Regarding Rotator Cuff Injury...

A 23-year-old man presents following a fall onto his left shoulder whilst playing rugby. He complains of pain throughout the shoulder and on examination has weakness when testing internal rotation of the arm compared to the contralateral side.
Radiographs are negative.

Injury to which tendon would explain his symptoms?
A Deltoid
B Infraspinatus
C Subscapularis
D Supraspinatus
E Teres minor

Answer:

A first-time mother brings in her 5-day-old baby for a well-child visit....

A first-time mother brings in her 5-day-old baby for a well-child visit. The nurse weighs the infant and reports a weight of 7 lb 5 oz to the mother. The mother looks concerned and tells the nurse that her baby weighed 7 lb 10 oz when she was discharged 4 days ago.

The nurse’s best response to the mother is:
A. “I will let the doctor know, and he will talk with you about possible causes of your infant’s weight loss.”
B. “A weight loss of a few ounces is common among newborns, especially for breastfeeding mothers.”
C. “I can tell you are a first-time mother. Don’t worry; we will find out why she is losing weight.”
D. “Maybe she isn’t getting enough milk. How often are you breastfeeding her?”

Answer:

A 40 Year old patient presenting with nausea, vomiting and abnormal liver function tests...

A 40-year-old school teacher develops nausea and vomiting at the beginning of the fall semester. Over the summer she had taught preschool children in a small town in Mexico. She is sexually active, but has not used intravenous drugs and has not received blood products.
Physical examination reveals scleral icterus, right upper quadrant tenderness, and a palpable liver. Liver function tests show aspartate aminotransferase of 750 U/L (normal < 40) and alanineaminotransferase of 1020 U/L (normal < 45). The bilirubin is 13 mg/dL (normal < 1.4) and the alkaline phosphatase is normal.

What further diagnostic test is most likely to be helpful?
a. Liver biopsy
b. Abdominal ultrasound
c. IgM antibody to hepatitis A
d. Antibody to hepatitis B surface antigen
e. Determination of hepatitis C RNA

Answer:

Aortic Regurgitation - History, Examination And Study Questions & Answers

Clinical History
· Patients may be asymptomatic (but may have normal or depressed left ventricular function).

· Dyspnoea and fatigue (due to left ventricular impairment and low cardiac output initially on exertion).
· Symptoms of left ventricular failure in later stages.
· Angina pectoris is less common than in aortic stenosis; it usually indicates coronary artery disease.

Examination

1. Pulse
· Collapsing pulse (large volume, rapid fall with low diastolic pressure).
· Visible carotid pulsation in neck (dancing carotids or Corrigan's sign).

· Capillary pulsation in fingernails (Quincke's sign).
· A booming sound heard over femorals ('pistol-shot' femorals or Traube's sign).
· To and fro systolic and diastolic murmur produced by compression of femorals by stethoscope
(Duroziez's sign or murmur).

2. Heart
· Heart sounds are usually normal.
· Apex beat is displaced outwards and is forceful.
· Third heart sound (in early systole with bicuspid aortic valve).
· Early diastolic, high-pitched murmur is heard at the left sternal edge with the diaphragm - if not
readily apparent, it is important to sit the patient forward and auscultate with the patient's breath held
at the end of expiration. When the ascending aorta is dilated and displaced to the right, the murmur
may be heard along the right sternal border as well.
· An ejection systolic murmur may be heard at the base of the heart in severe aortic regurgitation
(without aortic stenosis). This murmur may be as loud as grade 5 or 6, and underlying organic stenosis can be ruled out only by investigations.
· Ejection click suggests underlying bicuspid aortic valve.
· Mid-diastolic murmur of Austin Flint may be heard at the apex. It is typically low-pitched, similar to the murmur of mitral stenosis but without a preceding opening snap.
· Loud pulmonary component of second sound (suggests pulmonary hypertension).

3. General examination
· Head nodding in time with the heart beat (de Musset's sign) may be present.
· Visible carotid pulsation may be obvious in the neck - dancing carotids or Corrigan's sign.
· Check the blood pressure (wide pulse pressure).
· Look for systolic pulsations of the uvula (Muller's sign).
· Check pupils for Argyll Robertson pupil of syphilis.
· Look for stigmata of Marfan's syndrome - high arched palate, arm span greater than height.
· Check joints for ankylosing spondylitis and rheumatoid arthritis.

QUESTIONS

Splenomegaly - Case Study

This man presents with tiredness and lethargy. Please examine his abdominal system and discuss your
diagnosis.

Clinical signs To Look For: 

General

• Anaemia
• Lymphadenopathy (axillae, cervical and inguinal areas)
• Purpura

Abdominal
• Left upper quadrant mass that moves inferomedially with respiration, has a notch, is dull to percussion and you cannot get above nor ballot
• Estimate size
• Check for hepatomegaly

Underlying cause

• Lymphadenopathy
• Haematological and Infective
• Stigmata of chronic liver disease 
• Cirrhosis with portal hypertension
• Splinter haemorrhages, murmur, etc. 
• Bacterial endocarditis
• Rheumatoid hands 
• Felty’s syndrome

Discussion

Causes Of Splenomegaly

A 26-year-old G1P0 woman at 39 weeks’ gestation is admitted to the hospital in labor.

A 26-year-old G1P0 woman at 39 weeks’ gestation is admitted to the hospital in labor. She is noted to have uterine contractions every 7 to 10 minutes. Her antepartum history is significant for a nonimmune rubella status.
On examination, her blood pressure (BP) is 110/70 mm Hg and heart rate (HR) is 80 beats per minute
(bpm). The estimated fetal weight is 7 lbs.
On pelvic examination, she has been noted to have a change in cervical examinations from 4-cm dilation to 7 cm over the last 2 hours. The pelvis is assessed to be adequate on digital examination.

What is your next step in the management of this patient?

Next step in Management: Continue to observe the labor.

Learning Objectives In this Case

1. Know the normal labor parameters in the latent and active phase for nulliparous and multiparous patients.
2. Be familiar with the management of common labor abnormalities and know that normal labor does not require intervention.
3. Know that rubella vaccination, as a live-attenuated preparation, should not beadministered during pregnancy.

Case Discussion: