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Clinical Examination

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Gower's sign which indicates proximal muscle or hip muscle weakness. The sign describes a patient that has to use their hands and arms to "walk" up their own body from a squatting position due to lack of hip and thigh muscle strength.

Besides, Duchenne muscular dystrophy, it may also be seen in:

  1. Other muscular dystrophies
  2. Proximal ascending pseudomyopathic diseases
  3. Spinal muscular atrophy
  4. Polymyositides
  5. Discitis
  6. Juvenile idiopathic arthritis

Gower's sign in a child with DMD

By: Sulav Shrestha on: 7:50 AM

History:
Disposable travel diapers for infants were first marketed prior to 1940. Those were not waterproof. PlayTex introduced their "Stretchy Baby Pants" in 1937 in the USA, the first mass-marketed waterproof pants.
In the late 1950s disposable underpads were introduced to the hospital and nursing home industry in the USA. Kendall Mills was the leading supplier. By then infant disposables with combined poly-plastic outer layer were being sold. Those did not have sticky tapes attached, so they were either held together with the same diaper pins used on cloth diapers, or separate sticky tape was used. That was similar to ordinary medical adhesive tape.
Based on the Pampers R&D efforts, which advanced the design of automated disposable diaper manufacturing machines, P&G started a division to perfect adult disposables. Marketing of those Attends in trade ads in hospital and nursing publications began in the early 1970s. PaperPak Corporation had become a large maker of disposable underpads to the hospital industry by the early 1980s and started making some adult disposables.
Kimberly Clark Corporation decided to enter the baby disposable business with Huggies to rival Pampers during the 1970s. Eventually they started a low key R&D effort in the adult disposable line, but they held back actually making a major marketing effort until KCC was convinced there actually were enough adult disposables being sold to make it profitable.
By the time KCC rolled out Depend in the early 1980s Attends were being sold in most supermarkets and drug stores. The marketing department at KCC made the bold decision to hire June Allyson, a singing dancing sweetheart actress from the 1940s to be the spokesperson on TV for Depend.
Newer Diapers are now available for adults to best comfort and usability.
Problem statement:
Incontinence is a common embarrassing problem which has a profound effect on social and psychological well-being. People wear absorbent products for urine and/or faeces and protect their clothes.
Who are the major users of adsorbent product?
·         younger women after reproductive age
·         older men with prostate disease like BPH
·         patients with neurological conditions like paralysis, spinal injuries, Multiple sclerosis
·         older people with mobility and mental impairment- Alzheimers disease, Parkinson disease and more
For light incontinence – small pads
For moderate-heavy incontinence - large absorbent pads: with a capacity of 2-3 litres


As per studies, of the disposable designs, the more expensive pull-up and T-shaped diaper designs were not better overall than the diaper for men, but the diaper was better than the insert (the cheapest), making the diaper the most cost-effective disposable design for men both day and night.Washable diapers are the least expensive design but are unacceptable to most women at any time.

Inference:
1.       Diapers are the most cost-effective disposable design for men.
2.       Disposable pull-ups are most preferred for women
3.       Disposable inserts are a cheaper alternative (except in nursing homes where diapers are preferred to inserts at night).
4.       Washable diapers are the cheapest design but have limited acceptability.
Sponsor
Lifree adult adsorbent diaper is claimed to be Japan’s number one brand, now available in Indian markets. The adsorbent product are stretchable, with high adsorptive capacity, user friendly and leak proof. If you are user of adsorbent products, you should give Lifree a try.
DISCLAIMER: *Data source: INTAGE SRI, ADULT DIAPERS SALES, APR’10- JAN’16 . The views about the product described here are solely in experience of the writer and does not represent view of the Lifree company or this website.


History of Modern Day Adult Diapers

By: Admin on: 7:47 AM
Eachtime a baby feeds on breast milk or bottle milk, it swallows air (~90%). Burping a baby after each feed will allow release of gas and hence prevent feed regurgitation and abdominal colic in infants. It has also been seen to be useful in preventing GER ( Gastroesophageal reflux).

