小兒科雜記Pediatrics topic 1: Unconjugated hyperbilirubinemia in the newborn

Unconjugated hyperbilirubinemia in the newborn

0. Metabolism process review
-- Heme-->[heme oxygenase]-->biliverdin-->[biliverdin reductase]-->bilirubin-->[UGT1A1]-->conjugated bilirubin-->[beta-glucuronidase]-->unconjugated bilirubin

1. Total bilirubin:
-- usually > 1mg/dL
               # hematocrit 50~60% (more RBC)
               # shorter life span of RBC (85 days)
               # deficient UGT1A1

               # increased enterohepatic circulation

-- can reach 10~14 mg/dL @ 3~5 days old (East-Asians) 
-- resolves within the first one to two weeks after birth
-- >25 mg/dL:  bilirubin-induced neurologic dysfunction (BIND)--> kernicterus


2. Neonatal hyperbilirubinemia (>35 wks)
-- check hour-specific Bhutani nomogram: >95th percentile
-- severe if
             # appear at first 24 hrs
             #  >95th percentile
             # 0.2 mg/dL ↑ per hour
             # after 2 weeks
             # conjugated >1 mg/dL or >20 percent

3. Breast milk jaundice
-- >5 mg/dL for several weeks (max. 12 wks)
-- etiology: some unknown factor in milk promoting enterohepatic circulation

4. Breast feeding failure jaundice
-- combined with low output (urine+stool), hypovolemia, weight loss

實戰課題Medical Internship topic 2-2: Physical examinations

Medical Internship topic 2-2: Physical examinations

So let's continue with the PE video review...

1. Kussmaul respirations

https://www.youtube.com/watch?v=TG0vpKae3Js

-- DKA (metabolic acidosis-->respiratory alkalosis)

2. Kussmaul's sign

https://www.youtube.com/watch?v=VCQKA_SPCGs

-- restrictive cardiomyopathy, pericardial effusion, constrictive pericarditis, RV infarction or failure

3. Marcus Gunn pupil
https://www.youtube.com/watch?v=xXIIoMhitqQ
-- retinopathy, nerve damage

4. Horner's syndrome
https://www.youtube.com/watch?v=TToQbaZvNns
https://www.youtube.com/watch?v=JBVGh0gyyYc
-- PAM(ptosis, anhidrosis, miosis)

5. Oppenheim's sign
https://www.youtube.com/watch?v=EiwD6s8dmu4
--UMN lesion

6. Palmomental reflex
https://www.youtube.com/watch?v=Y3Ebk5Yv1Ns
-- frontal lobe lesion

7. Quincke's pulse
https://www.youtube.com/watch?v=ZzwoYTYVHSI
-- aortic insufficiency

8. Cushing syndrome and related findings (no picutres)
This clip contains no pictures but I like it so much. Cushing syndrome is well explained.
https://www.youtube.com/watch?v=2-5XAbjAKpE

9. Tinel's sign
https://www.youtube.com/watch?v=VtrC9dnVrrQ
-- carpel tunnel syndrome

10. Titubation
https://www.youtube.com/watch?v=FpiEprzObIU
-- cerebellar disease

11. Trousseau's sign
https://www.youtube.com/watch?v=SBuquydjZDc
-- hypercalcemia, tetany

12. Xanthelasma
https://www.youtube.com/watch?v=fUdxDxTtCRE

實戰課題Medical Internship topic 2-1: Physical examinations

Medical Internship topic 2-1: Physical examinations

There are some physical examinations that are just too hard to remember.

I think watching videos is a good way to memorize them, so....

here are some YouTube links I think would benefit our learning .

※ Copyrights belong their owners. This is just sharing for a non-profit purpose.

0. Breathing sounds
https://www.youtube.com/watch?v=O8OC7EiqBKQ

1. Anisocornia

https://www.youtube.com/watch?v=jgVJyEOXVvM

-- CN3 palsy

-- Adie's pupil : post viral infection, denervation, sphincter function↓, more common in young women

-- Argyll Robertson pupil: bilateral, related to DM, syphilis, and other systemic diseases

-- Horner's syndrome

Way of description:

mydriasis --> dilated pupils

myosis     --> constricted pupils

2. Angiokeratomas

https://www.youtube.com/watch?v=ddwGZcxBchY

3. Arcus senilis

https://www.youtube.com/watch?v=rhAs5LjXoN8

cp. limbus sign

4. Pterygium, pinguecula

https://www.youtube.com/watch?v=8CcPA9WxEig

5. Brushfield spots

https://www.youtube.com/watch?v=gqSVGaQB4eE

6. Buffalo hump

https://www.youtube.com/watch?v=Y5AvsSUm9pg

7. Bullous myringitis
https://www.youtube.com/watch?v=R2KDzw9TMFM
-- mycoplasma pneumonia

8. Cafe au lait spot
https://www.youtube.com/watch?v=NOqNGq3iG9c
-- neurofibromatosis
-- Von Recklinghausen disease

9. Chaddock's reflex
https://www.youtube.com/watch?v=PFoKzgLxFzw
-- pyramidal tract lesion

10. Chvostek's sign
https://www.youtube.com/watch?v=kvmwsTU0InQ
-- tetany

11. Corrigan's pulse
https://www.youtube.com/watch?v=5YQsd6di6B4

12. Erythema marginatum
https://www.youtube.com/watch?v=5RTeRwfcD9o

13. Gibbus deformity
https://www.youtube.com/watch?v=xXNIuOdjQ24
--Pott's disease(tuberculosis spondylitis)

14. Hoffman's sign
https://www.youtube.com/watch?v=QjtiasgMgwY
-- pyramidal tract disease (unilateral!!!)

15. Koplik's spot
https://www.youtube.com/watch?v=UxKv77tS7bY

耳鼻喉科Otolaryngology topic sixteen: Diseases of oropharynx/OSA/neck mass

Diseases of oropharynx/OSA/neck mass

***Some of these contents overlap with the note of "Diseases of oral cavity".***

1. Anatomy boundary:

-- lower part: hyoid bone

-- upper part: hard/soft palate junction, circumvallate papilla

-- lateral part: palatine tonsil 

2. Innervation

-- soft palate: CN5-2--> sensory, CN10--> motor

-- tongue base: CN7

-- tongue movement: CN9, 10

Otalgia

-- tympanic branch of CN9

-- auricular branch of CN10

3. LN

-- level 2, 3

-- retropharyngeal LN(behind pharynx)

4. Closer look of anatomy

-- crypt: blind tubules

-- cervical spaces

5. Swallowing process

-- oral phase

-- pharyngeal phase < 1 sec

-- tool for examination: barium swallow study, flexible endoscope

6. UADT (upper aerodigestive tract)

-- pharyngitis: mucosal, submucosal inflammation

-- bac.: group A Streptococcous (suppurative, rheumatic fever) , Hemophilus influenza

-- virus(30~60%): rhinovirus, coronarivus, RSV, parainfluenza, influenza
-- fungus: candida(thrush)

-- Waldeyer's ring of lymphoid tissue: direct contact with other tissues

7. Tonsillectomy and adenoidectomy
-- minimal effects to immune system
-- indication: airway obstruction, recurrent infection, suspect neoplasm, few are absolute

8. SOB and sleep disorders
-- sleep pattern: NREM-->REM
-- SOB: primary snoring -->upper airway resistance syndrome(UARS)/EEG change -->OSA;  associated with age & BW
-- DDx: hypopnea, central apnea, obstructive 

-- nasopharyngoscope 
-- cephalometry: facial skeleton, do not assess soft tissue
-- polysomnography: gold standard
-- AHI= apnea index+hypopnea index (frequency in one hour)
-- Friedman staging for UPPP

--treatment: life style change/BW↓, correct hormone, nCPAP, UPPP(surgery, snoring↓ but OSA 50% remain), MMA, radiofrequency tissue volume reduction, pillar implant

9. Neck mass
-- fascia: superficial layer-->muscles, middle layer-->trachea, esophagus, larnyx,thyroid, deep layer
--  etiology: inflammatory, congenital, neoplastic (keypoint: age!!!)

10. 2nd brachial anomalies
11. Thyroglossal duct cyst: midline, Sistrunk operation
12. Metastatic neck mass: firm, fixed, rapid growth

耳鼻喉科Otolaryngology topic fifteen: Diseases of oral cavity

Diseases of oral cavity

1. Oral cavity and pharynx: border
-- junction of hard and soft palate
-- circumvallate papillae

2. LN drainage

From "Cancer Research UK"

3. Taste
-- anterior 2/3 of tongue: CN7, chorda tympani
-- posterior 1/3 of tongue: CN9, glossopharyngeal nerve

4. Gland secretion
-- stimulated: parotid gland
-- automatic: submandibular gland

5. Diseases of oral cavity

Infection: viral or bacterial or fungal(Candida albicans)

Fungal infection
--> acute atrophic candidiasis
--> angular cheilitis (DDx: vitamin B2 deficiency)
-- treatment: neomycin
-- white spot: can be removed

Herpangina
-- young children, more common in summer and autumn
-- Coxsackie A mainly
-- DDx: bacterial infection (pus-like lesions!)

Hand-Foot-and-Mouth
-- Coxsackie A
-- may develope into meningitis, myocarditis

Herpes simplex
-- recurrent cold sore

VZV
-- may associate with Ram-Say-Hunt syndrome

Papilloma
-- associated with HPV infection
-- Oral papilloma is much more benign than recurrent respiratory papillomatosis.

