Lines on anterior Abdominal Wall

This photo shows surface anatomy of some lines on the anterior abdominal wall like:
1-McBurney's point is halfway between the umbilicus and the ASIS ( anterior superior illiac spine ) and it is a common location where surgeons use for an incision to remove the appendix.
2-The linea alba is a fibrous structure that runs down the midline of the abdomen and seperates the left and right rectus abdominus muscles.
3-The arcuate line demarcates the lower limit of the posterior layer of the rectus sheath.
4-The inguinal ligament is a band running from the pubic tubercle to the anterior superior iliac spine, its anatomy is very important for operating on hernia patients.
This ligament passes between two bony points of the hip bone, the anterior superior iliac spine laterally and the pubic tubercle medially. It has an expanded medial end, the lacunar ligament.
The inguinal ligament is the thickened, recurved free inferior border of the external oblique muscle. It forms the floor of the inguinal canal along which passes the spermatic cord in the male or the round ligament of the uterus in the female.

5-The linea semilunaris is a curved tendinous line placed one on either side of the rectus abdominus and corresponds with the lateral border of the rectus muscle.

Scaphoid fractures overview

A Scaphoid fracture is the most common type of wrist fracture which is almost always caused by a fall on the outstretched hand..Scaphoid fractures usually cause pain and swelling at the base of the thumb. The pain may be severe when you move the thumb or wrist, or when the patient try to grip something.
Anatomic snuffbox tenderness is a highly sensitive test for scaphoid fracture, whereas scaphoid compression pain and tenderness of the scaphoid tubercle tend to be more specific. Initial radiographs in patients suspected of having a scaphoid fracture should include anteroposterior, lateral, oblique, and scaphoid wrist views.

scaphoid view
Anteroposterior, lateral, and oblique radiographic views are required for evaluation of a suspected scaphoid fracture. Occasionally, a special radiograph called a scaphoid view may be helpful; the wrist is ulnarly deviated and extended while the film is shot from a dorsalvolar angle. When a fracture is visible, appropriate treatment may be instituted.

Initial radiographs do not always detect scaphoid fractures. In one prospective trial,8 the sensitivity of initial radiographs was 86 percent. However, a great deal of variability in the sensitivities (higher and lower) of radiographs is found in the literature. Nondisplaced fractures of this bone are known to be difficult to see on initial radiographs. In these cases, one treatment option includes placing the patient in a cast and performing a follow-up physical examination and repeat radiography in two weeks. Recent improvements in technology may allow alternate approaches in this situation.
(Left) This x-ray shows a scaphoid fracture fixed in place with a screw. (Right) This x-ray was taken 4 months after surgery. The fracture of the scaphoid is healed.

X-ray Osgood-Schlatter disease

Osgood Schlatters disease is a very common cause of knee pain in both children and young athletes usually between the ages of 10 and 16. It occurs due to a period of rapid growth, combined with a high level of sporting activity.

Imaging Findings

* Normal x-ray findings do not exclude the disease, which is diagnosed clinically
* Radiographs have Limited role "Clinical diagnosis" and are usually obtained to exclude other causes of pain
* Conventional radiography
o Not helpful if tubercle has not calcified (usually around 9 [girls]-11 [boys] years of age)
o Best seen on lateral knee
o Irregular ossification or fragmentation of tibial tubercle..... Separated from remainder of tibial tubercle
o Soft tissue swelling
o Calcification in or thickening of the patellar tendon
 Lateral radiograph of the knee demonstrating fragmentation of the tibial tubercle with overlying soft tissue swelling.

Hallux varus in X-ray

Hallux varus is a deformity of the big toe joint where the hallux is deviated medially (towards the midline of the body) away from the first metatarsal bone. The hallux usually moves in the transverse plane.
The condition of Hallux varus deformity has various degrees of severity and causes. Hallux varus most commonly caused by rupture of the lateral collateral ligament at the MTP joint following a surgical procedure "as a previous bunion surgery" or trauma but it can also be due to removal of sesamoid bones, arthritis, or congenital deformity.

This Radiography of the left foot of a Stickler syndrome patient with an AP at age of 18 years foot radiograph showed progressive hallux varus and marked osteoarthritis in the base of the first toe.