Two Methods have been demonstrated in the video.




1. Over the Shoulder method
  •  Sitting 
  •  Standing 
  •  Alternate sitting and standing 

2. On the Lap method

Find which suites you best and don't worry if baby does not burp each time.



Hope the video helped you solve your queries.

How to Burp a Baby after feeding? 2 Methods video demo

By: Sulav Shrestha on: 7:26 AM

Complement System is part of Innate immunity. Complement cascades are activated against foreign body, bacteria and viruses. Here is an easy explanation of activation for complement system in human body. The video is illustrative and self explanatory.

 The complement cascade can be activated in 3 ways:

  1. Classical pathway 
  2. Alternative pathway 
  3. Lectin pathway 


 For the full text on complement system: Complement system made easy

Complement System Activation : Video explanation

By: Admin on: 7:30 AM


Incontinence of urine or stool is one of the problems of elder age group specially in people who are affected by specific diseases or conditions. We have explained the Urinary incontinence earlier ( link to Medchrome Article 1). One solution is the Lifree Adsorbent pants, Japan’s number 1 brand* .



Popularly referred to as Adult adsorbent briefs,  are innovations that allow the incontinent elderly people to stay dry .  One can again become socially active and talk with heads high.  

[ DISCLAIMER *data source: INTAGE SRI, ADULT DIAPERS SALES, APR’10- JAN’16]


Adsorbent diapers have enormous soaking power and is proven leak proof, hence ensuring dryness. Built for comfort and lightness, they allow easy consumer experience with easy wearing and undoing. Pant type diaper has elastic that hold the pant like an under-pant. Another type is tape type that is usually chosen for bed ridden patients, Critically ill patients in ICUs and has been widely used by many ICUs even for young patients. It is an innovation that changes  the life style of hundreds and thousands of elderly people suffering from issues of urinary and fetal incontinence. The video here is a piece of  inspiration.


Choosing Right One –


For more details visit- <link> http://www.lifree.co.in/cm/index.html,< link>
Pull up pant types are more popular among the mobile and active population. This has set a mark in changing the lifestyle of such population increasing their age of productivity, socialization and a happier life. Keep no stigma, it is not a diaper, it is an Adsorbent pant.

Disclaimer: The views about the product described here are solely in experience of the writer and does not represent view of the Lifree company or this website


Writer- Mr Kumar, Health Article Freelance writer, India

Adult adsorbent briefs : How to Choose right one

By: Admin on: 12:07 AM


The Examination of Nervous system is one of the long cases that is kept for exams. All Medical students, PG students and doctors have to be in flow with the proper neurological examination.
Usually time alloted for Complete neurological examination is 20 minutes - maximun 30 minutes. With practice and creating pattern, you will gradually be able to complete examination in time. For this, the steps should not come from the brain but from a spinal level.

The Preferred sequence of examination is
1 Higher Mental Function
2. Cranial Nerves Examination
3.Motor system examination
4. Sensory System examination
5. Cerebellar signs examination
6. Gait
7. Abnormal movements
8.Skull and spine
9. Autonomic nervous system.

Macleoad's Clinical examination videos and book are the best resource available and Hutchington is equally well writtern in the CNS section.
However, we have included a complete neurological examination video and the video is of 22 minute. We belive that if you follow the sequence, you will eventually be able to finish you examination by 20 minutes during exams.

