K, ↓Po4). 3. Overexertion (producing dehydration by profuse sweating, heat cramps, miner’s cramp, swimmer’s cramps, leg cramps in long distance bus drivers). 4. Motor neurone disease, e.g. amyotrophic lateral sclerosis. Cramp 53 5. Metabolic: chronic renal failure, hypothyroidism, McArdle’s disease, phosphofructokinase deficiency, haemodialysis. 6. Peripheral neuropathy: Diabetes mellitus, alcohol or vincristine- induced. 7. Cramps in professionals: writers, tailors, typists. 8. Muscular dystrophies: X-linked variety, myotonia. 9. Others: chronic wasting disease (e.g. tuberculosis), pregnancy, dehydration due to any cause, tetany, peripheral arterial disease, deep vein thrombosis. * Muscle ‘spasm’ may occur in tetanus, tetany, epilepsy, myoclonus, etc. NOCTURNAL LEG CRAMPS Majority of healthy persons at sometime or other has had experienced muscle cramp. Usually it occurs at night, especially when the feet are cold, after a day of unusually strenous activity. Muscles of calf and foot are commonly affected. The onset is sudden and may awaken the person. The muscle is visibly and palpably taut, as well as painful. Massage and vigorous stretch of the cramped muscle may give relief. Visible fasciculations may precede and follow muscle cramp. This type of nocturnal cramps are nortorious for recurrence. All causes mentioned above are responsible for nocturnal cramps with a special reference to: Idiopathic Electrolyte abnormalities Deep vein thrombosis Hypoglycaemia Diabetic neuropathy Peripheral vascular insufficiency Alcohol use DIFFERENTIAL DIAGNOSIS (CRAMP) The single most important condition to be differentiated is intermittent claudication. POST-EXERCISE LEG PAIN Think of –– Atherosclerosis obliterans Buerger’s disease Deep vein thrombosis 54 Pearls in Medicine for Students Lumbar canal stenosis (i.e. neurogenic) Venous claudication Popliteal cyst McArdle’s disease (muscle phosphorylase deficiency) Popliteal artery entrapment syndrome Tetany (↓Ca, ↓Mg or alkalosis) CALF PAIN (COMMON CAUSES) Intermittent claudication (needs meticulous clinical examination) Deep vein thrombosis (do Doppler studies) Rupture of Baker’s cyst (perform arthrography of knee joint) Referred pain from lumbar spine (MRI scan of lumbar cord to demonstrate compression) Spastic calf muscle (diagnosed by clinical examination) CALF SWELLING (UNILATERAL) This may be due to local inflammation, or obstruction/damage to a vein or lymph channel. The possibilities are: 1. Deep vein thrombosis (↓ flow on Doppler ultrasound scan, filling defect in venogram). 2. Cellulitis (↑ leucocytes, response to antibiotics). 3. Ruptured Baker’s cyst (usually suffering from rheumatoid arthritis. Arthrogram reveals leakage of contrast from joint capsule). 4. Traumatic (may have tender haematoma formation). 5. Filariasis or abnormal lymphatic drainage (e.g. trypanosomiasis in tro- pics, or pelvic malignancy)–obstruction revealed in lymphangiogram. TETANY It is increased neuromuscular irritability due to decrease in the concentation of free calcium ion in the plasma. This special variety of paroxysmal cramps occur mainly in the extremities. Normal serum calcium level in 9-11 mg/dl and the ionic fraction is 4.5-5.6 mg/dl. The common symptoms are: Irritability Muscle cramp (carpopedal spasm) Peripheral paraesthesia Triad of symptoms in children, i.e. carpopedal spasm, laryngismus stridulus (stridor, respiratory distress, cyanosis), and convulsions Dysphagia, dyspnoea, dysuria, abdominal colic Cramp 55 PHYSICAL SIGNS IN TETANY 1. Trousseau’s sign–When the pressure is raised above the systolic BP for 2-3 minutes, typical carpal spasm occurs in hands within 3 minutes. There is flexion of MCP joints with extension of interphalangeal joints, and the flexed thumb takes its position in between the index and the middle finger (opposition of thumb). This is known as “main d’ accoucheur” or obstetrician’s hand. Pedal spasm is less frequently demonstrated. Latent tetany is best demonstrated by this sign. 2. Chvostek’s sign–Tapping of the facial nerve (by finger or hammer) in front of the ear will produce twitching of facial muscles. 