2 Medical One Liners 151 - 160

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151. Sitting Duck shaped Heart is seen in Persistant Truncus Arteriosus.

152. Sherman paradox is seen in Fragile X syndrome. (It is Anticipation phenomenon in Fragile X syn)

153. Trethowans sign is positive in slipped femoral epiphysis.

Normally : If an anteroposterior view of the hip joint is taken then a line drawn along the superior surface of the neck should pass through the femoral head. ( This line is Klein's Line )
If the line remains superior to the femoral head then this is termed Trethowans sign.

154. Amrinone and Milrinone - Side effect - Thrombocytopenia.

155. In PSVT (Paroxysmal supraventricular tachycardia), QRS is normal.

156. DOC for typical absence seizures: Ethosuximide 

157. DOC for atypical absence seizures: Valproate

158. Hyperventilation provokes absence seizures.

159. Ring enhancing lesion on CECT Brain - think about NCC and Tuberculomas.

160. JME (juvenile myoclonic epilepsy) never shows complete remission.

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0 Horseshoe Kidney

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Reformated CT image demonstrating Horseshoe kidney with a cyst at its Isthmus.

Image Courtesy : DrAyushGoel

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MedicoNotebook - Founder : DrShiviMudgal , Co-Founder : DrAyushGoel

2 Micro and Macrocephaly

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Micro and Macrocephaly

Microcephaly : > 3 SD below mean

Macrocephaly : > 2 SD above mean

Newborn Head circumference - 35 cm , By 2year sge - it reaches 48cm (i.e 90% of adult head circumference is achieved in 2yr)

Other causes of Microcephaly :

• Familial (AR)
• Down's syndrome
• Edward syndrome
• PEM
• HIE
• Hypoglycemia
• Fetal Alcohol syndrome
• Fetal hydantoin syndrome

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MedicoNotebook - Founder : DrShiviMudgal , Co-Founder : DrAyushGoel

1 Cystic Fibrosis

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Cystic Fibrosis

• Mutation in CFTR gene located on Chromosome 7
• Delta F 508 is the most common mutation (66-70%) seen in CFTR gene. (Though in India, this mutation is seen in 25-30% cases)
• It is considered most common lethal disorder in caucasians.

Normally : CFTR gene ---> Cl channel --- Cl ions out of cell.

Mutation : Cl remains inside. Thus

1. Mucous comes
2. Recurrent infections {Most common : Early - Staph ; Late - Pseudomonas (mucoid) Pneumonia , Burkholderia cepacea }
3. Pancreatic insufficiency - (in Adutls - due to gall stone , alcohol ) , (In Child - due to Cystic Fibrosis)
4. Meconium Ileus
5. Azoospermia

Diagnosis :

• Sweat Cl > 60meq/L on 2 occasions (Normally < 40 )
• Nasal electrode potential difference (diagnostic) (Not in India)
• CFTR mutation
• GER - Barium swallow
• Tc based Nuclear Scan
• Lung function test : Increased RV/TLC

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MedicoNotebook - Founder : DrShiviMudgal , Co-Founder : DrAyushGoel

0 Calcium Regulation

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0 Bronchiolitis

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Bronchiolitis

• Inflammatory obstruction of small airways

• Usually < 2years ( mostly at 6 months )

• Viral infection : RSV ( 50% cases)

Risk factors :

• Top feed ( Breast milk is protective as it has IgA against RSV )
• Smoking mothers

Clinical features :

• Viral prodorme
• Wheezing

 Note :

• Wheezing in < 2year old - think Bronchiolitis
• Wheezing in Adults - think Asthma.

Chest X-Ray : Hyperinflation.

Drug of choice : Humidified Oxygen. ( Antibiotics are not used )



Q. When is Ribavirin used and when is Palivizumab used in cases of Bronchiolitis? 

Answer : When associated with

1. Cyanotic congenital heart disease - Use Ribavirin or Palivizumab
2. Chronic Lung disease patients (Preterm - Bronchopulmonary hypoplasia) - Use Palivizumab

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MedicoNotebook - Founder : DrShiviMudgal , Co-Founder : DrAyushGoel

0 Boomerang sign

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MCQ 120

Q. Boomerang sign is seen on MRI of Brain when the lesion is located in ?

a. Genu of Corpus callosum

b. Body of Corpus callosum

c. Splenium of corpus callosum

d. Any of the above.

