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This ten minute clip talks about Chest Trauma including discussion of the following topics:
-Rib Fracture
-Traumatic Rupture of the trachea or bronchus
-Flail Chest
-Pulmonary Contusion
-Myocardial Contusion
-Traumatic Rupture of the Aorta

Written and narrated by a USMLE Expert. ENJOY!!

Thoracic ultrasound for pneumothorax

instructional video discussing the use of thoracic ultrasound for pneumothorax

Tracheal Stenosis

Endoscopic view of stenosis
Resected segment of trachea
3-D CT reconstruction of trachea showing stenosis at mid level

Tracheal stenosis is a narrowing or scarring of the inside of the trachea can produce difficulty breathing;
treatment may be surgical excision, dilation, or stenting.


This algorithm is everything you need to know for the diagnosis and management of Meningitis for your exam. It is written and narrated by a USMLE Expert, and is to the point. All of Meningitis in less than 5 minutes.

Laparoscopic Hysterectomy

Laparoscopic hysterectomy is a surgical removal of the uterus,Laparoscopic hysterectomy is alternative to abdominal hysterectomy.Hysterectomy is the second most common major operation performed in the United States today, second only to cesarian section.The first laparoscopic hysterectomy (LH) was performed in January 1988 by Harry Reich in Pennsylvania.The indications for laparoscopic hysterectomy are similar to the generally accepted indications for hysterectomy.
The contraindications for laparoscopic hysterectomy include postpartum hysterectomy and adnexal masses which cannot be removed with an endobag. The size of the uterus and access to it also limit the scope of the procedure depending on the experience of the surgeon.Hysterectomy is usually performed for problems with the uterus itself or problems with the entire female reproductive complex. Some of the conditions treated by hysterectomy include uterine fibroids (myomas), endometriosis (growth of menstrual tissue outside of the uterine cavity), adenomyosis (a more severe form of endometriosis, where the uterine lining has grown into and sometimes through the uterine wall), several forms of vaginal prolapse, heavy or abnormal menstrual bleeding, and at least three forms of cancer (uterine, advanced cervical, ovarian). Hysterectomy is also a surgical last resort in uncontrollable postpartum obstetrical haemorrhage.Tags,laparoscopic hysterectomy recovery,laparoscopic vaginal hysterectomy

Rotator cuff muscles

"The SITS muscles":
· Clockwise from top:
  • Supraspinatus
  • Infraspinatus
  • Teres minor
  • Subscapularis
· A pro baseball pitcher has injured his rotator cuff muscles. As a result, he SITS out for the rest of the game, and then gets sent to the minor leagues.

How to identify Hematoma in Mammography ??

In this article We will show WELL-CIRCUMSCRIBED and ILL-DEFINED HEMATOMA as seen in Mammogaphy...

Most commonly caused by blunt or surgical trauma, although hematomas may develop in patients who are anticoagulated or have clotting abnormalities. The combination of hemorrhage and edema more commonly results in an ill-defined mass or a diffuse area of increased density. Although the mammographic findings simulate carcinoma, a history of trauma suggests a conservative approach. Follow-up examinations show gradual decrease in size or even disappearance of the lesion. An organized hematoma may occasionally persist as a more sharply defined mass.

Imaging Findings:
Medium to high-density mass, often having slightly irregular margins. Overlying skin edema is usually present in the acute stage if the hematoma is secondary to trauma.
Hematoma. (A) Mammogram of a firm, palpable mass that arose at a recent biopsy site shows a dense lesion associated with skin thickening (arrows). (B) Three months later, there has been almost complete resolution of the hematoma with only minimal residual architectural distortion (arrows).

Overlying skin thickening from edema and bruising may simulate carcinoma. Hematomas tend to resolve within 3 to 4 weeks.

Imaging Findings:
May appear as an ill-defined lesion (more commonly a relatively well-defined mass or a diffuse increase in density).

Hematoma. Ill-defined area of increased density (arrows) in the area of a lumpectomy performed 2 weeks previously.

Algorithm for neonatal resuscitation

Though neonatal resuscitation shares the foundation concepts of airway, breathing, and circulation with adult and pediatric resuscitation, the neonatal algorithm incorporates other concepts central to the care of the newly born infant (e.g. thermal control), emphasizes the importance of establishing adequate lung expansion and ventilation, and dictates key variations in practice resulting from anatomic and developmental differences between neonatal and older pediatric patients.
The algorithm for neonatal resuscitation begins with rapid assessment and the initial steps of resuscitation, then continues through positive-pressure ventilation (including intubation), chest compressions, medications, and special considerations.

This figure shows The algorithm for neonatal resuscitation that begins with a rapid assessment of the infant and continues through the initial steps of resuscitation, positive-pressure ventilation, chest compressions, and medications. Endotracheal intubation may be considered at several steps during resuscitation.

A case of Pityriasis Rosea

A 26-year-old female presents with this rash. She states the rash is minimally pruritic and developed over the last week. She has had some virus-like symptoms and reports the rash began as a large salmon-colored patch on her chest area. The most likely diagnosis is ??
A) tinea versicolor
B) pityriasis rosea
C) varicella
D) psoriasis
E) cocciodiomycosis

The answer is B. (Pityriasis rosea)
Pityriasis rosea is a self-limited, exanthematous skin disease that develops acutely and is characterized by the appearance of slightly inflammatory, oval, papulosquamous lesions on the trunk and proximal areas of the extremities. Pityriasis rosea is largely a disease of older children and young adults. It is more common in women than men.
A prodrome of headache, malaise, and pharyngitis may occur in a small number of cases, but except for itching, the condition is usually asymptomatic. The eruption commonly begins with a “herald patch”: a single round or oval, sharply demarcated pink or salmon-colored lesion on the chest, neck, or back, 2 to 5 cm in diameter. The lesion soon becomes scaly and begins to clear centrally, leaving the free edge of the scaly lesion directed inwards toward the center. A few days or a week or two later, oval lesions similar in appearance to the herald patch, but smaller, appear in crops on the trunk and proximal areas of the extremities The long axes of these oval lesions tend to be oriented along the lines of cleavage of the skin. This characteristic Christmas-tree pattern is most evident on the back, where it is emphasized by the oblique direction of the cleavage lines in that location.

Most cases of pityriasis rosea need no treatment other than reassurance and proper patient education. Topical steroids with moderate potency are helpful in the control of itching. They can be applied to the pruritic areas two or three times daily. Topical antipruritic lotions such as prax, pramagel, or sarna may also be helpful.

The 5 Ts of Right to left shunt

The 5 Ts

1. Truncus arteriosus (1 vessel)
2. Transposition of great arteries (2 vessels transposed)
3. Tricuspid atresia (3 =Tri)
4. Tetralogy of fallot (4 =Tetra)
5. Total anomalous pulmonary venous return (5 =5 words)

Higher Healthcare Costs in 2011

WASHINGTON :- The amount employers spend on their workers' healthcare costs will reach a 5-year high in 2011, and employees will also face larger out-of-pocket costs for their medical care next year, according to a forecast released Monday by the consulting group Hewitt Associates.

Because of higher medical claim costs, an aging population, and changes under the new healthcare reform law, employers can expect to pay nearly 9% more toward their employees' healthcare costs than they did in 2010.
The findings are in line with a recent survey by the National Business Group on Health that asked large employers what they expected to pay for their workers' medical costs in 2011. The answer: about 9% more than in 2010.

The average total healthcare premium per employee working at a large firm will be $9,821 in 2011 -- up from $9,028 in 2010.

Employees will contribute, on average, $2,209, or 22.5% of the total premium, which is a few hundred dollars more than in 2010, when the average employee at a large firm paid 21.8% of their total premium, to total slightly less than $2,000. Once out-of-pocket costs for co-pays and deductibles are factored in, employees can expect to pay about $486 more than they paid toward their medical costs in 2010.

The authors of the Hewitt report say that the new figures mean that healthcare premiums have more than doubled in the past decade and employees' share of their medical costs will have more than tripled.

The high 2011 cost projections are based on a number of factors, the study authors said. For one, employers haven't hired many new employees in recent years, which has resulted in a slightly older work force that is more prone to expensive medical conditions.

Certain insurance market reforms contained in the Affordable Care Act (ACA) -- such as covering dependents until age 26 and eliminating lifetime and annual limits -- contributed to about 1% to 2% to the 9% increase in what employers are likely to pay in 2011.

"After 18 months of waiting for healthcare reform to play out, employers find themselves in a very challenging cost position for 2011," said Ken Sperling, Hewitt's healthcare practice leader, in a press release. "Reform creates opportunities for meaningful change in how healthcare is delivered in the U.S., but most of these positive effects won't be felt for a few years. In the meantime, employers continue to struggle to balance the significant healthcare needs of an aging work force with the economic realities of a difficult business environment."

Hewitt's data came from a database with detailed census, cost, and plan design information for 350 large U.S. employers representing 14.4 million participants and $51.9 billion in 2010 healthcare spending.

Take care of Depression among medical students!!

Medical students with moderate to severe depression more frequently endorsed several depression stigma attitudes than nondepressed students and had a higher rate of suicidal thoughts, according to a study in the September 15 issue of JAMA, a theme issue on medical education.

"Medical students experience depression, burnout, and mental illness at a higher rate than the general population, with mental health deteriorating over the course of medical training. Medical students have a higher risk of suicidal ideation and suicide, higher rates of burnout, and a lower quality of life than age-matched populations," the authors write. They add that medical students are less likely than the general population to receive appropriate treatment, perhaps because of the stigma associated with depression. "Students may worry that revealing their depression will make them less competitive for residency training positions or compromise their education, and physicians may be reluctant to disclose their diagnosis on licensure and medical staff applications."

Thomas L. Schwenk, M.D., of the University of Michigan, Ann Arbor, and colleagues conducted a study to assess the prevalence of self-reported depression and suicidal ideation among medical students and to assess the perceptions of depression stigma by both depressed and nondepressed students. In September-November 2009, the researchers surveyed all students enrolled at the University of Michigan Medical School (n = 769). The survey response rate was 65.7 percent (505 of 769).

Gallblader Ultrasound - Cholecystitis

Histopathology Lung--Bronchiectasis

Endoscopic Anterior Skull Base Resection by RRC

An endoscopic anterior skull base resection may be necessary in select neoplasms. Obviating the need for any external incisions, this approach has become increasingly valuable to address a number of sinonasal neoplasms affecting the anterior skull base, through a minimally invasive technique. This video reviews the endoscopic anterior skull base approach for a typical esthesioneuroblastoma. It also touches on the reconstructive technique using a free alloderm graft, which has been in use by us for over 10 years, and has yielded consistent results, with no CSF leaks.

