Difference between temporal bone fracture types: Longitudinal Vs Transverse: Made Easy

The temporal bone fracture are common with head injury accounting for 30 % of all head trauma and 75 % of all motor vehicle accident. 31% of temporal bone fracture are associated with Motor vehicle accident. 

Longitudinal fracture are common fracture caused by lateral forces over the mastoid and temporal squamosa and fracture line parallels petrous pyramid axis. It is generally anterior and extra-labyrinthine.

NEURAL SYMPTOMS WITH TRANSVERSE #

PHYSICAL SYMPTOMS WITH LONGITUDINAL #

Difference between temporal bone fracture types: Longitudinal Vs Transverse

Nerve Injury or neural component more common with transverse # Facial nerve injury(VII), vertigo(VIII: Vestibular Nerve), Sensorineural hearing loss(VIII: Auditory Nerve) and Nystagmus (vestibular Nerve/ CNS component) are more common and intense with transverse fracture.

Physical damage like bleeding demonstrated as  Hemotympanum and otorraghia , fractures seen as  CSF otorrhea, Conductive hearing loss due o disruption of ossicles and Tympanic membrane perforation, are common with longitudinal fracture. Neural component less common or less intense than it’s contrary.

Differential diagnoses of various otological symptoms

Parameter		Longitudinal Fracture	Transverse Fracture
Direction Of  Fracture		Along The Axis Of Petrous Pyramid	Perpendicular To Petrous Pyramid
Incidence		More Common (80%)	20%
Mechanism		Parieto Temporal Trauma	Fronto Occipital Trauma
Otoraghia	PHYSICAL DAMAGE	Common	Rare
Hemotympanum		Common	Possible
TM Perforation		Common	Rare
CSF Otorrhoea		Common	Occasional
Hearing Loss		Conductive	Sensorineural	NEURAL DAMAGE
Facial Nerve Injury		Less Common (20%) Often Temporary Delayed Onset	More Common (50%) Often Permanent Acute Onset
Vertigo		Common (Less Intense)	More Intense
Nystagmus		Common (Less Intense)	Common Third Degree

Indications for Cesarean Section: Mnemonics

Cesarean Section is the delivery of the product of conception after the period of viability by making an incision in the anterior wall of the Uterus.

Cesarean section step by step procedure (Flowchart)

Indication for Cesarean Section:  Mnemonic

Points to be noted are

1.       Product of Conception can be living or dead.

2.       Before viability, if POC is removed by undergoing surgical Procedure it will be called Hyste-RO-tomy (Not Hyste-REC-tomy) and not caesarean section.

3.       The delivery is made by making an incision on the anterior wall of the UTERUS. Though incision on anterior wall of the ABDOMEN is necessary to reach the anterior wall of uterus, the definition of cesarean section will be incomplete just by mentioning the anterior abdominal wall. So delivery of ruptured uterus and abdominal pregnancy is not C section.

Absolute Indication For C Section

Absolute Indications for Cesarean section.

1.       Central Placenta Previa

2.       Contracted Pelvis/ Absolute Cephalopelvic disproportion

3.       Advanced Carcinoma of Cervix

4.       Pelvic masses Causing obstruction of pathway.

5.       Vaginal Canal Obstruction Stenosis or atresia

6.       Umbilical Cord Prolapse

7.       Transverse lie

8.       Eclampsia and HELLP Syndrome (Life threatening condition)
              
 Learn about history taking in Obstetrics.

