Archive | July 2010

Cryoglobulinaemia

A medical condition in which the blood contains large amounts of cryoglobulins.

Etiology:

  1. clonal B-cell abnormalities
  2. blood cancers such as multiple myeloma
  3. hepatitis C infection.

Manifestations:

  1. blood vessel inflammation
  2. increased blood viscosity

 Immunology and biochemistry:

Cryoglobulins –

  • are a type of immunoglobulins, a type of gamma globulin.
  • cryoglobulin – zre an abnormal blood protein that has the unusual properties of precipitating from the blood serum when it is chilled (hence the “cryo-“) and redissolving when it is rewarmed.
  • Cryoglobulins congeal or gel at cold temperatures.
  • These proteins are made by B lymphocytes or their derivative cells, plasma cells.

 

Three types of cryoglobinemia:

Type I isolated monoclonal immunoglobulins 10-15% of the total cases These are composed of a single monoclonal immunoglobulin paraprotein (usually IgM). Sometimes, these are represented by light chains only and can be extracted from the urine, or they will accumulate in blood serum in the event of renal failure.[5]
Type II immunocomplexes formed by monoclonal IgM 50-60% of reported cases They usually have a polyclonal component, usually IgG, and a monoclonal component, usually IgM, which has an RF function. The IgM can recognize intact IgG or either the Fab region or Fc region of IgG fragments. This is why most type II cryoglobulins are IgM-IgG complexes.[5]
Type III immunocomplexes formed by polyclonal IgM 25-30% of the reported cases These have very similar function to the type II cryoglobulins, however they are composed for polyclonal IgM and IgG molecules

Stenosing tenosynovitis

Condition of the progressive restriction of the sheath surrounding a tendon, causing inflammation (tenosynovitis).

Implication of tenosynovitis:

Trendelenburg test

Determines the competency of the valves in communicating veins between the superficial and deep veins of the leg. 

Trendelenburg test:

  • Used to evaluate the competence of the valves in the great saphenous vein and in the communicating veins between the superficial and deep venous systems.
  • Elevate the patient’s leg to 90 degrees to empty it of venous blood.
  • Place a tourniquet around the upper thigh tightly enough to occlude the great saphenous
  • Ask the patient to stand
  • Normally this takes about 35s for the saphenous vein to fill from below
  • Release of the tourniquet at 60 s produces no sudden increment in venous filling if the saphenous valves are competent.

Bates, Barbara. 1974. A Guide to Physical Examination. J.B. Lippincott Company, Toronto.

Uterine Fibroids (leiofibromyoma)

Uterine Fibroids are benign smooth muscle tumours of the uterus.

Originates from the myometrium, smooth muscle layer of the uterine wall and the accompanying connective tissue.

It is the most common benign tumour in women.

May present as:

  1. heavy and painful menstruation.
  2. painful sexual intercourse
  3. urinary frequency and urgency

the mass(es), if large, may be felt through the abdominal wall.

 Treatment and management:

ultrasound is a diagnostic tool used to visualize the abdomen.

used to diagnose and differentiate from other forms of abdominal or reproductive cancers.

Uterine fibroid embolization is the non-surgical removal of the growths through the use of a catheter.

Prognosis:

Fibroids often cause no symptoms and need no treatment, and they usually shrink after menopause, but are monitored for changes.

Surgical excision of the fibroid(s) is required for large, painful, symptomatic fibroids.

The malignant version of a fibroid is uncommon and termed a leiomyosarcoma.

Peripheral Arteries

 

Arterial pulses of the arm:

  1. Brachial artery: medial to the biceps muscle above the elbow.
  2. Radial artery
  3. Ulnar Artery at the wrist

 

  • the radial and ulnar arteries are interconnected by two vascular arches within the hand.
  • Circulation to the hand and fingers is thereby doubly protected aainst possible arterial occlusion.

 

Pulses in the legs:

  1. Femoral artery: below the inguinal ligament midway between the anterior superior iliac spine and the symphysis pubis
  2. The Popliteal artery: behind the knee
  3. The dorsalis pedalis artery: on the dorsum of the foot
  4. The posterior tibial artery: just behind the medial malleolus.

 

  • The foot is protected like the hand by an interconnecting arch between the two chief arterial branches supplying it.

Bates, Barbara. 1974. A Guide to Physical Examination. J.B. Lippincott Company, Toronto.

Prostate Examination

 

 

The normal prostate gland: Palpated through the anterior rectal wall, the normal prostate is a rounded heart-shaped structure about 2.5cm in length, projecting less than 1 cm into the rectal lumen. The median sulcus can be felt between the two lateral lobes. Only the posterior surface of the porstate is palpable. Anterior lesions, including those that may obstruct the urethra, may not be detectable by physical examination.

Benign Prostatic Hypertrophy: A very common condition in men over 50yrs. Benign prostatic hypertrophy presents as a firm smooth symmetrical enlargement of the gland. It may bulge more than 1 cm into the rectal lumen. The hypertrophied tissue tends to obliterate the median sulcus.

  Carcinoma of the Prostate: A hard irregular nodule, producing asymmetry of the gland and a variation in its consistency, is especially suggestive of carcinoma. Prostatic stones and chronic inflammation can produce similar findings, and differential diagnosis often depends upon biopsy. Later in its course, the carcinoma grows in size, obliterates the median sulcus and may extend beyond the confines of the gland, producing a fixed, hard irregular mass.

Prostatitis: Acute inflammationof the prostate. Presents as swollen, tender and often somewhat asymmetrical. The gland of chronic prostatitis is variable: it may

  1. feel normal
  2. be somewhat enlarged, tender and boggy
  3. contain scattered firm areas of fibrosis

 

Bates, Barbara. 1974. A Guide to Physical Examination. J.B. Lippincott Company, Toronto.

Pulmonary Fibrosis

A condition characterized by deposition of fibrous tissue in the lung. It decreases lung compliance and results in a restrictive ventilatory defect as seen on pulmonary function testing. A chronic lung inflammation with progressive scarring of the alveolar walls that can lead to death.

Physiology:

Fibrosis, build up of tissue, changes the surface area of lung tissue available for gas exchange. Decreased gas exchange at the lungs results in impaired oxygenation of the body tissues.

Etiology:

Prolonged inflammation, infection or disease of the lungs results in activation of an immune response. Immune cells trigger fibroblasts that replaced damaged lung cells with tough, fibrous cells creating scar tissue or fibrosis in the place of the former healthy lung tissue.

Manifestations:

  1. Dyspnea
  2. Dry cough