Others

Leukoplakia
-- beware of malig. change

Aphthous stomatitis
-- herpetiform ulcers: fused ulcers, painful
-- treatment: CCl3COOH,  AgNO3

Lichen planus
-- DDx: leukoplakia

Burning Mouth syndrome
-- peri-/post- menopausal women
-- PE: no findings
-- local neuropathy
-- treatment: ani-epileptic drug
-- DDx: LPR

Geographic tongue (benign migratory glossitis)
-- unknown cause

Fissured tongue 
-- unknown cause
-- no treatment

Hairy tongue 
-- unknown cause
-- treatment: hygiene-->brushing

Ranula
-- recurrent sublingual gland obstruction 
-- treatment: marsupialization, remove wall/sublingual gland

Benign neoplasm
-- torus
-- lingual thyroid: midline in area of foramen cecum, +thyroglossal duct cyst, 70% hypothyroidism
-- cysts: F/U if no symptoms
-- fibroma, pyogenic granuloma: response to chronic stimultion
-- neurofibroma: smooth, may occur at other sites at the same time
-- hemangioma: do not bleed as much as hemangioma at other sites
-- pleomorphic adenoma: benign if from salivary gland

Oral cavity cancer
-- most common @ tongue, buccal mucosa
-- risk factor: including drinking alcohol
-- examination tools: upper GI endoscope, chest CT(N2b↑), head and neck CT, PET/MRI... 
-- micro: most common-->SCC, tumor thickness directly associated with meta. and survival
-- treatment: surgery, >0.5 cm --> need neck dissection (LN!)

耳鼻喉科Otolaryngology topic fourteen: Larynx & pharynx

Larynx & pharynx

1. Anatomy

Larynx

-- laryngeal cartilage: x 9

-- cricoid cartilage: the only cartilage 360° surrounding the trachea 

-- arytenoid: 4 intrinsic laryngeal muscles attached

Pharynx

-- narrowest at cricopharyngeal m. (upper esophageal sphincter)

2. Microstructure for phonation

-- cover: epithelium

-- transition: lamina propria

-- body: thyroiarytenoid

--> mucosa wave

3. Innervation

-- superior laryngeal n. external branch: CT muscle

-- recurrent laryngeal n. : all the other intrinsic muscles

4. Swallowing: 5 steps

-- soft palate closure

-- larynx elevation/ anterior movement

-- epiglottis 

-- constrictor muscle

-- crycopharyngeal m. relaxation

*** Right side bronchus: more straight, beware of choking with foreign body

5. Congenital abnormalies

-- laryngomalacia: cartilage/soft tissue collapsing inward during inhalation 

-- vocal cord paralysis: children--> bilateral, combined with other CNS defects 

6. Acquired diseases

-- acute laryngitis: virus infection

-- acute epiglottitis: Hemophilus influenza, airway obstruction, 2~6 y/o children/immunocompromised

-- laryngopharyngeal reflux(LPR): foreign body sensation, granuloma(LPR induced), need 24 hr pH monitor

-- Reinke's edema(polypoid vocal cord): @superficial lamina propria, smokers

-- laryngotracheal trauma: external, iatrogenic(bilateral)

-- laryngotracheal stenosis

-- foreign body ingestion (2/3)/aspiration(1/3):@ cricopharygeal m., 2~4 y/o

               --> pins

               --> peas

               --> coins

               --> meat, bones 

7. Head and neck cancers

-- male >> female : most obvious difference in esophageal cancer

-- 10~20% distal metastasis, mostly to lungs

-- treatment: anterior parts, ex: oral cavity--> surgery; naso/oropharynx: CCRT

 

耳鼻喉科Otolaryngology topic thirteen: Maxillofacial injury

Maxillofacial injury

1. Types and presentations

-- sport injury: from frontal bone to mandible  ↓

-- traffic injury:  from the lower part of a head to the upper  ↑

2. Top priority: airway

Beware of

-- fallen teeth

-- tongue

-- blood clot

3. Circulation

-- rarely cause shock

4. Secondary survey

-- medical record, drug history, allergy, CBC, CXR, urine routine...

5. Intervention

-- surgery: 5~8 days afterwards

-- suture: DO NOT create dead space

-- DO NOT offer morphine as they depress cough reflex and constrict pupils

-- Avoid treatment if no significant displacement of zygoma is present.

-- intervention when orbital floor damage>50%

-- can use iliac crest for reconstruction

6. Trauma

-- 70% lower extremity 

-- 50% ↑upper extremity, chest

7. PE/CT check key spots

-- eminence(-) --> check zygoma 

-- vertical buttress

-- mandible 

-- orbit 

-- soft tissue if complex injury ( eyes, facial n., dental occlusion...)

***Forced duction test: check orbit floor fracture

***Medial canthal ligament

8. Le Fort classification of maxilla fracture

From: RosarioVanTulpe
Red: type 1
Blue: type 2
Green: type 3, craniofacial

-- type 1: floating palate

-- type 2: infraorbital nerve, 35~55% (highest!)

-- type 3: worst-->raccoon eyes, panda face, CNS leakage, olfactory n. damage; least common

9. Zygoma fracture

-- lateral canthal ligament: causing diplopia 

10. Sinus fracture & CSF rhinorrhea

-- caution: anterior cranial fossa, cribriform plate, ethmoid sinus (maxillary sinus-->less likely)

-- 25% CSF leakage

-- CSF rhinorrhea after 1 wk, unilateral, wet handkerchief test, beta-2 transformin

-- treatment: absolute bed rest 7~10 days, avoid weight-lifting, acetazolamide, surgery

*** Antibiotics are NOT needed.

-- localization of CSF rhinorrhea: lumber puncture + contrast media/radioactive agents

11. Children

-- anatomy: cranium to face ratio↑

-- earlier treatment