3. Erb’s sign–Muscular contractions can be produced by application of subthreshold electrical stimulation (0.5-2.0 milli-amps). 4. Peroneal sign–Tapping of peroneal nerve at the neck of fibula will produce pedal spasm, i.e. plantiflexion and adduction of the foot, while the knee is extended. 5. [ECG–Prolonged Q-T interval]. * All are features of ↑ neuromuscular irritability. Tetany is due to ‘unstable depolarisation’ of the distal segments of the motor nerves. Carpopedal spasm may uncommonly spread over face, neck and trunk muscles (except the eye muscles). Psychoneurotic patients may have tetany during hyperventilation. Hyperventilation and ischaemia of muscles ↑ the tendency of carpopedal spasm. TREATMENT OF CRAMPS 1. Massaging, and passive and vigorous stretching of the affected muscles. 2. Tetany: Inj. calcium gluconate (10% solution) 10 ml by IV route, slowly (inj. calcium chloride may be given). If tetany is not controlled by calcium, administration of magnesium may be necessary. 3. Tab quinine sulphate–300-600 mg three times daily. 4. Tab procainamide–250-500 mg three times daily. 5. Tab diphenhydramine hydrochloride–50 mg at bedtime. 6. Carbamazepine, clonazepam, muscles relaxants (e.g. tizanidine) may be of some help. 7. Idiopathic nocturnal cramp may be alleviated by tocopherol, 400 mg twice daily; carnitine may be of some help. –––– o –––– 56 16....................... Pearls in Medicine for Students CHAPTER Depressed Bridge of the Nose FIGURE 16.1: Typical saddle-nose deformity in a patient with ectodermal dysplasia POSSIBILITIES 1. Lepromatous leprosy (thick and coarse skin of face, especially the infiltrated earlobes, madarosis, occasional perforated nasal septum, deeper lines of face, bronzed hyperpigmentation, leonine face). 2. Thalassaemia major (frontal bossing, hypertelorism, mongoloid slant of eyes, malar prominence, dental malocclusion, icterus and pallor → the ‘chipmunk’ facies). Depressed Bridge of the Nose 57 FIGURE 16.2: Short stature (cretinism) FIGURE 16.3: A rare patient of congenital syphilis having saddle nose with depressed bridge of the nose and peg-shaped upper central incisors (part of Hutchinson’s teeth) 58 Pearls in Medicine for Students FIGURE 16.4: High arched palate in a suspected case of Marfan’s syndrome 3. Down’s syndrome (microcephaly, upwards slanting of eyes with epicanthic folds, low set ears, hyperlelorism, high arched palate, large and fissured longue with an idiotic look → mongol facies). 4. Cretinism (broad-flat nose with big nostrils, hypertelorism, thick- everted lower lip with macroglossia, sparse and dry skin, dull and idiotic look). 5. Congenital syphilis (frontal bossing, small and broad nose, poorly developed maxilla, ground-glass cornea, Hutchinson’s teeth, ‘Mulberry’ molars [sixth-years molars have multiple poorly deve- loped cusps instead of four] and rhagades at the angle of mouth). 6. Ectodermal dysplasia (frontal bossing, small and broad nose, fine wrinkling in skin of face, sparse and dry hair, poor dentition with conical and pointed tip of teeth, poorly developed maxilla and often there is absence of sweating). 7. Wegener’s granulomatosis (purulent or bloody nasal discharge, small and broad nose may result from nasal septal perforation). 8. Midline granuloma (small and broad nose, nasal discharge with septal perforation, perforation of soft and hard palate, conjunctival inflammation or ulceration, and loosening of teeth). 