ANSWER:

Ans: C

It is Boomerang shaped splenial lesions, visualized as hyperintense lesions on T2-weighted images, fluid attenuated inversion recovery, and diffusion-weighted MR images.

Differential Diagnosis :

• Transient lesion in splenium
• Ischemia
• Posterior reversible encephalopathy syndrome
• Diffuse axonal injury
• Multiple sclerosis
• Marchiafava–Bignami disease
• Lymphoma, and 
• Extrapontine myelinolysis.

Apart from brain imaging : Boomerang sign can also be seen in peroneus brevis split syndrome.

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MedicoNotebook - Founder : DrShiviMudgal , Co-Founder : DrAyushGoel

0 Epiglottitis

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Epiglottitis

Severe Bacterial infection.

Organisms :

• Streptococcus Pyogenes (MC)
• Strep. Pneumoniae
• Staph. Aureus

Features :

• Toxic, febrile, drooling saliva
• Respiratory failure

X-Ray : Thumb Sign

May require Emergency Thracheostomy
DOC : Ceftriaxone with Sulbactam

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MedicoNotebook - Founder : DrShiviMudgal , Co-Founder : DrAyushGoel

0 April 17 - World Hemophilia Day

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World Hemophilia Day is an international observance held annually on April 17 by the World Federation of Hemophilia FH. It is an awareness day for hemophilia and other bleeding disorders, which also serves to raise funds and attract volunteers for the WFH. It was started in 1989; April 17 was chosen in honor of Frank Schnabel's birthday.

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MedicoNotebook - Founder : DrShiviMudgal , Co-Founder : DrAyushGoel

0 Medical One Liners 141 - 150

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141. BP 120/80 is HTN in child <12yrs.

142. Sodium nitropuruside should not be given for >72hrs - else thiocynate toxicity will occur.

143. Sodium nitropuruside and Lineazolid are sensitive to light.

144. In PSVT , QRS is normal and P wave is either absent or inverted.

145. Wheeze/Rhonchi - whistling sound - means air trapped in bronchioles : Seen in

• Asthma (Adults)
• Bronchiolitis ( < 2year old )

146. Klinefelter syndrome is usually not be diagnosed until puberty.

147. NADPH oxidase deficient in chronic granulomatous disease of childhood.

148. Rhabdomyoma (benign cardiac tumor) is associated with tuberous sclerosis.

149. Type I thyroplasty is used for Medialization of cord.

150. Vitamin K dependent coagulation factors are

• II
• VII
• IX
• X
• protein C and S

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0 Rheumatic fever - Causitive organism

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MCQ 119

Q. Rheumatic fever most commonly follows pharyngeal infections with ?

a. Group A Streptococci

b. Group B Streptococci

c. Group C Streptococci

d. Group D Streptococci

ANSWER:

Ans : A
Please see, many times people confuse it with Group B streptococci.
It is Beta haemolytic but Group A , Not Group B.
Do not confuse Beta with Group B.

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MedicoNotebook - Founder : DrShiviMudgal , Co-Founder : DrAyushGoel

0 Contrast enhancement in Astrocytic tumors

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MCQ 118

Q. Contrast enhancement is seen in all except ?

a. Pilocytic astrocytoma - WHO grade I

b. Astrocytoma - WHO Garde II

c. Anaplastic astrocytoma - WHO Grade III

d. Glioblastoma Multiforme - WHO grade IV

ANSWER:

Ans : B

WHO grade II astrocytoma tends to infiltrate along white matter tracts, but the blood brain barrier remains intact. Necrosis and haemorrhage are usually absent.

Contrast enhancement is notably absent in WHO grade II tumors.

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MedicoNotebook - Founder : DrShiviMudgal , Co-Founder : DrAyushGoel

0 CROUP

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CROUP

• Mild infection.
• Viral : Parainfluenzae Virus  
• Barking Cough

X-Ray : The steeple sign is a radiologic sign found on a frontal neck radiograph where subglottic tracheal narrowing produces an inverted "V" shape within the trachea itself. The presence of the steeple sign indicates a diagnosis of croup.

