Bed sore Stages

Classification
The definitions of the four pressure ulcer stages are revised periodically by the National Pressure Ulcer Advisory Panel (NPUAP) in the United States. Briefly, however, they are as follows:

Stage I is the most superficial, indicated by non blanchable redness that does not subside after pressure is relieved. This stage is visually similar to reactive hyperemia seen in skin after prolonged application of pressure. Stage I pressure ulcers can be distinguished from reactive hyperemia in two ways: a) reactive hyperemia resolves itself within 3/4 of the time pressure was applied, and b) reactive hyperemia blanches when pressure is applied, whereas a Stage I pressure ulcer does not. The skin may be hotter or cooler than normal, have an odd texture, or perhaps be painful to the patient. Although easy to identify on a light-skinned patient, ulcers on darker-skinned individuals may show up as shades of purple or blue in comparison to lighter skin tones.

Stage II is damage to the epidermis extending into, but no deeper than, the dermis. In this stage, the ulcer may be referred to as a blister or abrasion.

Stage III involves the full thickness of the skin and may extend into the subcutaneous tissue layer. This layer has a relatively poor blood supply and can be difficult to heal. At this stage, there may be undermining damage that makes the wound much larger than it may seem on the surface.

Stage IV pressure ulcerStage IV is the deepest, extending into the muscle, tendon or even bone.

Unstageable pressure ulcers are covered with dead cells, or eschar and wound exudate, so the depth cannot be determined.

Antibiotic Resistance and Factors leading to It

Antibiotic resistance

View more presentations from Sulav Shrestha.

Tuberculosis - TB - Gallery

TB Spine Xray Lateral

Scrofuloderma

TB Pleural effussion CXR-PA

Gibbus deformity

Causes of Hemoptysis : Coughing out Blood

• Infections. These include pneumonia; tuberculosis; aspergillosis; and parasitic diseases, including ascariasis, amebiasis, and paragonimiasis.
• Tumors that erode blood vessel walls.
• Drug abuse. Cocaine can cause massive hemoptysis.
• Trauma. Chest injuries can cause bleeding into the lungs.
• Vascular disorders, including aneurysms, pulmonary embolism, and malformations of the blood vessels.
• Bronchitis. Its most common cause is long-term smoking.
• Foreign object(s) in the airway.
• Blood clotting disorders.
• Bleeding following such surgical procedures as bronchial biopsies and heart catheterization.

Irrirtable Bowel Syndrome IBS : Short review and Rome II Criteria

Irritable bowel syndrome (IBS) is a term for a variety of diseases causing discomfort in the gastro-intestinal tract. Also called spastic colon, it is a functional bowel disorder characterized by chronic abdominal pain, discomfort, bloating, and alteration of bowel habits in the absence of any organic cause.

In some cases, the symptoms are relieved by bowel movements.Diarrhea or constipation may predominate, or they may alternate (classified as IBS-D, IBS-C or IBS-A, respectively). IBS may begin after an infection (post-infectious, IBS-PI) or a stressful life event or may begin at onset of maturity without any other medical indicators.

Differential Diagnosis

celiac disease, mild infections, parasitic infections like giardiasis, several inflammatory bowel diseases, functional chronic constipation, and chronic functional abdominal pain.


Symptoms
The primary symptoms of IBS are abdominal pain or discomfort in association with frequent diarrhea or constipation, a change in bowel habits. There may also be urgency for bowel movements, a feeling of incomplete evacuation (tenesmus), bloating or abdominal distention. People with IBS more commonly than others have gastroesophageal reflux, symptoms relating to the genitourinary system, psychological symptoms, fibromyalgia, chronic fatigue syndrome, headache and backache.


Rome Process for Diagnosing IBS
The cardinal requirement for the diagnosis of IBS is abdominal pain. The Rome II criteria is used to diagnose IBS after a careful examination of the patient's medical history and physical abdominal examination which looks for any 'red flag' symptoms. More recently, the Rome III criteria, incorporating some changes over the previous set of criteria, have been issued. The Rome II and III efforts have integrated pediatric contents to their set of criteria.