Skin Prick Testing

This test measures specific IgE attached to Mast cells in the skin

Allergen solutions for skin prick testing: PONI F

  • Positive control (histamine)
  • Occupational allergens (ammonium persulphate, platinum salts, antibiotics, and latex)
  • Negative control (diluent)
  • Inhaled allergens (house dust mite (HDM), grass pollen, cat dander, dog hair)
  • Food allergens

Disadvantages of skin prick test: FISH

  • Food allergens (less standardized), less reliable than inhaled allergens
  • Itching
  • Skin conditions (eczema or dermatographism) interfere with interpretation
  • Histamine antagonists (antihistamines) suppress skin reaction

Mitral Valve Prolapse and Mitral Regurgitation

Mitral valve prolapse and consequent mitral valve regurgitation is seen during TEE examination in a patient undergoing mitral valve repair. The P2 scallop of the posterior mitral leaflet is seen as prolapsed with a flail chord. Color Doppler shows a mitral regurgitant jet.

Increased Medical Student Debt

    The average medical school debt today, according to the Association of American Medical Colleges(AAMC), is $156,456. USA is the only country in the world were future doctors have to bear such a financial burden of their education. That places significant strain on any relationship involving an American medical student.
    Student debt statistics
    •  $156,456 – According to the Association of American Medical Colleges (AAMC), the average educational debt of indebted graduates of the class of 2009.
    •  79 percent of graduates have debt of at least $100,000.
    •  58 precent of graduates have debt of at least $150,000.
    Why medical education debt has increased
    Medical education debt is driven by rising tuition. AAMC data show that median private medical school tuition and fees increased by 50 percent (in real dollars) in the 20 years between 1984 and 2004. Median public medical school tuition and fees increased by 133 percent over the same time period. Other recent 20-year periods show similar trends. Tuition is just one source of increasing debt burdens. Other causes include:
  •  Interest accrued on loans over time significantly adds to the total cost of student debt.
  •  Students are now entering medical school with more education debt from undergraduate education.
  •  Increasing numbers of “non-traditional” students who have children to support.

Diagnostic Criteria for Transverse Myelitis

The term “transverse myelitis” describes a heterogeneous group of inflammatory disorders that are characterized by acute or subacute motor, sensory, and autonomic (bladder, bowel, and sexual) spinal cord dysfunction (Table above).
The clinical signs are caused by an interruption in ascending and descending neuroanatomical pathways in the transverse plane of the spinal cord, and a resulting sensory level is characteristic of the syndrome.

The transverse myelitis syndrome may arise from various causes, but it most often occurs as an autoimmune phenomenon after an infection or vaccination (accounting for 60% of the cases in children) or as a result of a direct infection, an underlying systemic autoimmune disease, or an acquired demyelinating disease such as multiple sclerosis or the spectrum of disorders related to neuromyelitis optica (Devic's disease, a demyelinating disease that is defined by transverse myelitis and optic neuritis).
However, after detailed evaluation, 15 to 30% of the cases of transverse myelitis are ultimately categorized as idiopathic.

1st movie by Doctors Gate :D

Excisional biopsy in melanoma

A 42-year-old female presents with the lesion (shown below) on the back of her calf. She has no significant medical problems and otherwise feels well. The lesion has not bled, but seems to have grown over the last few months. Appropriate initial management of this skin lesion should be??

  • A) observation and removal if bleeding or further change occurs
  • B) complete excision with normal margins
  • C) complete excision with wide margins
  • D) shave biopsy
  • E) electrodessication and curettage

The answer is B. (Complete excision with normal margins) Even in the hands of experienced dermatologists, there is an approximately 15% false negative rate in determining the presence of melanoma based on examination alone; therefore, histologic confirmation is essential for both tumor diagnosis and staging. A complete excision with normal skin margins is preferable when possible as the first diagnostic step (e.g., excisional biopsy).
An incisional biopsy can be performed for larger lesions when complete excision is not practical and when the suspicion of melanoma is low; incisional biopsy does not adversely affect survival. Shave biopsies should be avoided because they may not provide enough tissue for diagnosis and do not allow for accurate depth measurement. All biopsies of lesions suspected of being melanomas should provide a piece of full-thickness skin extending to the subcutaneous fat.

When considering the diagnosis of melanoma, shave biopsies should be avoided because they may not provide enough tissue for diagnosis and do not allow for accurate depth measurement. All biopsies of lesions suspected of being melanomas should provide a piece of full-thickness skin extending to the subcutaneous fat.

Musculoskeletal System &Lumbar Spine Examination

Rectal bezoars in children

A bezoar is a solid mass formed in the gastrointestinal tract as a result of the consumption of indigestible or poorly digestible substances. Bezoars most commonly form in the stomach, but can occur in the small intestine and, rarely, in the colon or rectum. They are usually classified according to the material of which they are derived, for example, trichobezoars (hair), lactobezoars (milk curd), phytobezoars (plant fibre) and medication bezoars. The term originates from the Arabic term badzehar, meaning "antidote," a reference to historical medicinal use of these concretions found in animal gastrointestinal tracts in the treatment of human poisonings.

See this case of a previously well 8 year-old boy was brought to the emergency department with a three-day history of constipation. He had consumed three handfuls of flavoured unshelled sunflower seeds four days previously. His mother had unsuccessfully tried several sodium biphosphate and sodium phosphate enemas at home, as well as the use of bran to aid defecation. On examination, the patient’s abdomen was soft and nontender with normal bowel sounds. A bolus of stool mixed with unshelled sunflower seeds was visible at the anus.

A radiograph of the abdomen showed stool extending from the descending colon down to the rectum, which contained a large mass . Oral phosphate soda and a mineral oil enema were ineffective. The patient was taken to the operating room for digital and instrumental extraction under general anesthesia. He was monitored in hospital for 24 hours and discharged when he was taking liquids and passing soft stool.

