Stigmata of infective endocarditis

• Fever (often spiking)
• Continuous presence of micro-organisms in the bloodstream in serial collection of blood cultures
• Vegetations on valves on echocardiography, which sometimes can cause a new or changing heart murmur, particularly murmurs suggestive of valvular regurgitation
• Vascular phenomena:

Septic emboli - mitral regurg -> LA dilatation -> ectopic foci -> stasis in LA -> formation of thrombi -> circulatory problems such as stroke or gangrene of fingers

Janeway lesions (painless hemorrhagic cutaneous lesions on the palms and soles)

hemorrhage: intracranial hemorrhage, conjunctival hemorrhage, splinter hemorrhages

• Immunologic phenomena: Glomerulonephritis, Osler's nodes (painful subcutaneous lesions in the distal fingers), Roth's spots on the retina, positive serum rheumatoid factor

References:

• http://en.wikipedia.org/wiki/Endocarditis
  

Peroneus tendons

Remember that ligaments are
structures that connect bone to bone wheras tendons are structures that muscle to bone.

The peroneus tendons are often involved in inversion sprains of the ankle if they are overstretched.

The peroneus longus muscle arises from the head and lateral/superior shaft of the fibula. It follows a path down the lateral side of the leg passing behind the lateral malleolus and goes under the lateral aspect of the foot to attach on the plantar surface (bottom) of the foot on the medial cuneiform and the base of the first metatarsal. It performs ankle plantarflexion and eversion.

The peroneus brevis muscle arises from the shaft of the fibular, but more distally on the shaft than peroneus longus. It also passes down the lateral aspect of the lower leg and behind the lateral malleolus to insert on the lateral tubercle of metatarsal V. Unlike peroneus longus, it does not go under the foot. It also performs plantar flexion and eversion of the ankle.

References:

• http://www.dubinchiro.com/features/PDF/16ankle.pdf
• http://www.courses.vcu.edu/DANC291-003/unit_8.htm
  

Management of AF

References:

• http://www.aafp.org/afp/20020715/249.html
  

Difference between a twitch and a tremor

A twitch is a jerky or spasmodic movement.

A tremor is an involuntary, rhythmical, alternating movement.

Pars defect

Spondylolysis is a condition in which the there is a defect in a portion of the spine called the pars interarticularis (a small segment of bone joining the facet joints in the back of the spine). The pars interarticularis defect can be on one side of the spine only (unilateral) or both sides (bilateral). The most common level it is found is at L5-S1, although spondylolisthesis can occur at L4-5 and rarely at a higher level.

Spondylolysis is the most common cause of isthmic spondylolisthesis, in which one vertebral body is slipped forward over another.

References:

• http://www.spine-health.com/topics/cd/spondy/spondy01.html
• http://www.chirogeek.com/005_Spondylo-Slide-Show.htm
  

Ottawa ankle rules

Online resources

• Wikipedia has a nice, short summary of these rules.
• An online version of these rules in also available.

References

• http://www.mdcalc.com/anklekneerules
  

S1Q3T3

What it is

The S1Q3T3 is the ECG manifestation of acute pressure and volume overload of the right ventricle.

It is characterised by:

• Lead I - an S wave signifying a complete or more often incomplete RBBB.
• Lead III - a Q wave, slight ST elevation, and an inverted T wave. These findings are due to the pressure and volume overload over the right ventricle which causes repolarization abnormalities.

Causes

Any cause of acute cor pulmonale can cause the S1Q3T3 finding on the ECG. This includes PE, acute bronchospasm, pneumothorax, and other acute lung disorders. In addition, transient LPFB may cause this finding as well.

What this means for Dx'ing PE

The ECG is often abnormal in PE, but findings are not sensitive & not specific. S1Q3T3 pattern is present in only in 20% of cases of PE.

The ECG is a poor diagnostic tool for PE. The greatest utility of the ECG in the patient with suspected PE is ruling out other potential life-threatening diagnoses such as MI.


References:

• http://medicine.ucsf.edu/housestaff/Chiefs_cover_sheets/ecg_pe.pdf
• http://www.ispub.com/ostia/index.php?xmlFilePath=journals/ijem/vol3n1/cor.xml
  

Ileus

Ileus is a partial or complete non-mechanical blockage of the small and/or large intestine. It causes colic, vomiting, and constipation.

Ileus occurs because peristalsis stops. Causes of ileus include:

• peritonitis
• disruption or reduction of the blood supply to the abdomen e.g. post-operatively
• kidney diseases, especially when potassium levels are decreased
• gallstone ileus - obstruction of the large intestine by a gallstone that has blocked the intestinal opening.

References:

• http://www.answers.com/topic/ileus
• http://www.answers.com/gallstone%20ileus
  

Pneumoperitoneum

Pneumoperitoneum is air or gas in the abdominal (peritoneal) cavity.

A pneumoperitoneum is deliberately created by the surgical team in order to perform laparoscopic surgery. This is achieved by insufflating the abdomen with carbon dioxide.

Aetiology

The most common cause is a perforated abdominal viscus, generally a perforated ulcer, although any part of the bowel may perforate from a benign ulcer, tumor or trauma.

A perforated appendix seldom causes a pneumoperitoneum.

Diagnosis

It is often seen on x-ray, but small amounts are often missed and CT is nowadays regarded as the gold standard in the assessment because CT can visualize as small as 5 cm cubic air.

Complications

Increased intrathoracic pressure -> decreased venous return. This means that DVT prophylaxis is required!!

References:

• http://en.wikipedia.org/wiki/Pneumoperitoneum