9. Sarcoidosis (lupus pernio in the skin of face [deeper nodules and plaques], conjunctival nodules, uveitis, dry eye with destruction of nasal bone may be present). Depressed Bridge of the Nose 59 10. Others: Blastomycosis, yaws, carcinoma of the nose or nasopharynx, vasculitis. MECHANISMS RESPONSIBLE Due to hyperplasia of lesser wing of sphenoid bone in thalassaemia In others, it is due to chronic granulomatous destruction of anterior nasal septum. SADDLE-NOSE DEFORMITY 1. Small and broad nose, plus. 2. Big nostrils, plus. 3. Depressed bridge of the nose. * Classically found in 1, 5, 6, 7, 8 of above mentioned possibilities; also seen after overzealous septal excision operation or in polychondritis * ‘Destruction of nasal structures’ are seen in 1, 7, 8 and lupus vulgaris. FRONTAL BOSSING OF SKULL (PROMINENT FOREHEAD) Thalassaemia major Rickets Hydrocephalus Congenital syphilis Ectodermal dysplasia Acromegaly Achondroplasia HIGH ARCHED PALATE (Arbitrarily diagnosed when the roof of the palate is not visible if the examiner’s eyes are kept at the level of the patient’s upper incisor teeth) Down’s syndrome Marfan’s syndrome Thalassaemia Congenital cyanotic heart diseases Turner’s syndrome SABRE TIBIA (ANTERIOR TIBIAL BOWING) Rickets Congenital syphilis Paget’s disease 60 Pearls in Medicine for Students Osteogenesis imperfecta * ‘Sabre’ literally means cavalry sword with curved blade. In sabre tibia, the anterior border of tibia mimics the sword. HUTCHINSON’S TRIAD 1. Hutchinson’s teeth (centrally notched, widely spaced, peg-shaped upper central incisor). 2. Interstitial keratitis. 3. Nerve deafness. * Hutchinson’s triad is a stigma of congenital syphilis –––– o –––– CHAPTER 17....................... Chapter 61 Diffuse Aches and Pains POSSIBLE AETIOLOGY Soft-tissue rheumatism Fibromyalgia Post-viral myalgia Myxoedema Polymyalgia rheumatica Hypermobility Chronic fatigue syndrome Hypophosphataemia Polymyositis/dermatomyositis Metabolic bone disease * One should never forget osteomalacia and multiple myeloma as causes of diffuse pain in the body. NECK AND ARM PAIN Cervical spondylosis Musculoskeletal strain Trauma Rotator cuff syndrome Bicipital tendonitis Arthritis: glenohumeral, acromioclavicular Pancoast tumour Thoracic inlet syndrome Ischaemic heart disease 62 Pearls in Medicine for Students CHRONIC FATIGUE SYNDROME (CFS) Controversial topic; previously known as neurasthenia or myalgic encephalomyelitis. Commonly seen in females in between ages 20-50 years. The chief complaint is chronic fatigue which is made worse by minimal exertion. It is a combined physical and mental (e.g. poor concentration, irritability) fatigability. Aetiological factors are post-viral (e.g. viral hepatitis, infectious mononucleosis), physical inactivity and sleep difficulties. Though the role of stress is uncertain, there is presence of mood disorder in many patients. The onset may be sudden (fibromyalgia is insidious in onset) and tender trigger points are not associated with CFS. Psychotherepy is essential; antidepressants work better in the presence of mood disorder or insomnia. FIBROMYALGIA (FIBROSITIS SYNDROME) It is a chronic multisystem illness characterised by widespread pain and associated with neuropsychological symptoms including fatigue, anxiety, depression, and many medically unexplained symptoms in other systems. Objective signs of inflammation are absent with normal laboratory studies including ESR. It is very often a diagnosis of exclusion; the cardinal feature is specific tender trigger points (note: in anxiety, tender points are present ‘all over’ the body). Women are the worst sufferer (F:M=10:1) who struggles much in family/day to day life. H/O familial disharmony is present in some patients; many have sleep disturbances who awake unrefreshed with poor mental concentration. There is widespread, unremitting pain. The patient may also suffer from irritable bowel syndrome, CFS, tension headache or premenstrual syndrome. There is associated subjective feeling of muscle swelling. Available evidence implicates the central nervous system as key in maintaining pain and other core symptoms of fibromyalgia. Reassurance, sympathetic attitude, aerobic exercise, NSAIDs, antidepressants (amitriptyline, dothiepin), trigger point injections (local anaesthetics/corticosteroid) or acupuncture may be of some help. Many patients do not respond to therapy. SOFT-TISSUE RHEUMATISM This refers to aches and pains which arise from structures surrounding the joint such as tendons, muscles, bursae, and ligaments. D/D with arthritis is done by, Tenderness away from the joint line margin Diffuse Aches and Pains 63 Pain elicited with active