Although small rectal bezoars may pass spontaneously, options for the care of patients presenting to clincians with symptomatic rectal bezoars include the use of enemas and extractions with conscious sedation or general anesthesia. Formation of bezoars from sunflower seeds may be more likely in children or preteens who are unable or unwilling to spit out the shells, particularly with flavoured shells.

Oxyhemoglobin dissociation curve

Current Indications for Tonsillectomies

Tonsillectomy-strong indications

1. Carcinoma of the tonsil. The best technique for optimal results from biopsy and staging requires complete removal of the tonsil.
2. Peritonsillar abscess (PTA) . A bacterial abscess, PTA is most often caused by anaerobic organisms. Incision and drainage is mandatory. Recurrent abscess rate is 10% and recurrent abscess may be fatal. Therefore, the tonsil should be removed. This may be done at the time of the initial PTA presentation or may be done electively 6 weeks later.
3. Congestive heart failure. Failure of the right-side of the heart can be caused in young children by a constant upper airway obstruction (SDB/OSA). This is reversed by tonsillectomy.
4. Tonsillitis causing respiratory difficulties, dysphagia, and requiring hospitalization. Any episode of tonsillitis causing respiratory embarrassment, or so severe that hospitalization is required, is best treated by elective tonsillectomy 6 weeks after the episode.

Tonsillectomy-philosophic indications

1. Recurrent tonsillitis. It is currently believed by most otolaryngologists that a patient having four or more episodes of tonsillitis a year for at least 2 years that necessitates their missing 10 or more days a year of school or work will benefit from a tonsillectomy.
2. Sleep disturbances. Sleep disordered breathing/obstructive sleep apnea, and snoring can be caused by upper respiratory tract lymphoid tissues that prolapse into and obstruct the airway during sleep. In these cases, tonsillectomy, adenoidectomy, and even partial palatectomy with uvulectomy (UP3) may improve the airway.

differential diagnosis of inflammatory neck mass

Algorithm for differential diagnosis of inflammatory neck mass. Dx = diagnosis; CT = computed tomography; CBC = complete blood cell count; PT = patient; Bx = biopsy; WBC = white neck mass. Dx = diagnosis; CT = computed tomography; CBC = complete blood cell count; PT = patient, Bx = biopsy; WBC = white blood cell count.

Epley maneuver for Vertigo

The manuever starts sitting upright . This maneuver should be done by a doctor or physical therapist both for safety (you may be dizzy) and to observe the eye movements.

This maneuver is done with the assistance of a doctor or physical therapist. A single 10- to 15-minute session usually is all that is needed. When your head is firmly moved into different positions, the crystal debris (canaliths) causing vertigo will move freely and no longer cause symptoms.

The Epley maneuver is also called the particle repositioning or canalith repositioning procedure. It was invented by Dr. John Epley.
It involves sequential movement of the head into four positions, staying in each position for roughly 30 seconds. The recurrence rate for BPPV( Benign Paroxysmal Positional Vertigo ) after these maneuvers is about 30 percent at one year, and in some instances a second treatment may be necessary.

When performing the Epley maneuver, caution is advised should neurological symptoms (for example, weakness, numbness, visual changes other than vertigo) occur. Occasionally such symptoms are caused by compression of the vertebral arteries ), and if one persists for a long time, a stroke could occur.

Carpal Tunnel Choices

This 3D medical animation depicts carpal tunnel syndrome and carpal tunnel release. Carpal tunnel syndrome is a nerve disorder of the hand caused by compression of the median nerve.2 different types of carpal tunnel release are animated, an open carpal tunnel procedure and the endoscopic approach.

Physical Examination of Respiratory System

part I

part II

Imaging findings in Bladder Rupture

-Diagnostic evaluation of bladder rupture includes voiding cystourethrography (VCUG) or CT scan

o Voiding cystourethrography historically been preferred contrast enhanced
study for diagnosis of bladder rupture
o Bladder needs to be fully distended and evaluation of a post-voiding
film essential
* Plain film:
o "Pear-shaped" bladder
o Paralytic ileus
o Upward displacement of ileal loops
o Flame-shaped contrast extravasation into perivesical fat
+ Best seen on postvoid films
+ May extend into thigh / anterior abdominal wall
One image from an IVU shows a flame-shaped density adjacent to
right lateral wall of bladder representing extra-peritoneal contrast from a bladder rupture

* US
o "Bladder within a bladder" = bladder surrounded by fluid collection

Is Evidence-Based Medicine a Barrier to Cost-Effective Care?

August 29, 2007 presentation by Alan Garber for the Stanford School of Medicine Medcast lecture series.

Alan Garber, MD, PhD, professor of medicine and the director of the Center for Health Policy and of the Center for Primary Care and Outcomes Research at Stanford University, discusses the importance of distinguishing between a treatment's effectiveness and its value, and in turn what role evidence-based medicine should play in today's coverage decisions.

Lower lobe predominance mnemonic


* B: Bronchiectasis
* A: Aspiration pneumonia
* D: Drugs, Desquamative interstitial pneumonia
* A: Asbestosis
* S: Scleroderma and other Collagen vascular diseases


* C: Collagen vascular disease
* I: Idiopathic pulmonary fibrosis
* A: Asbestosis


diopathic pulmonary fibrosis

Algorithm for determining the cause of the Hypernatremia

Hypernatremia is defined as a serum sodium > 145 mEq/L

- hypernatremia can be due to:-

* net loss of water and sodium from the body with inadequate water replacement (commonest cause)
* inadequate water intake
* increased water loss from the body
* increased sodium load

- hypernatremia most commonly results from a net loss of water and sodium from the body coupled with inadequate water intake

- the hypotonic fluid loss can be due to renal (osmotic diuresis or diuretics) or extra-renal (skin or GIT) causes

Inadequate water intake is a universal prerequisite for the evolution of hypernatremia

(* hypernatremia due to indequate water intake is rarely seen in alert patients with a normal thirst mechanism + access to water + an ability to obtain and drink water)

Disorders of the Parathyroid, Pituitary, and Pancreas: MEN 1

Multiple endocrine neoplasia type 1(MEN 1):It is a relatively uncommon "1 person in every 30,000 people" inherited "autosomal dominant disorder, but it may also occur sporadically as a result of new mutations" disease described by Wermer In 1954 .