Relative Indications

Relative Indications of CS

1.       Relative Cephalopelvic Disproportion

2.       Previous Cesarean section

a.       Two previous C Section

b.      Scar dehiscence

c.       Previous CS was for recurrent condition

d.      Previous Classical CS

3.       Dystocia

a.       Power: Poor effort by mother, inefficient uterine contractions

b.      Passage: CPD

c.       Passenger:  Large Fetus,

4.       Fetal Distress

a.       Non Reassuring CTG

b.      Fetal Asphyxia and acidosis

5.       Antepartum Hemorrhage

a.       Placenta Previa (type IIb,III)

b.      Abruptioplacentae

6.       Malpresentation

a.       Primi Breech

b.      Non Frank Breech

c.       Brow

d.      Shoulder

7.       Failed Progression of Labor

a.       Secondary Arrest

b.      Prolonged Labor

c.       Failed Instrumental Delivery

8.       Failed Induction of labor (Drugs, Artificial Rupture of Membrane)

9.       Bad Obstetrics history

10.   Hypertensive Disorders

a.       Severe Preeclampsia

b.      Eclampsia

11.   Infections

a.       Chorioamnionitis

b.      HPV (Condyloma Acuminata)

c.       HIV

12.   Multifetal Pregnancy

a.       Mono amniotic twin

b.      Conjoint Twins

13.   Gynecological Illness

a.       Mechanical Obstruction due to Benign or Malignant pelvic tumor

b.      Following repair of VVF (vesicovaginal Fistula)

14.   Medical Conditions

a.       Uncontrolled Diabetes Mellitus

b.      Heart Disease (Rheumatic/ Congenital/ Coarctation of aorta)

c.       Marfan Syndrome

Learn about Gravida, Para with clinical case scenarios.

Mnemonics: Breast Cancer causes

Risk Factors for Development of Breast Cancer (A to G Guide)

For easy remembrance of the risk factors that can cause breast cancer, it is grouped into 7 major titles that start from A to G, and under each heading both protective factors or factors that has least causative effect and factors that has strong risk are classified and described.

Risk Factors for development of Breast Carcinoma

		Risk	Protective
A	Age	Old age >90 years (~20%)	Rare <20 years
B	Benign Breast Conditions	Hyperplasia (1.5-3 fold) Papilloma (1.5-3 fold) Ductal / Lobular Atypical hyperplasia (5 fold)
C	Cancer	Cancer of contralateral Breast (3-4 fold) Cervix Ovary Colon Prostate Radiation Therapy for Hodgkin's Lymphoma
D	Diet	Alcohol Phytoestrogen Deficiency	Vitamin C
E	Estrogen (Conversion of Steroid hormone to estradiol in the body fat)	Nulliparous Obese Postmenopausal Women Exogenous Estrogen (OCP, Mixed prep HRT)	Breast feeding Late Menarche Early Menopause Early age at 1st child birth
F	Familial History	2-10 fold risk in family history of Breast, Colon, Ovarian and Prostate Carcinoma
G	Genetics	BRCA 1 (Breast Ovarian, prostate and Colorectal Ca ) BRCA2 (Male Breast Ca) p53 HER 2
G	Geography	African american (Western world 1-3 % of all death of women )	Rare in Japan and Taiwan

Source: Bailey and Love’s Short Practice of Surgery.

Causes of altered sensation of Smell

Learn how to examine the sense of smell.

Anosmia (No smell)

Atrophic rhinitis

Peripheral neuritis

Degenerative Disease of Nose

Injury to factory nerve

Injury to olfactory bulb

Anterior Cranial fossa fracture

Intracranial abscess

Intracranial tumors

Meningitis

Causes of various types of Nasal discharge.

Parosmia (Perversion of smell)

Recovery Phase of post influenza anosmia

Intracranial tumor

Clinical Examination of Nose and PNS

Hyposmia (Decreased Smell)

Nasal Polyp

Enlarged Turbinate

Edema of Mucosal Membrane

Common cold

Vasomotor Rhinitis

Allergic Rhinitis

Rule of 9: Burn

Wallace Rule of Nine
For rough estimation of the body surface area that is affected by Burn, Wallace rule of nine is used. It  is used for adult. Slight modification is done in case of children as they have larger head compared to adults and hence Lund and Browder chart is used. The skin is grossly allocated the value of 9% as demostrated in the chart and diagram below.