Treatment :

1. Nebulized Racemic Epinephrine
2. High dose Dexamethasone (single) - 0.6 mg/kg

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Image src : http://en.wikipedia.org/wiki/File:Croup_steeple_sign.jpg

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MedicoNotebook - Founder : DrShiviMudgal , Co-Founder : DrAyushGoel

0 Pneumonia in Child

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No Pneumonia	Pneumonia (P)	Severe	Very Severe
Only Cough and cold	Respiratory rate – high >60 : in < 2mnths >50 : in 2 – 12 mnths >40 : in 12 – 60 mnths	P + Chest indrawing	Severe + Cyanosis
T/t – Symptomatic	Cotrimoxazole	IV or IM Penicillin	IV Chloramphenicol

In Child, they are mostly Viral - RSV (MC)

other:
Parainfluenzae
Influenzae
Adenovirus

Chest X-Ray - B/L diffuse interstitial infiltrates.

Bacterial Pneumonia - Causes (Age wise)
In < 2 months	3 months – 3 years	>3 years
Klebsiella ( MC ) E.Coli Staph. Aureus	Pneumococci and Staph H.Influenzae ( Because of vaccination , its not MC now )	Pneumococcus and Staph.

 Drug of choice and MCQ points : 

1. Community Acquired Neonatal Pneumonia : DOC - Ampicillin + Gentamycin

2. Hospital Acquired Neonatal Pneumonia : DOC - Cefotaxime + Amikacin

3. Staph aureus : DOC - Cloxacillin { MRSA : DOC - Vancomycin }

• Can have empyema ( Staph is MC cause of empyema in child )
• Pneumatocele ( other cause - Kerosene oil poisoning )

4. Atypical Pneumonia

• Symptoms : Dry hacking cough
• Pathology : Interstitial (like Viral)
• Organism : Chlamydia , Mycoplasma
• Rare in child < 4 years
• DOC : Macrolides - Erythro , Azithro
• No cell wall in organism - thus Ceftriazone (acts on cell wall) not effective.

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MedicoNotebook - Founder : DrShiviMudgal , Co-Founder : DrAyushGoel

0 Stridor

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Stridor

Stridor is a high-pitched wheezing sound resulting from turbulent air flow in the upper airway.

Its an emergency.

 Causes : 

1. Congenital :

• Laryngomalacia
• Laryngeal Webs

2. Infectious :

• CROUP ( Laryngo-tracheal Bronchitis)
• Epiglottitis
• Laryngeal Diphtheria

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MedicoNotebook - Founder : DrShiviMudgal , Co-Founder : DrAyushGoel

0 April 11 - World Parkinson's Day

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World Parkinson's Day is held on the 11 April of every year, the day is used to promote awareness of Parkinson's Disease and to advocate support for various causes that assist Parkinson's Patients.

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0 Kawasaki disease

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Kawasaki disease 

Self limmiting acute vasculitis of unknown etiology.

Age : 6 months to 2 years

In 20-30% - leads to coronary artery aneurysm -- later MI

Diagnostic criteria

1. Fever > 4days
2. Changes in extremities - erythema , edema , desquamation
3. B/L Conjunctivitis (not ass. with exudates)
4. Polymorphous rash (Not vessicular)
5. B/L cervical LN
6. Changes in lips and oral cavity : Pharyngeal erythema , dry fissure , swollen lips , strawberry tongue , sand pepper rash.

Prevent Coronary complication : 
IV-Immunoglobulin 2g/Kg during acute phase
with Asprin - anti-inflammatory dose- 100mg/Kg/day (2wks)

ECHO : 
if no aneurysm , then do echo every 3-6 months (because they can appear latter too)
if Aneurysm : Life long Asprin (Anti-thrombotic dose : 3-5 mg/Kg/day)

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MedicoNotebook - Founder : DrShiviMudgal , Co-Founder : DrAyushGoel

0 Pediatric Causes of CHF

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Pediatric Causes of CHF 

• In Preterm : PDA , Fluid overload

• In term : Asphyxial Cardiomyopathy

• In 1st wk life : Atresias , Malpositions

• 6 - 10 wks : Acynotic heart disease

• Infant : Coxsackie type B Myocarditis

• Older > 5yrs : Rheumatic fever

MCQ points :

• CHF - leads to RIGHT shift of "Frank starling curve".