Parathyroid tumors
Hyperparathyroidism is the most common manifestation of MEN 1.Clinical manifestations include urolithiasis, bone abnormalities, and, in severe cases, generalized weakness and mental or cognitive dysfunction.
Hyperparathyroidism in MEN 1 differs from sporadic cases by earlier age at presentation, involvement of multiple glands, and high recurrence rate postoperatively (50% by 8-12 y after surgery).

Enteropancreatic tumors
Pancreatic islet cell tumors represent the second most common manifestation of MEN 1 and occur in 80% of patients.
Nonfunctioning pancreatic endocrine tumors are the most common pancreatic tumors, occurring in 80-100% of cases
Gastrinomas are the most common cause of symptomatic disease and are found in approximately 60% of patients with MEN 1. Compared with the sporadic form of gastrinomas in Zollinger-Ellison syndrome (ZES), tumors in MEN 1 are more often duodenal, small, and multicentric, thus diminishing the probability of surgical cure. The features predictive of poor prognosis include pancreatic location of lesions, metastases, ectopic Cushing syndrome, and height of gastrin levels. Development of gastrinomas is preceded by multifocal hyperplasia of the gastrin-producing cells. Long-standing MEN 1/ZES may lead to development of gastric carcinoid tumors that might be aggressive.
Insulinomas account for approximately 20-35% of functional pancreatic islet cell tumors. Similar to gastrinomas, they can be multicentric (10-20%), where 25% metastasize either to regional lymph nodes or to the liver.
Glucagonomas occur in 3% of patients with MEN 1 and are silent or present with hyperglycemia. Only a few patients show the typical skin lesions known as necrolytic migratory erythema.

The occurrence of the watery diarrhea, hypokalemia, hypochlorhydria, and acidosis (WDHA) syndrome (incidence approximately 1%) may be due either to either a pancreatic islet cell or to a carcinoid tumor.

Pituitary tumors
These often-multicentric tumors occur in more than 50% of patients and are clinically apparent in up to 20% of patients. These tumors tend to be larger and more aggressive than those not associated with MEN 1.

Prolactinomas are the most common pituitary tumor in patients with MEN 1.

Growth hormone–producing tumors account for 25% of these adenomas. Growth hormone levels rise due to autonomous secretion from the pituitary tumor or, less commonly, by production of growth hormone–releasing factor by a pancreatic or other endocrine tumor.

A pituitary tumor or carcinoid tumor that produces corticotropin can cause Cushing syndrome in patients with MEN 1. Ectopic production of corticotropin-releasing factor from a pancreatic islet cell tumor also has been described.

To read a case of MEN 1 : Click Here

Antrochoanal Polyp

Antrochoanal polyps, are solitary polyps arising from the maxillary antrum. They were first described by Killian in 1906. Although their etiology remains unknown, allergy has been implicated.

These polyps originate in the lining of the maxillary antrum and gradually prolapse through the natural or an accessory ostium into the nasal cavity and enlarge towards the posterior choana and nasopharynx.

They cause nasal obstruction mostly in expiration and serous otitis media if they occlude the eustachian tube. Surgical removal is indicated. Recurrence is frequent and may necessitate a Caldwell-Luc operation.
Endoscopic photograph of right nasal cavity showing an antrochoanal polyp arising from the middle meatus and blocking the right posterior choana.

Coronal CT scan image showing the above antrochoanal polyp arising from the right maxillary antrum and extending into the right nasal cavity through the widened natural ostium of the sinus.

Diabetes-Related Atherosclerosis


Melatonin and it`s uses

Melatonin is a hormone secreted by the pineal gland in the brain. It helps regulate other hormones and maintains the body's circadian rhythm. The circadian rhythm is an internal 24-hour “clock” that plays a critical role in when we fall asleep and when we wake up. When it is dark, your body produces more melatonin; when it is light, the production of melatonin drops. Being exposed to bright lights in the evening or too little light during the day can disrupt the body’s normal melatonin cycles. For example, jet lag, shift work, and poor vision can disrupt melatonin cycles.

It also helps determine when a woman starts to menstruate, the frequency and duration of menstrual cycles, and when a woman stops menstruating (menopause).And has strong antioxidant effects.

Some researchers also believe that melatonin levels drop as we age(as in the diagram).Some people think lower levels of melatonin may explain why some older adults have sleep problems and tend to go to bed and wake up earlier than when they were younger.

Melatonin supplements may help people with disrupted circadian rhythms (such as people with jet lag or those who work the night shift) and those with low melatonin levels (such as some seniors and people with schizophrenia) to sleep better. A review of clinical studies suggests that melatonin supplements may help prevent jet lag, particularly in people who cross five or more time zones.

A few clinical studies suggest that when taken for short periods of time (days to weeks) melatonin is more effective than a placebo in reducing the time it takes to fall asleep, increasing the number of sleeping hours, and boosting daytime alertness. It’s not clear how well melatonin works, however – some studies suggest that it only reduces the amount of time to fall asleep by a few minutes.