According to the Rome II committees and the Functional Brain Gut Research Group, IBS can be diagnosed based on at least 12 weeks, which need not be consecutive, of the preceding 12 months there was abdominal discomfort or pain that had two out of three of these features:

Relieved with defecation; and/or
Onset associated with a change in frequency of stool; and/or
Onset associated with a change in form (appearance) of stool.
Symptoms that cumulatively support the diagnosis of IBS:

Abnormal stool frequency (for research purposes, "abnormal" may be defined as greater than 3 bowel movements per day and less than 3 bowel movements per week);
Abnormal stool form (lumpy/hard or loose/watery stool);
Abnormal stool passage (straining, urgency, or feeling of incomplete evacuation);
Bloating or feeling of abdominal distention.
Supportive symptoms of IBS:

A) Fewer than three bowel movements a week
B) More than three bowel movements a day
C) Hard or lumpy stools
D) Loose (mushy) or watery stools
E) Straining during a bowel movement
F) Urgency (having to rush to have a bowel movement)
G) Feeling of incomplete bowel movement
H) Passing mucus (white material) during a bowel movement
I) Abdominal fullness, bloating, or swelling
Diarrhea-predominant: At least 1 of B, D, F and none of A, C, E; or at least 2 of B, D, F and one of A or E.
Constipation-predominant: At least 1 of A, C, E and none of B, D, F; or at least 2 of A, C, E and one of B, D, F.

Red flag symptoms which are not typical of IBS:

Pain that awakens/interferes with sleep
Diarrhea that awakens/interferes with sleep
Blood in the stool (visible or occult)
Weight loss
Fever
Abnormal physical examination

An update to these criteria was issued at the Rome III conference and published in May 2006.The validity of subtypes is called into question:

Management: Davidson

Lupus Manifestations: SLE and skin

Lupus Manifestations

Diagnostic Criteria For Systemic Lupus Erythematosus, ACR

The American College of Rheumatology established eleven criteria in 1982, which were revised in 1997 as a classificatory instrument to operationalise the definition of SLE in clinical trials. They were not intended to be used to diagnose individuals and do not do well in that capacity. For the purpose of identifying patients for clinical studies, a person has SLE if any 4 out of 11 symptoms are present simultaneously or serially on two separate occasions.

1. Serositis: Pleuritis (inflammation of the membrane around the lungs) or pericarditis (inflammation of the membrane around the heart); sensitivity = 56%; specificity = 86% (pleural is more sensitive; cardiac is more specific).
2. Oral ulcers (includes oral or nasopharyngeal ulcers).
3. Arthritis: nonerosive arthritis of two or more peripheral joints, with tenderness, swelling, or effusion; sensitivity = 86%; specificity = 37%.
4. Photosensitivity (exposure to ultraviolet light causes skin rash, or other symptoms of SLE flareups); sensitivity = 43%; specificity = 96%.
5. Blood—hematologic disorder—hemolytic anemia (low red blood cell count) or leukopenia (white blood cell count<4000/µl), class="mw-redirect">lymphopenia (<1500/µl) sensitivity =" 59%;" specificity ="">
6. Renal disorder: More than 0.5g per day protein in urine or cellular casts seen in urine under a microscope; sensitivity = 51%; specificity = 94%.
7. Antinuclear antibody test positive; sensitivity = 99%; specificity = 49%.
8. Immunologic disorder: Positive anti-Smith, anti-ds DNA, antiphospholipid antibody, and/or false positive serological test for syphilis; sensitivity = 85%; specificity = 93%. Presence of anti-ss DNA in 70% of cases (though also positive with rheumatic disease and healthy persons)
9. Neurologic disorder: Seizures or psychosis; sensitivity = 20%; specificity = 98%.
10. Malar rash (rash on cheeks); sensitivity = 57%; specificity = 96%.
11. Discoid rash (red, scaly patches on skin that cause scarring); sensitivity = 18%; specificity = 99%.

The mnemonic to remember the 11 symptoms is 'SOAP BRAIN MD'.

Some people, especially those with antiphospholipid syndrome, may have SLE without four criteria, and also SLE may present with features other than those listed in the criteria.

