- pigmentation usually generalized but more prominent over sun-exposed area such as the face,extensor surfaces,elbows,knees,knuckles and scars (which formed after the onset of disease)
- may also affect the palmar crease,mucous membrane,nail beds,vaginal and perianal mucosa
Addison disease
Case 1 : Addison disease
Case 1 : Addison disease
A 12-year-old girl presented with vague abdominal discomfort for 6 months. She had noticed occasional diarrhoea but had not passed any blood. She admitted to weight loss (6kg) and anorexia. On examination, she was obviously pigmented, although she thought this was sun induced; however, her buccal mucosa and gums were also brown. There were no other physical signs.
She had a low cortisol level and her response to the adrenocorticotrophic hormone in a Synacthen test was poor. A diagnosis of adrenal cortical failure was made. X-ray of her abdomen showed no calcified areas in either adrenal gland, and her serum contained antibodies to adrenal cortex, consistent with a diagnosis of Addison's disease due to autoimmune adrenalitis. Her serum also contained antibodies to pancreatic islet cells and thyroid microsomes. In view of her young age at presentation and these serum antibodies, she will be followed at yearly intervals to see if she develops other autoimmune endocrinopathies.
from: www.immunologyclinic.com
Adrenal gland
- found at the level of T12
- divided into 2 area : adrenal cortex and adrenal medulla
- form the core of adrenal gland
- made up by chromaffin cells that produce
- catecholamine : adrenaline and noradrenaline
- dopamine
- form the outer layer of adrenal gland
- consist of 3 layers : zona glomerulosa ,zona fasciculata, zona reticularis
- zona glomerulosa :
- the outermost layer of the cortex
- produce mineralocorticoids mainly aldosterone
- zona fasciculata:
- middle layer
- produce glucocorticoids mainly cortisol
- zona reticularis
- innermost layer
- produce small number of androgens
atrial pressure
- a wave : atrial contraction
- c wave: as ventricle contracts - due probably to bulging of AV valve into atria
- v wave: increases slowly at atrium fills with blood from periphery
atrial pressure reduces when :
- x descent: atrium relaxes and tricuspid valve is pulled downwards
- y descent : tricuspid valve opens and blood flows into right ventricle
cardiac cycle
CARDIAC CYCLE
- one cardiac cycle : one complete cycle that encompasses atrial and ventricle contraction and relaxation
P wave atrial depolarization & contraction fills the ventricles cuspid valves open while valves of vena cava and pulmonary veins are closed QRS complex atrial repolarization and relaxation & simultaneous ventricular depolarization and contraction empties the ventricles cuspid valves are closed while semilunar valves are open T wave ventricular repolarization and relaxation heart relaxes cuspid and semilunar valves are closed pause myocardium at rest atria fill after a pause of some length valves of vena cava and pulmonary veins open so atria can fill
Hypothermia
External signs of hypothermia
- indistinct, blurred margin of pink or brownish pinkish
- usually over the extensor surface of the knee,elbow and hip joint
- not in area where hypostasis might occur
- may have necrosis or blister
- may have frost bites
- Pinkish margin occurs because in hypothermia, cells have a lesser degree of oxygen uptake, thus the pinkish margin id due to oxygenated blood that remains in the blood vessel
- gastric ulceration : blackish or brownish
- patches of fat necrosis
- haemorrhagic pancreatitis
- diffuse lung haemorrhage and pulmonary odema
Case presentation : Occult hip fracture
An 87-year-old man tripped and fell; subsequently, persistent pain developed in the left hip. A radiograph of the left hip 2 weeks after the fall revealed diffuse osteopenia with no evidence of fracture (Panel A). Because clinical suspicion of fracture was great, magnetic resonance imaging (MRI) of the hip was performed, which revealed edema (on fat-suppressed fast spin–echo T2-weighted coronal imaging [Panel B, arrows]) and a nondisplaced fracture line (on T1-weighted coronal imaging [Panel C, arrows]) in the intertrochanteric left hip. The patient desired nonoperative management, and therefore he was given restrictions on weight-bearing activity with close orthopedic follow-up. He was treated empirically with calcium and vitamin D supplementation and a bisphosphonate. The patient has done well, with resolution of hip pain after 4 months of restricted weight-bearing. If hip fracture is not promptly recognized (such as on MRI) and treated, a nondisplaced fracture may, over time, become displaced because of continued weight-bearing, requiring more-invasive surgery, such as hip arthroplasty, for treatment.
From New England Journal of Medicine
Emily N. Vinson, M.D.
Duke University Medical Center
hypopyon,iris prolapse
b) iris prolapse : iris prolapse that occurs thru the opening of the surgical excision post operatively (cataract surgery)
Cataract surgery - ICCE , ECCE, PHACO
intracapsular cataract extraction (ICCE):
-incision is made in the cornea or the anterior sclera
-entire capsule and lens are removed using the cryoprobe
-IOL is placed in the anterior chamber
-incision is then sutured close
-indication: subluxated cataractous lens
extracapsular cataract extraction (ECCE)
-incision is made in the cornea or the anterior sclera (about 10 mm)
-the anterior capsule is opened
-nucleus expression
-aspiration of the lens cortex
-posterior chamber lens implanted into the capsular bag- using haptic lense
Phacoemulsification with IOL
-open the anterior capsule(incision only 3mm)
-fragment the nucleus by using the ultrasonic power ,then remove
-aspirate the lens cortex
-place the post chamber lens into the capsular beg
cataract
morgagnian cataract: liquefaction of the lens cortex while the central nucleus has turned brown and sunken to the bottom of the capsular bag due to gravity
cortical cataract : radial spoke-like opacities
nuclear cataract : nuclear opacification
venous flares
- subdermal
- commonly seen at medial malleoli
- a/w superficial stem perforators and/or deep venous incompetence
- indicative of incompetence direct perforating vein above the calf
- to determine the site of incompetent perforating vein :
- draw imaginary line extended from the anterior and posterior borders of venous flare
- the point it crosses is the incompetent perforating vein
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The Chosen One
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