Melatonin supplements may help with sleep problems associated with menopause. However, it does not appear to relieve other symptoms of menopause, such as hot flashes. Peri- or postmenopausal women who use melatonin supplements should do so only for a short period of time since long term effects are not known.

3-Benzodiazepine Withdrawal
Some clinical research has found that melatonin may help elderly people with insomnia who are tapering off or stopping benzodiazepines such as diazepam (Valium), alprazolam (Xanax), or lorazepam (Ativan). Taking controlled-release melatonin improved sleep quality in those stopping benzodiazepine use.

4-Breast Cancer
Several studies suggest that melatonin levels may be associated with breast cancer risk. For example, women with breast cancer tend to have lower levels of melatonin than those without the disease. Laboratory experiments have found that low levels of melatonin stimulate the growth of certain types of breast cancer cells, while adding melatonin to these cells slows their growth. Preliminary evidence also suggests that melatonin may strengthen the effects of some chemotherapy drugs used to treat breast cancer. In a study that included a small number of women with breast cancer, melatonin (given 7 days before beginning chemotherapy) prevented the lowering of platelets in the blood. This is a common complication of chemotherapy that can lead to bleeding.

In another small study of women who were taking tamoxifen for breast cancer but seeing no improvement, adding melatonin caused tumors to modestly shrink in more 28% of the women. Women with breast cancer should ask their doctors before taking melatonin.

5-Prostate Cancer
Studies show that people with prostate cancer have lower melatonin levels than men without the disease. In test tube studies, melatonin blocks the growth of prostate cancer cells. In one small-scale study, melatonin -- combined with conventional medical treatment -- improved survival rates in 9 out of 14 men with metastatic prostate cancer. More research is needed before doctors can make recommendations in this area.

6-Attention Deficit Hyperactivity Disorder (ADHD)
Some evidence suggests that melatonin may help promote sleep in children in ADHD, although it does not seem to improve the behavioral symptoms of ADHD.

Vascular invasion: way to follicular thyroid carcinoma

There are 4 types of thyroid carcinoma: papillary, follicular, medullary, and anaplastic carcinoma. One of these types, follicular thyroid carcinoma, can look very much like a benign thyroid adenoma. Both follicular carcinoma and thyroid adenoma are composed of follicles (resembling normal thyroid follicles).
The only way to tell apart follicular thyroid carcinoma (which is malignant) from thyroid adenoma (which is benign) is to take out the entire nodule and examine the entire thing very carefully. If you see tumor cells invading the capsule, or if you see them within vessels (as in the photo above), that means it’s follicular carcinoma. Malignant tumor cells invade; benign ones do not.

Classification of Wound by Sterility

The Centers for Disease Control and Prevention (CDC) “Guidelines for prevention of surgical site infection” identifies four surgical wound classifications.

* an uninfected surgical wound in which no inflammation is encountered and the respiratory, alimentary, genital, or uninfected urinary tracts are not entered.
* clean wounds are primarily closed and, if necessary, drained with closed drainage.
* Surgical wound incisions that are made after nonpenetrating (ie, blunt) trauma should be included in this category if they meet the criteria.
* a surgical wound in which the respiratory, alimentary, genital, or urinary tracts are entered under controlled conditions and without unusual contamination.
* Specifically, surgical procedures involving the biliary tract, appendix, vagina, and oropharynx are included in this category, provided no evidence of infection is encountered and no major break in technique occurs.

* open, fresh, accidental wounds.
* surgical procedures in which a major break in sterile technique occurs (eg, open cardiac massage) or there is gross spillage from the gastrointestinal tract and incisions in which acute, nonpurulent inflammation is encountered are included in this category.
* old traumatic wounds with retained or devitalized tissue and those that involve existing clinical infection or perforated viscera.
* This definition suggests that the organisms causing postoperative infection were present in the wound before the surgical procedure.
A 41-year-old woman presents with amenorrhea for 9 mo.She is found to have a prolactin secreting pituitary adenoma. Laboratory data reveals a serum calcium level of 12.0 mg/dL and hypoglycemia (serum glucose of 49 mg/dL). Which of the following is the most likely diagnosis?
  • a.MEN 1 syndrome
  • b.MEN 2A syndrome
  • c.MEN 2B syndrome
  • d.Sipple syndrome

The answer is (a).  The patient most likely has multiple endocrine neoplasia or MEN 1(Wermer syndrome), an autosomal dominant disorder, consisting of tumors of the Pancreas, Pituitary, and Parathyroid gland (PPP).
MEN 2A(Sipple syndrome) consists of Pheochromocytoma, hyperParathyroidism, and medullary carcinoma of the Thyroid (PPT). Patients with MEN 2B syndrome present with Pheochromocytoma, Neuromas, and medullary carcinoma of the Thyroid (PNT).

Connective Tissue Histology

Shave and Punch Skin Biopsy

Erythema Marginatum Pic in rheumatic

Erythema marginatum is described as the presence of pink rings on the trunk and inner surfaces of the arms and legs which come and go for as long as several months. The rings are barely raised and are non-pruritic. The face is generally spared.

It occurs in less than 5% of patients with rheumatic fever and sometimes called erythema marginatum rheumatica , but is considered a major Jones criterion when it does occur.

It is an early feature of rheumatic fever and may be associated with mild carditis.


In developed countries, rheumatic fever has become very rare and this rash occurs in no more than 2 to 5% of cases of rheumatic fever. However, rheumatic fever has become as common in New Zealand as in some developing countries, especially amongst the Maori children. In the 1990s there appeared to be a resurgence of rheumatic fever in the USA. Erythema marginatum was uncommon in patients with rheumatic fever reported in a large series from Pittsburgh.