Chest Pain Differential Diagnosis

Myocardial Ischaemic Pain

The main feature of myocardial ischaemia (impending infarction) is usually prolonged chest pain. Typical characteristics of the pain include:
Duration usually over 20 minutes
Located in the retrosternal area, possibly radiating to the arms (usually to the left arm), back, neck, or the lower jaw
The pain is described as pressing or heavy or as a sensation of a tight band around the chest; breathing or changing posture does not notably influence the severity of the pain.
The pain is continuous, and its intensity does not alter
The symptoms (pain beginning in the upper abdomen, nausea) may resemble the symptoms of acute abdomen. Nausea and vomiting are sometimes the main symptoms, especially in inferoposterior wall ischaemia.
In inferoposterior wall ischaemia, vagal reflexes may cause bradycardia and hypotension, presenting as dizziness or fainting.
Electrocardiogram (ECG) is the key examination during the first 4 hours after pain onset, but normal ECG does not rule out an imminent infarction.
Markers of myocardial injury (cardiac troponins T and I, creatine kinase-MB mass) start to rise about 4 hours after pain onset. An increase of these markers is diagnostic of myocardial infarction irrespective of ECG findings.
Minor signs of myocardial infarction in ECG, see Table 1 in the original guideline document
Nonischaemic Causes of Chest Pain

Illness/condition Differentiating symptoms and signs
Reflux oesophagitis, oesophageal spasm
No ECG changes
Heartburn
Worse in recumbent position, but also while straining, like angina pectoris
The most common cause of chest pain

Pulmonary embolism
Tachypnoea, hypoxaemia, hypocarbia
No pulmonary congestion on chest x-ray
Clinical presentation may resemble hyperventilation.
Both arterial oxygen pressure (PaO2) and partial arterial pressure of carbon dioxide (PaCO2) decreased.
Pain is not often marked.
D-dimer assay positive

Hyperventilation
Hyperventilation Syndrome

The main symptom is dyspnoea, as in pulmonary embolism.
Often a young patient
Tingling and numbness of the limbs, dizziness
PaCO2 decreased, PaO2 increased or normal
Secondary Hyperventilation

Attributable to an organic illness/cause; acidosis, pulmonary embolism, pneumothorax, asthma, infarction, etc.

Spontaneous pneumothorax
Dyspnoea is the main symptom.
Auscultation and chest x-ray

Aortic dissection
Severe pain with changing localization
Type A dissection sometimes obstructs the origin of a coronary artery (usually the right) with signs of impending inferoposterior infarction
Pulses may be asymmetrical
Sometimes broad mediastinum on chest x-ray
New aortic valve regurgitation

Pericarditis
Change of posture and breathing influence the pain.
A friction sound may be heard.
ST-elevation but no reciprocal ST depression

Pleuritis
A stabbing pain when breathing. The most common cause of stabbing pain is, however, caused by prolonged cough

Costochondral pain
Palpation tenderness, movements of chest influence the pain
Might also be an insignificant incidental finding

Early herpes zoster
No ECG changes, rash
Localized paraesthesia before rash

Ectopic beats
Transient, in the area of the apex

Peptic ulcer, cholecystitis, pancreatitis
Clinical examination (inferior wall ischaemia may resemble acute abdomen)

Depression
Continuous feeling of heaviness in the chest, no correlation to exercise
ECG normal

Alcohol-related
A young male patient in a casualty department, inebriated


ST changes resembling those of acute ischaemia
ST segment elevation
Early repolarization in V1–V3. Seen particularly in athletic men ("athlete's heart")
Acute myopericarditis in all leads except V1, aVR. Not resolved with a beta-blocker.
Pulmonary embolism – in inferior leads
Hyperkalaemia
Hypertrophic cardiomyopathy



ECG
ST segment depression
Sympathicotonia
Hyperventilation
Pulmonary embolism
Hypokalaemia
Digoxin
Antiarrhythmics
Psychiatric medication
Hypertrophic cardiomyopathy
Reciprocal ST depression of an inferior infarction in leads V2–V3–V4
Circulatory shock

QRS changes resembling those of Q wave infarction
Hypertrophic cardiomyopathy
Wolff-Parkinson-White (WPW) syndrome
Myocarditis
Blunt cardiac injury
Massive pulmonary embolism (QS in leads V1–V3)
Pneumothorax
Cardiac amyloidosis
Cardiac tumours
Progressing muscular dystrophy
Friedreich's ataxia