Tips for exam-
1. Use standard book Macleods
2. Keep the sequence at Spinal level via repeated practice
3. Keep practicing at regular intervals before exam
4. Discuss it in groups
5. Keep a timer to ensure a proper timing.
6. Watch friends examine a patient and try to figure the shortcomings and comment.
7. Read probable viva questions.
8. Neurokit


Enjoy some extra resources- https://meded.ucsd.edu/clinicalmed/neuro2.htm

Complete Neurological examination video: Best for exam

By: Admin on: 11:49 AM

Preoperative preparation: Following medical conditions must be ruled out -
  1. Local infection—including scrotal skin infection, active sexually transmitted infection (STI), balanitis, epididymitis, or orchitis
  2. Previous scrotal injury
  3. Systemic infection or gastroenteritis
  4. Large varicocele
  5. Large hydrocele
  6. Filariasis; elephantiasis
  7. Local pathological condition (e.g., intrascrotal mass, cryptorchidism, or inguinal hernia)
  8. Bleeding disorders
  9. Diabetes
  10. AIDS
Requirements: Warm room temperature to relax the scrotum - The temperature of the operating room should be at least 70 to 80 degrees F (approximately 20 to 25 degrees C)

Instruments:
  1. Ringed clamp
  2. Dissecting forceps
  3. Straight scissors
Supplies:
  1. Scissors for scrotal hair clipping
  2. Sterile gloves
  3. Antiseptic solution for cleaning the operative area
  4. Sterile drapes
  5. 10-cc syringe with a 1 & 1⁄2-inch, 25- or 27-gauge needle
  6. 1% or 2% lidocaine without epinephrine
  7. Supplies for vasal occlusion according to the surgeon’s preference (examples: a cautery unit; chromic catgut or nonabsorbable silk or cotton for ligation)
  8. Sterile gauze
  9. Adhesive tape or Band-Aid for dressing the wound
Anesthesia: 
  1. After making the superficial skin wheal, advance the needle parallel to the vas within the external spermatic fascial sheath toward the inguinal ring.
  2. Advance the full length of the needle, 1 & 1⁄2 inches, without releasing any of the anesthetic. Gently aspirate to ascertain that the needle is not in a blood vessel.
  3. Without withdrawing the syringe, slowly inject 2 to 5 cc (depending on concentration) of lidocaine within the external spermatic fascial sheath around the vas deferens.
  4. When the needle is in proper position and the injection is performed inside the external spermatic fascia, there is no resistance to the injection.
  5. Epinephrine is not recommended because it contracts the blood vessels and results in less apparent bleeding at the time of surgery
  6. The maximum individual dose of lidocaine without epinephrine should not exceed 4.5 mg/kg (2 mg/lb) of body weight.
Procedure:

1. Apply ringed clamp to scrotal skin: Using the three-finger technique, tightly stretch the skin overlying the vas. Apply the ringed clamp, with the shaft at a 90-degree angle perpendicular to the vas.

2. Elevate the underlying vas: While the ringed clamp is still grasping the scrotal skin and the underlying right vas, transfer the instrument to your left hand. Then lower the handles of the ringed clamp, causing a bend in the vas.

3. Puncture the scrotal skin:
  • Midway between the top of the testes and the base of the penis
  • Hold the dissecting forceps in the right hand, points curved downward, in preparation for puncturing the vas. Hold the instrument so that there is a 45-degree angle between the closed tips of the forceps and the lumen. Then open the forceps; using only the medial blade of the forceps, pierce the scrotal skin just superior to the upper edge of the ringed forceps.
  • Gently open the tips of the dissecting forceps transversely across the vas, to create a skin opening twice the diameter of the vas.
 4. Isolate the vas: The vas and surrounding tissue may then be elevated through the incision. After further blunt dissection, the fibrous layer surrounding the vas is incised longitudinally. Now fully isolated, the vas is ready for division.

5. Manage the vas:
  • Ligate the vas at 2 sites or use electrocautery
  • Remove the segment between two vasal ends: Removal of at least 15 mm is recommended to prevent the risk of recanalization
6. Procedure must be repeated at the contralateral side as well

7. Clean the wound and close with tapes

8. Scrotal support

No Scalpel Vasectomy (NSV) - Video

By: Admin on: 3:37 AM
Neonatal seizures are often the most difficult thing to identify, specially wen seizures are subtle.
In newborns, Seizure can present with following features-

  1. Autonomic instability- Tachycardia, respiratory changes, High BP
  2. Sucking movements of lips
  3. Tonic eye deviation
  4. Vacant staring episodes
  5. Paddling/Cyclical limb movements
  6. Stiffening of the body
  7. In case of myoclonic seizures- head drops, salam spells.
  8. Sometimes electrical seizures can occur that is identified on EEG only.