Pediatric Bone Marrow Aspiration

Algorithm for the diagnosis of Hyperkalemia

Causes of hyperkalemia:

* tight tourniquets and/or fist clenching
* small needle and/or venous sampling in a high vacuum tube
* over-vigorous centrifugation of the blood specimen and/or laboratory error
* red cell hemolysis
* thrombocytosis
* marked leucocytosis
* abnormal red cell membrane and potassium leakage

Excess potassium intake

* transfusion of old blood
* IV potassium administration
* KCl-containing salt substitutes
* Drugs containing potassium - IV penicillin, potassium citrate
* Unusual po sources - geophagia (clay soil), cautopyreiphagia (burnt match heads), black molasses

Redistributional or transcellular shifts

* cellular damage - burns, crush injury
* IV hemolysis
* tumor lysis
* rhabdomyolysis
* acidemia
* hypertonicity - mannitol, hyperglycemia
* medications - digoxin, somatostatin, succinylcholine, beta blockers
* severe physical exertion
* prematurity (first 72 hours of life)
* fasting in a dialysis patient
* toxins - palytoxin, tetrodotoxin, hydrofluouric acid, cocaine
* familial hyperkalemic periodic paralysis


* lack of renin substrate - very advanced liver failure
* hyporeninemia - diabetic nephropathy, interstitial nephritis, type IV RTA, drugs (NSIAD's, beta-blockers, heparin, cyclosporine)
* decreased aldosterone synthesis - congenital adrenal disease (21 hydroxylase enzyme deficiency and other specific synthetic defects) or acquired adrenal disease (Addison's disease, TB of the adrenals)
* absence or blockade of the aldosterone receptors - pseudohypoaldosteronemia type I, drugs (spironolactone,amiloride, triamterine, cyclosporine, trimethoprim, pentamidine)

Acute renal failure

Chronic renal failure

Urinary tract obstruction

Tubular defects in potassium secretion
* interstitial nephritis
* sickle cell disease
* diabetic nephropathy
* amyloidosis
* renal allograft
* drugs - sulfas, penicillin, rifampin, NSIAD's

Angioneurotic Edema

Angioedema: is the development of large welts below the surface of the skin, especially around the eyes and lips. The welts may also affect the hands, feet, and throat. The condition can be associated with allergies and histamine release.

Infant CPR

Hormonal and Other Changes in Patients with Hypothalamic Amenorrhea.

In patients with hypothalamic amenorrhea, there are alterations of hormones and other factors that affect the secretion of gonadotropin-releasing hormone (GnRH), including :
# low levels of leptin and
# high levels of both ghrelin and neuropeptide Y (NPY).
β-endorphin, corticotropin-releasing hormone (CRH), dopamine, and γ-aminobutyric acid (GABA) are factors that negatively influence GnRH secretion. Some of these factors may also serve as hunger signals from the peripheral to the central nervous system and as links between nutrition and reproduction.
Hallmark findings in adolescents and young women with hypothalamic amenorrhea include overactivity of the hypothalamic–pituitary–adrenal axis, suppression of the hypothalamic–pituitary–ovarian axis, and alterations in thyroid hormone regulation. FSH denotes follicle-stimulating hormone, LH luteinizing hormone, TSH thyrotropin, and T3 triiodothyronine.

“Cotton Wool” Appearance of Paget's Disease

A 63-year-old man presented with a long-standing history of sinusitis and 3 weeks of frontal headache. The physical examination was unremarkable.
The alkaline phosphatase level was elevated at 434 IU per liter (upper limit of the normal range, 129). The serum calcium level was within normal limits.

Radiography of the skull (Panel A) showed thickening of the outer and inner tables of the cranial bones, widening of the diploë, and a “cotton wool” appearance caused by irregular areas of sclerosis (arrows). Computed tomography of the skull (Panel B) confirmed bony expansion, cortical bone thickening, and irregular areas of sclerosis (arrows). These imaging findings reflect the mixed osteolytic and osteoblastic phases of Paget's disease, resulting in accelerated bone turnover with bone deposition and expansion.
The patient was treated with alendronate, which resulted in improvement in frontal headache.

Palate of pipes smokers :Nicotine Stomatitis

Description: The classic form of this disease occurs in the palate of those who smoke pipes. The palatal mucosa is white and criss-crossed by fissures, giving the appearance of a dried creekbed. Small red elevations scattered throughout the lesion are thought to be inflamed orifices of minor salivary gland ducts. It produces no symptoms and may be discovered in a routine oral examination.

Etiology: This lesion is caused by smoking, chiefly pipe smoking. A report of thermally induced nicotine stomatitis in a woman who drank scalding hot tea and soup suggests heat rather than tobacco products are responsible for this condition.

This disease usually dissappears after discontinuance of smoking.
Differential diagnosis: The clinical appearance of nicotine stomatitis coupled with a history of pipe smoking is virtually diagnostic. Biopsy is seldom necessary.

What will you do if your patient swallow your tools!!

Dan Meyer being x-rayed

Frontal X-rays of Dan Meyer

Watch as sword swallower Dan Meyer swallows a 19 inch surgical forceps on moving x-ray fluoroscope.
Dan was honored to receive the 2007 Ig Nobel Prize in Medicine at Harvard for co-authoring the article "Sword Swallowing and it's side effects" published in the December 2006 BMJ British Medical Journal.
Meyer now speaks and entertains at science medical events, festivals, museums, medical associations, and corporate functions around the world.