ST changes resembling those of a non-Q wave infarction
Increased intracranial pressure – subarachnoid bleed – skull injury
Hyperventilation syndrome
Post-tachyarrhythmia state
Circulatory shock – haemorrhage – sepsis
Acute pancreatitis
Myopericarditis

CAUSES OF ABDOMINAL PAIN: DD

Possible causes include:

Appendicitis (inflammation of the appendix)
Bowel obstruction
Cholecystitis (inflammation of the gallbladder) with or without gallstones
Chronic constipation
Dissecting abdominal aortic aneurysm
Diverticular disease, including diverticulitis
Easly-stage shingles (a viral infection where pain begins before the appearance of a rash)
Excessive gas
Food allergy
Food poisoning (salmonella, shigella)
Gastroesophageal reflux
Heartburn or indigestion
Hernia
Infectious mononucleosis
Inflammatory bowel disease (Crohn's disease or ulcerative colitis)
Intussusception -- while uncommon, this is a serious possible cause of pain in an infant who may be bringing the knees to the chest and crying
Irritable bowel syndrome
Kidney stones
Lactose intolerance
Pancreatitis (inflammation of the pancreas)
Parasitic infections (Giardia)
Sickle cell crisis
Spinal fracture
Ulcers
Urinary tract infections
Viral gastroenteritis (stomach flu)

List Of All Infectious Diseases

Viral infectious diseases
AIDS – Chickenpox (Varicella) – Common cold – Cytomegalovirus Infection – Colorado tick fever – Dengue fever – Ebola hemorrhagic fever – Hand, foot and mouth disease – Hepatitis – Herpes simplex – Herpes zoster – HPV – Influenza (Flu) – Lassa fever – Measles – Marburg hemorrhagic fever – Infectious mononucleosis – Mumps – Norovirus – Poliomyelitis – Progressive multifocal leukencephalopathy – Rabies – Rubella – SARS – Smallpox (Variola) – Viral encephalitis – Viral gastroenteritis – Viral meningitis – Viral pneumonia – West Nile disease – Yellow feverBacterial Anthrax –

Bacterial
Meningitis –
Botulism – Brucellosis – Campylobacteriosis – Cat Scratch Disease – Cholera – Diphtheria – Epidemic Typhus – Gonorrhea – Impetigo– Legionellosis – Leprosy (Hansen's Disease) – Leptospirosis – Listeriosis – Lyme disease – Melioidosis – Rheumatic Fever;MRSA infection – Nocardiosis – Pertussis (Whooping Cough) – Plague – Pneumococcal pneumonia – Psittacosis – Q fever – Rocky Mountain Spotted Fever (RMSF) – Salmonellosis – Scarlet Fever – Shigellosis – Syphilis – Tetanus – Trachoma – Tuberculosis – Tularemia – Typhoid Fever – Typhus– Urinary Tract Infections

Parasitic infectious diseases
African trypanosomiasis – Amebiasis – Ascariasis – Babesiosis – Chagas Disease – Clonorchiasis – Cryptosporidiosis – Cysticercosis – Diphyllobothriasis – Dracunculiasis – Echinococcosis – Enterobiasis – Fascioliasis – Fasciolopsiasis – Filariasis – Free-living amebic infection – Giardiasis – Gnathostomiasis – Hymenolepiasis – Isosporiasis – Kala-azar – Leishmaniasis – Malaria – Metagonimiasis – Myiasis – Onchocerciasis – Pediculosis – Pinworm Infection – Scabies – Schistosomiasis – Taeniasis – Toxocariasis – Toxoplasmosis – Trichinellosis – Trichinosis – Trichuriasis – Trichomoniasis – Trypanosomiasis

Fungal infectious diseases
Aspergillosis – Blastomycosis – Candidiasis – Coccidioidomycosis – Cryptococcosis – Histoplasmosis – Tinea pedisPrion infectious diseases transmissible spongiform encephalopathy – Bovine spongiform encephalopathy – Creutzfeldt-Jakob disease – Kuru–Fatal Familial Insomnia–Alpers Syndrome –