Neonatal Seizure : Video

By: Sulav Shrestha on: 7:12 AM
Pill rolling tremor (Parkinsonism): Patient attempts to maintain body position at rest. Flexed elbow, wrist and MCP joint with flexion-extension and rotatory movement between thumb and finger (thumb moving across tips of all fingers). It is improved by activity and worsened at rest. Proximal muscles, lips and tongues are also frequently involved.

Pill rolling tremor

By: Admin on: 8:09 AM


Emergency decompression of a Tension Pneumothorax can be a life saving procedure. Various causes leads to tension pneumothroax, specially in patients with lung disease, in critically ill and ventilated patients and in patients undergoing procedures, tension pneumothrax is likely. It is rapidly a fatal condtion and a dire emergency. All the time, Radiological confirmation might not be possible and clinical signs and symptoms, strong suspicion with examination can let us reach the diagnosis. Decompression of Pneumothorax is a procedure no Medical personal can not know. A simple needle decompression can be worthy enough to save a life. Knowing the right procedure and site of insertion of needle is demonstrated in this video. For the definite treatment, Intercostal drainage insertion should be planned for after this.

Above video demonstrates proper device with one-way valve. For resource limited settings, Underwater seal can be used.


Please provide us feed back.

Emergency decompression of Tension pneumothorax: Tutorial video

By: Admin on: 7:43 PM
The fate of your child depends upon how you start and maintain your child's feeding habit and lifestyle. Here is one insightful video that has re-winded the life of a patient with heart attack. Think and decide, is this what you want your child to meet at the end. Less TV, more outdoor games, regular exerciser, healthy diet and cut off sweets and drinks.

Heart Attack Patient Time travels to his Past: What went wrong? Video

By: Admin on: 6:05 AM
Sleep is a necessity of body homeostasis. Inadequate sleep or sleep lapse can cause tremendous amount of consequence on brain and bodily performance. How many hours of sleep per day is required is a big question. The requirement is variable but on an average a normal human needs an 8 hour sleep. The video given below is self explanatory.

The hazards of Sleep deprivations- Read symptoms and signs of sleep deprivation.

How much sleep do we need in a day?

By: Admin on: 6:36 AM
Tracheotomy and tracheostomy are surgical procedures on the neck to open a direct airway through an incision in the trachea (the windpipe). It is performed in emergency situations, in the operating room , or at bedside of critically ill patients. This procedure, technically called a cricothyroidotomy, should be undertaken only when a person with a throat obstruction is not able to breathe at all-no gasping sounds, no coughing-and only after you have attempted to perform the Heimlich maneuver three times without dislodging the obstruction.

Procedure
  1. Find the person's Adam's apple (thyroid cartilage).
  2. Move your finger about 1 inch down the neck until you feel another bulge. This is the cricoid cartilage. The indentation between the two is the cricothyroid membrane, where the incision will be made.
  3. Take the razor blade or knife and make a 1/2 inch horizontal incision. The cut should be about half an inch deep. There should not be too much blood.
  4. Pinch the incision open or place your finger inside the slit to open it.
  5. Insert your tube in the incision, roughly one-half to one inch deep.
  6. Breathe into the tube with two quick breaths. Pause 5 seconds, then give 1 breath every 5 seconds.
  7. You will see the chest rise and the person should regain consciousness if you have performed the procedure correctly. The person should be able to breathe on their own, albeit with some difficulty, until help arrives.

The term tracheostomy is sometimes used interchangeably with tracheotomy. Strictly speaking, however, tracheostomy usually refers to the opening itself while a tracheotomy is the actual operation.