• Digoxin - LEFT shift of Curve (Mnemonic DLC)

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MedicoNotebook - Founder : DrShiviMudgal , Co-Founder : DrAyushGoel

0 Rheumatic Fever

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Rheumatic Fever

Organism : Group A beta haemolytic Streptococci

Most frequent --> 5 - 15 years ( it is rare in <5years)
Latent period - 3 wks
After 3 wks - Autoimmune phenomenon - Therefore give Asprin , Steroids.

Modified Jones Criteria for diagnosis :

Major Criteria :

1. Migratory Polyarthritis (MC) (75-80%) - no residual deformity
2. Carditis (50-60%)
3. SubCutaneous Nodules
4. Erythema Marginatum
5. Chorea (late)

Minor Criteria:

Clinical

• Fever
• Arthralgia

Laboratory

• Acute phase reactants: Leukocytosis, elevated eritrosedimentation rate (ESR) and C-reactive protein (CRP)
• Prolonged P-R interval on electrocardiogram (ECG)

Essential Creteria : Past history of streptococcal infection

• Culture throat 
• Increased ASO titre
• Positive Antigen test

MC lesion in heart valve is MR (Mitral Regurgitation),
Later with Rheumatic heart disease - its MS (Mitral Stenosis)

Note: 

• AS (Aort. Stenosis) is never seen.
• Aschoff's nodule on Post mortem biopsy.
• If Chores - then its RF even without other criterias being fulfilled
• During recurrences - Only joint pain.

Treatment :

1. Complete rest till all Acute phase reactants subside
2. Asprin or Steroids for 12 wks

Primary prevention Not possible

Secondary Prevention

• High risk patients
• Give Benzathine Penicillin - 1.2 MU / IM every 3 wks 
• Ideally for life long or Minimum till 35 years / 5yrs from last attack.
• If lesion in heart - give Inf. Endocarditis prophylaxis

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MedicoNotebook - Founder : DrShiviMudgal , Co-Founder : DrAyushGoel

0 April 7 - World Health Day

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World Health Day is celebrated on 7 April to mark the anniversary of the founding of WHO in 1948. Each year a theme is selected for World Health Day that highlights a priority area of public health concern in the world.

The theme for 2013 is high blood pressure.

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MedicoNotebook - Founder : DrShiviMudgal , Co-Founder : DrAyushGoel

0 Ebstein's Anomaly

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Ebstein's Anomaly

• Downward displacement of Tricuspid valve into Right Ventricle.

• Thus there is Atrialization of right ventricle.

• RV is small and in competent , therefore decreased pulmonary blood flow.

• Cause : Maternal Lithium.

• Multiple murmurs - Systolic and diastolic

• Multiple heart sounds like a Quadruple rhythm

• Risk of Arrhythmias - PSVT , WPW

• On Cardiac catheterization - Dysconcordance between intracardiac pressure records and ECG.

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MedicoNotebook - Founder : DrShiviMudgal , Co-Founder : DrAyushGoel

0 Tricuspid Atresia

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Tricuspid Atresia

No blood from Right Atrium to Right Ventricle.
Thus ASD and VSD are required - else the child will not survive.

RV is small - therefore decreased pulmonary blood flow.

ECG - LVH and Left axis deviation

 Note : 
Think Tricuspid Atresia - if LVH and Left axis deviation with cyanosis.

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MedicoNotebook - Founder : DrShiviMudgal , Co-Founder : DrAyushGoel

0 MI in Child

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MI in Child

• ALCAPA - Anomalous origin of Left coronary artery from pulmonary artery

                            Newborn presents with MI -> ST elevation

                            => Anterolateral MI

• Hyperhomocysteinuria (AR) - is Atherosclerotic.

• Kawasaki's Disease - 20-30% cases - coronary artery aneurysm

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MedicoNotebook - Founder : DrShiviMudgal , Co-Founder : DrAyushGoel