Moving X-ray Fluoroscope of Sword Swallower Swallowing Surgical Forceps

External carotid artery mnenomic


* SALFOPSM represents the branches the external carotid artery. What does SALFOPSM mean? Who knows? But be thankful that it is easy to remember.

  • S: Superior thyroid artery
  • A: Ascending pharyngeal artery
  • L: Lingual artery
  • F: Facial artery
  • O: Occipital artery
  • P: Posterior auricular artery
  • S: Superficial temporal artery
  • M: Maxillary artery


* Some Angry Ladies Fighting Over PMS
* Some Anatomists Like Freaking Out Poor Medical Students
* Superman and Lois fornicate on Planet Mars Sometimes


Gross Anatomy: Cranial Meninges, Dural Venous Sinuses and Cerebrospinal Fluid

Description of Keratoacanthoma

This raised skin lesion with a central necrotic area has the appearances of a keratoacanthoma. The natural history of these lesions is that, if untreated, they rapidly increase in size over several weeks up to a maximum diameter of 3-4 cm. They then have a plateau phase and eventually regress over several months, leaving a small pit that frequently results in a poor cosmetic outcome.

This skin lesion is a keratoacanthoma. It is a benign, self-limiting skin lesion that occurs on exposed skin, most frequently on the hands and face. It begins as a small erythematous nodule that rapidly grows over 3 to 4 weeks to reach a final size of up to 3 cm in diameter. At this stage it macroscopically shows an area of central ulceration filled with a keratin plug. It has characteristics heaped up shoulders around the crater. Subsequent involution occurs over 3 to 4 months often leaving an ugly and irregular pitted scar if not treated surgically. Most keratoacanthomas are single lesions but a small number of patients develop multiple recurrent lesions.

The aetiology of these lesions is unknown. They are more common in men. The rapid growth often raises clinical suspicion of a squamous cell carcinoma. Diagnosis can be confirmed by a biopsy that transects the lesion, including subcutaneous tissue, as diagnosis depends on its histological architecture rather than cytological features. The important points differentiating a keratoacanthoma from a squamous cell carcinoma are the raised rolled edges with absence of rapidly dividing neoplastic keratinocytes below the level of the deepest skin appendages.
Treatment is by excision biopsy. This results in a cosmetically more acceptable scar than if spontaneous resolution is allowed to occur. Large lesions at sites where surgery may be difficult can be treated by radiotherapy (600 -1000cGy).

Basic Structure of the Nephron

Clinical Complications of Tracheostomy

Horner's Syndrome pic

Horner's Syndrome is a syndrome caused by a lesion in the sympathetic nervous system, especially the cervical chain or central pathways, and characterized by drooping upper eyelid(ptosis), pupillary contraction(miosis), absence of sweating(anhydrosis), and receding eyeball

Loss of sympathetic nervous system input to (in this case) right eye.

Note that right pupil is smaller than left. Also that right eyelid covers a greater portion of eye than on left
(known as ptosis). The etiology in this case was due to tumor infiltrating the sympathetic chain.



Heart Valve Surgery Animation

laparoscopic omentectomy

Location: Amman-Jordan
Osama Badran,M.D.,FACOG , american board certified gynecologist performing laparoscopy for resection of a 4-5 cm omental -metastatic- nodule in the infracoloic omentum . The omentum and nodule are resected.
The patient has endometrial adenocarcinoma , status post hysterectomy, radiation therapy, and chemotherapy. CT scan and PET scan showed a singleton metastatic lesion in the omentum.

Endoscopic Eustachian Tube Obliteration for a CSF Leak by RRC

Endoscopic obliteration of the eustachian tube is a reasonable option prior to attempting an external reexploration of patients who have undergone an acoustic neuroma resection complicated by persistent CSF leak.

Clubbing is Clubbing causes

It is described clinically as a bulbous uniform swelling of the soft tissue of the terminal phalanx of a digit with subsequent loss of the normal angle between the nail and the nail bed.

Since Hippocrates first described digital clubbing in patients with empyema, digital clubbing has been associated with various underlying pulmonary, cardiovascular, neoplastic, infectious, hepatobiliary, mediastinal, endocrine, and gastrointestinal diseases. Finger clubbing also may occur, without evident underlying disease

  • Cyanotic heart disease
  • Lung disease (hypoxia, lung cancer, bronchiectasis, cystic fibrosis)
  • UC/Crohn's disease
  • Biliary cirrhosis
  • Birth defect (harmless)
  • Infective endocarditis
  • Neoplasm (esp. Hodgkins)
  • GI malabsorption

Facts about Pinguecula

A pinguecula is often referred to as a fatty degeneration of the conjunctival tissue, but it may also reflect deposits of lipids from serous exudate. The fine, nearly transparent collagen fibers of the conjunctiva degenerate and are replaced by thicker, yellowish, more durable fibers and sometimes calcium crystals. This causes the elevated, yellow and sometimes whitish glistening area located near the cornea. There is no effect on vision by a pinguecula, which can appear after only a brief exposure to damaging irritation, such as excessive dryness or sun (ultraviolet radiation). The tissue damage increases with continued exposure.

It might take only a day or two to notice a new pinguecula but weeks or months for it to resolve. Removing the source of irritation and providing artificial lubricating drops may shrink and eliminate pingueculae in their early stages; however, long-standing pingueculae do not respond well to treatment and may be permanent. Pinguculae may indicate vitamin A deficiency.


USMLE ALGORITHMS: Bacterial Skin Infections

USMLE Step 3 Bacterial Skin Infections Algorithm with Voice explanation from USMLE Expert.

Principle of Rhinoplasty

Funny Medical Photos 2

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