Wallace Rule of Nine
(source: https://twitter.com/pjonline_news/status/596994284466802688)

Body part
Head	9%
Right upper extremity	9%
Left Upper extremity	9%
Anterior Chest	9%
Posterior Chest	9%
Anterior right lower extremity	9%
Posterior left lower extremity	9%
Posterior right lower extremity	9%
Posterior left lower extremity	9%
Perineum	1%
Total	100%

Body part

Head

9%

Right upper extremity

9%

Left Upper extremity

9%

Anterior Chest

9%

Posterior Chest

9%

Anterior right lower extremity

9%

Posterior left lower extremity

9%

Posterior right lower extremity

9%

Posterior left lower extremity

9%

Perineum

1%

Total

100%

Rule of 10 : Pheochromocytoma

As previous site was dedicated to certain medical conditions that can be described with a certain number. So is this blog. This collects Number 5-10.

Rule of 10

Pheochromocytoma 

Pheochromocytoma is a tumor most commonly arising from the adrenal medulla and secrete catecholamines (Adrenaline and Noradrenaline) in the vascular system however 10% arise from extraadrenal sites such as sympathetic chain around spinal cord, aorta, ureter and bladder. Generally these are benign tumors but 10% are malignant. 90 % occurs unilaterally and 10% occur in the family. Recently 10 gene mutations have been associated with the condition to add up to its list of 10. It rarely occurs in children (10%). And has tendency to recur (10%) even after surgical excision. 10% have been identified after the patient develops Stroke following malignant Hypertension.

Rule of 10 in pheochromocytoma

Pupillary Reaction to Various Drugs and Substances

PUPIL REACTION TO SUBSTANCE/DRUGS

Pupil of human eye constrict and dilate depending upon the need of the eye to focus on near object/far object, dim light/bright light and whether it is under stress/not. This response is solely dependent upon the muscles inside the eyes in the iris. The pupillae constrictor muscle respond to cholinergic agents and cause pupillary constriction while the dilator pupillae muscle is acted upon by sympathetic system and causes pupillary dilation.

Beside these natural response, the substances we come in contact with can also alter the pupillary size. Drugs such as Adrenaline, antidepresssants, antihistaminics, can cause pupillary dilatation. Pethidine being an exception is the only opoid to cause pupillary dilation. Herbal products such as belladona, strychinine, calotropis and Chemicals such as alcohol, formic acid, cyanide Carbon monoxide also have dilatatory effect based upon the dosing.

Phenols, Organophosphate, carbamates, Carbolic acid, cause pupillary cosntriction. Drugs such as Opoids, barbiturates, Benzodiaepines, methyl dopa and plant product such as Nicotine, caffiene and opium causes the dilatation of pupil. 

Know how to assess the pupillary reaction or light reflex.

DILATORS		CONSTRICTORS
A6 C5 (Big1 Co Ca Cola Can)		O2 B2 C5 ( Car Car Caf )
Formic Acid			Phenol (Carbolic Acid)
Pethidine2 (only exception in Opoid)		O	All Opoids2  (Except severe Acidosis/hypoxia/ respiratory depression)
Adrenaline*/ Ephidrine/Sympathetomimetics	A		Parasympathetomimetics*
Atropine*/ Belladona/ Dhatura	A	O	Organophosphate*
Amphetamine	A	B	Barbiturates
Alcohol3	A	B	Benzodiazepines
Antidepressants	A
Antihistaminics	A
Cocaine Crack	Co	Car	Carbamate
Carbon Monoxide/ CO	Ca/CO	Car	Carbolic Acid
Calotropis	Cola	Caf	Caffeine
Cannabis	Can		Coma of Alcohol3
Cyanide			Clonidine
Hypothermia*			Heat Stroke*
Strychnine			Nicotine4
			Methyl Dopa

HIPPUS: Alternating dilatation and constriction is done by ACONITE

Note: All A’s constrict the pupil. All B’s and O’s dilate the pupil.

¹ Big is not a part of drug rather means dilatation.

² Only opoid to cause pupillary dilatation is Pethidine.

³ Toxic Effect of alcohol causes pupillary constriction as patient develops coma.

⁴ Delayed effect of Nicotine is dilatation of pupil.

* The drugs/substances in row with different color across the table are physiological Counterparts