movements (never on passive movements) Swelling usually away from the joint Dramatic relief with local injections of corticosteroid THE ANATOMICAL BASIS OF PAIN ARISING IN MUSCULOSKELETAL SYSTEM Joint: Synovium–synovitis Joint capsule–capsulitis Periarticular (soft tissue): Bursa–bursitis soft-tissue Tendon–tendonitis rheumatism Tendon sheath–tenosynovitis Insertion of tendon, ligaments–enthesitis Bone TINGLING AND NUMBNESS This is the commonest paraesthesia in clinical practice → may occur in health due to sitting or sleeping in abnormal awkward position (e.g. sitting in the front rod of a bicycle) for some time (as a result of neuropraxia). Usually these are features of lesion in nerves (peripheral neuropathy), spinal roots (radiculopathy) or spinal tracts. Tingling sensation usually leads to numbness when there is total loss of function of touch as well as pain fibres. Common causes encountered in clinical practice are: 1. Peripheral neuropathy. 2. Carpal tunnel syndrome. 3. Cervical spondylitis. 4. Prolapsed intervertebral disc. 5. Lumbar canal stenosis. 6. Radiculopathy (e.g. from diabetes mellitus). 7. Hyperventilation (hysterical, salicylate overdose). –––– o –––– 64 18....................... Pearls in Medicine for Students CHAPTER Diplopia DEFINITION It is the perception of ‘double vision’ of a single object. MECHANISM OF PRODUCTION In health, coordination of ocular muscles gives rise to conjugate move- ments of the eyes, and as a result binocular vision is achieved. Thus, the visual stimulus falls exactly on the similar parts of two retinae (macula), and an object is perceived as a single unit. Conjugate movements of the eyes are maintained by cortex, brainstem, and via the IIIrd, IVth and VIth cranial nerves. Defective movement of one eye may result in images (from the two eyes) arising from different points on the two retinae → as a result binocular fusion cannot occur in visual cortex → two separate or overlapping images are formed. In paralytic squint, the image from the healthy eye (true image) is clear and distinct, but the image produced on the affected eye is indistinct and blurred (false image; image derived from the retina outside macula) → false image is perceived in the true direction of action of the weak extraocular muscle. Many a time, the head may be involuntarily turned in the dirction of action of paralysed or weak muscles (head tilt). True diplopia becomes single, if one eye is covered by hollow of the palm. Sudden appearance of diplopia usually points towards a neurological lesion. Diplopia results form loss of parallel visual axes, and is commonly due to IIIrd, IVth and VIth nerve palsy, myasthenia gravis and myopathy (e.g. thyrotoxicosis). Diplopia should be clinically assessed in nine cardinal direction of gaze (i.e. the test of voluntary movements of extraocular muscles). Diplopia 65 Cover one eye with a red glass, and ask the patient whether the red or the normally coloured image is the true imge → this ‘red glass test’ often indicates the affected eye. WHY THERE IS NO DIPLOPIA IN CONCOMITANT (NON- PARALYTIC) SQUINT? Squint is of two types: paralytic and concomitant (non-paralytic). In case of paralytic squint, the image on the paralysed side does not fall on the macula and thus diplopia occurs. Whereas in concomitant squint, the image formed by the defective eye is either rejected or suppressed by the occipital (visual) cortex and thus, there is no diplopia. Diplopia is maximum if the eye is moved in the direction of weak muscle. TYPES Binocular: Diplopia perceived when both eyes remain open Uniocular: Diplopia perceived when one eye remains open. POSSIBLE ASSOCIATIONS OF BINOCULAR DIPLOPIA a. Loss of parallel visual axes: Displacement of eyeball by intraocular SOL, orbital pseudotumour. b. IIIrd, IVth, VIth cranial nerve palsy: Intracranial SOL, demyelinating disease, cavernous sinus thrombosis, raised intracranial tension, meningitis, diabetes mellitus, vasculitis, vertebrobasilar insufficiency. c. Muscle disorders: Congenital weakness of extraocular muscles, myasthemia gravis, muscular dystrophy, severe exophthalmos from thyrotoxicosis. d. Miscellaneous: Ophthalmoplegic migraine, temporal arteritis, syphilis, restriction of eye movement (e.g. in pterygium, symblepharon). MONOCULAR (UNIOCULAR) DIPLOPIA Rare and due to eye disorders like: Incipient stage of cataract (water molecule within lens) Subluxation of the lens Peripheral iridectomy (large) Astigmatism Keratoconus Iridolysis as a result of injury Hysteria. 66 Pearls in Medicine for Students THE PEARLS IIIrd nerve palsy does not produce diplopia because of the presence of complete ptosis. Diplopia is complained by the patient as soon as the affected drooped upper eyelid is elevated by fingers In IIIrd, IVth and VIth nerve palsy, there is paralytic squint over and above diplopia In myasthenia gravis, diplopia is associated with diurnal variation of ptosis In concomitant squint, diplopia is absent In IVth nerve palsy, double vision is present for reading and walking downstairs. In IIIrd nerve palsy, diplopia and squint are maximum on looking up and in, while in VIth nerve palsy diplopia occurs in looking in the direction of affected muscle. In myaesthenia gravis and Graves’ disease, diplopia occurs in all directions of gaze Treatment is aimed at correction of the primary defect. In incapacitating diplopia, shielding of the affected eye is advised. –––– o –––– CHAPTER 19....................... Chapter 67 Discoloured Teeth POSSIBILITIES OF STAINED TEETH 1. Chronic betel-leaf chewer, tobacco staining by smokers. 2. Tetracycline therapy (if given during second half of pregnancy, in infancy or in childhood < 8 years of age → permanent discolouration of teeth as well as enamel hypoplasia)–irregularly stained appearance. 3. Minocycline therapy (affects middle part of teeth with a greyish pigmen- tation; involves permanent teeth in comparison to tetracycline which affects temporary teeth. The drug is used in leprosy and nocardiosis). 4. Fluorosis (produces chalky-which patches, yellowish-brown discolouration). 5. Congenital erythropoietic prophyria (teeth are brownish-pink). ↓ erythrodontia, as a result of high porphyrin content → orange-red fluorescence under Wood’s lamp. 6. Unhealthy oral hygiene (the yellowish-brown discolouration may be eradicated after repeated mouth wash/brushing). GRADES OF DENTAL FLUOROSIS Three grades like –– 1. White chalky opacities of patches on enamel with or without faint yellow lines. 2. Distinct brownish discolouration. 3. Pitting of enamel surface, sometimes with chipping of edges. Dental fluorosis which is classically known as ‘mottled enamel’ is essentially a dental hypoplasia with areas of ↓ calcification and ↓ mineralisation. 68 Pearls in Medicine for Students In Punjab, fluorosis manifests in one of the severest forms leading to advanced invalidism. In fluorosis, considerable disability is associated with spinal rigidity, restricted movements of the joints, and flexion deformity of the hips and knees. There is ↑ bone density; tendons, ligaments and even muscles may be mineralised. Ultimately, compressive myelopathy leads to progressive neurological disability. OSTEOSCLEROSIS (BONE TURNS ABSOLUTELY WHITISH IN X-RAY) Fluorosis Metastatic deposits from carcinoma of prostate (commonly), breast, intestine or bronchus Hodgkin’s disease (ivory vertebra) Marble bone disease (osteopetrosis) Osteopoikilosis Vitamin A or D toxicity Jaw in Paget’s disease Diffuse idiopathic skeletal hyperostosis (DISH). –––– o –––– CHAPTER 20....................... Chapter 69 Drop Attacks DEFINITION A fall occurring without warning, giddiness, tripping, apparent paralysis or loss of consciousness. DESCRIBE THE FALL The victims are usually middle-aged or elderly women. They suddenly drop (i.e. fall) to the floor while standing or walking. She/he feels her/ himself falling (intense leg weakness), then crashes the ground (knees buckle, striking the knees/nose upon the ground) and picks her/himself up almost immediately. Some patients describe sudden and momentary loss of power in the legs and

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