Tracheotomy Procedure with Animation tutorial

By: Sulav Shrestha on: 6:10 AM
Myiasis is the infestation of tissue with fly larvae, commonly referred to as maggots. Maggots infest nose, nasopharynx and paranasal sinuses causing extensive destruction and obvious deformity.

Treatment:
  1. Visible maggots should be picked up with forceps
  2. Instillation of chloroform water/ether and oil (liquid paraffin) kills them
  3. Nasal docuhe with warm saline is used to remove slough, crusts and dead maggots
  4. Avoid contact of the patient with flies by use of mosquito nets
  5. Nasal hygiene for prevention
For complete information about nasal myiasis: http://medchrome.com/minor/ent/nasal-myiasis-maggots-in-nose/

Nasal Myiasis Removal Video

By: Sulav Shrestha on: 2:23 AM
Systolic blood pressure normally falls during quiet inspiration in normal individuals. It is the accentuation of normal physiology where there is an inspiratory fall in systolic blood pressure more than 10 mmHg.

Pulsus paradoxus is defined as a fall of systolic blood pressure of more than 10 mmHg during the inspiratory phase. [Eur Respir J. 2012 Dec 6. Pulsus paradoxus. [Hamzaoui O Et Al]



Measurement:
1.Inflate the cuff beyond the point where you hear any Korotkoff sounds.
2.Slowly deflate the cuff until you start hearing any sounds. At the highest BP when you hear sounds intermittently (rather than with every heart beat), note the blood pressure. (This corresponds to the higher systemic blood pressure which is occurring during expiration).
3.Keep slowly deflating the cuff until you reach the highest BP in which you hear sounds every beat.
4.The difference between #2 and #3 is the “pulsus paradoxus.” If it is >10 mmHg, it is considered significant.

Cardiac causes
Cardiac tamponade
Pericardial effusion
Constrictive pericarditis
Restrictive cardiomyopathy
Pulmonary embolism
Acute myocardial infarction
Cardiogenic shock

Extracardiac pulmonary causes
Bronchial asthma
Tension pneumothorax

Early recognition of pulsus paradoxus can help to diagnose rapidly cardiac tamponade, assess the severity of acute asthma as well as its response to therapy. Its essential to have good clinical skill inspite of development of newer technology

Pulsus Paradoxus- Correct technique of measurement

By: Admin on: 2:09 AM
Indication: Evaluation of dry eye (Measures aqueous tear production)

Types:
1. Schirmer 1 (without anesthetic): measures baseline and reflex secretion
  • function of main lacrimal gland, whose secretory activity is stimulated by the irritating nature of filter paper
2. Schirmer 2 (without anesthetic): measures baseline secretion
  • function of accesory lacrimal glands (the basic secretors)
Materials required: 5 X 35 mm of Schirmer's strip or Whatman filter paper no. 41

Procedure:
  1. The eye is gently dried of excess tears
  2. The schirmer strip is folded 5 mm from one end and kept in the lower fornix at the junction of lateral 1/3 and medial 2/3 (do not touch cornea or lashes)
  3. The patient is asked to close the eyes.
  4. Tears in the conjunctival sac will cause progressive wetting of the paper strip.
  5. After 5 minutes, the filter paper is removed and the distance between the leading edge of wetness and the initial fold is measured, using a millimeter ruler.
Interpretation:
Normal: >15 mm
Mild-moderate Keratoconjunctivitis sicca (KCS): 5-10 mm
Severe KCS: <5 mm
<10 mm is considered abnormal in Schirmer 1 and < 5 mm in Schirmer 2
Causes of KCS:
  1. Idiopathic
  2. Congenial alacimia
  3. Xerophthalmia
  4. Lacrimal gland ablation
  5. Sensory denervation
  6. Collagen vascular disease: Sjogren syndrome, SLE, RA

Schirmer's test I & II: Dry Eye Screening

By: Admin on: 7:06 PM

 

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