A case of Alopecia areata

A 37y old man presents with rapid hair loss that has occurred over the last few weeks. He reports that his father had a similar condition. The most likely diagnosis is :
  1. A) alopecia areata
  2. B) tinea capitis
  3. C) androgenic alopecia
  4. D) secondary syphilis
  5. E) trichotillomania

The answer is A. "Alopecia areata" 
Alopecia areata is associated with sudden hair loss that occurs in round patches. The patches are well circumscribed, not associated with scarring or inflammation and the patients have no other symptoms. The most common area affected is the scalp; but, the condition may also affect the eyebrows or beard. Alopecia areata usually affects children and young adults and is recurrent.
A pathognomonic sign for alopecia areata is the “exclamation point” hair, which is wide distally and narrower at the base. These hairs are often found at the periphery of a patch of hair loss. Hair that regrows in the area of alopecia areata is in many cases white. Nail pitting may be also present. The treatment consists of injection of intralesional steroids and topical steroids. Most experience complete regrowth of hair.

Koplik’s spots as described

This was a patient who presented with Koplik’s spots on palate due to pre-eruptive measles on day 3 of the illness. Measles is an acute, highly communicable viral disease with fever, conjunctivitis, coryza, cough, and Koplik spots. Koplik spots are small, red, irregularly-shaped spots with blue-white centers found on the mucosal surface of the oral cavity.

The spots as described by Koplik in 1896:

If we look in the mouth at this period we see a redness of the fauces; perhaps, not in all cases, a few spots on the soft palate. On the buccal mucous membrane and the inside of the lips, we invariably see a distinct eruption. It consists of small, irregular spots, of a bright red colour. In the centre of each spot, there is noted, in strong daylight, a minute bluish white speck. These red spots, with accompanying specks of a bluish colour, are absolutely pathognomonic of beginning measles, and when seen can be relied upon as the forerunner of the skin eruption.

About head lice infestations

Which of the following statements is true regarding head lice infestations?
  • A) Females are more likely affected.
  • B) Retreatment with pyrethrin is rarely needed.
  • C) Head lice can live off the body up to 1 week.
  • D) Low socioeconomic children are more likely affected.
  • E) Dogs are a common vector for head lice.

The answer is:  ( A ).
Head lice are thought to be the most common type and are developing resistance to commonly used pediculicides. Every year, between 6 million and 12 million people in the United States, primarily children 3 to 10 years of age, are infested with head lice. Girls are at greater risk because they have more frequent head-to-head contact.
Head lice affect people of all socioeconomic status. Head lice are obligate parasites that live on human skin and survive on human blood. No other animal is affected. Head lice die if they are away from the host head for more than 2 days.

Lice are wingless and cannot jump, but they climb quickly from hair to hair when the hair is dry. Lice move slowly on wet hair and can be removed more easily with a gloved hand or a fine-toothed comb. The adult female louse lays 7 to 10 eggs daily that attach to human hair with a gluelike, water-soluble substance. By 7 to 10 days, a nymph emerges from the egg and is close enough to the scalp to obtain its first meal of blood. Adult lice, after the 7- to 10-day period of molting stages, live about 30 days. Infested people usually have no more than 10 to 12 live head lice at a time, but can harbor hundreds of eggs and nits. Those affected describe itching and a sensation of “something crawling on my head"? Scratching may cause excoriations and secondary infection. Most infestations are asymptomatic.

Prior to treatment, live lice can be identified under a magnifying glass, which is best done when the hair is wet. After infestation is confirmed, treatment consists of application of a pediculicidal agent to the hair, followed by mechanical removal. 
The hair should not be washed for 2 to 3 days after the pediculicide is applied. Thorough physical removal of lice and nits with a sturdy, fine-tooth comb is recommended for several days after application because no pediculicide guarantees total eradication of lice. First-line topical agents containing pyrethrins or permethrin are available over the counter and are relatively nontoxic. Retreatment is advised 7 to 10 days after the first application of pyrethrins. Because permethrin remains active for a longer period, retreatment generally is not necessary. Permethrin 5% cream is available by prescription for use in resistant cases. Alternative agents include lindane or malathion. Lindane has been shown to have limited success and is systemically absorbed, so its use is now considered second-line. Malathion was recently labeled by the U.S. Food and Drug Administration (FDA) for the treatment of head lice and is available in a lotion that is left on the head for 8 to 12 hours. Oral agents include ivermectin and trimethoprim–sulfamethoxizole. Resistance is possible with any treatment because of reduced susceptibility or incorrect use of the medication.

All household members with active infestation should be treated simultaneously. For children younger than 2 years, there is no recommended pediculicide; therefore, treatment consists of manual removal only. Lice that remain active 8 to 12 hours after treatment may require an alternative agent. Itching may persist for up to 10 days after successful treatment and should not be mistaken for treatment failure. The Centers for Disease Control and Prevention recommend that all clothing and bedding in contact with the infested person during the 2 days before application of the pediculicide be laundered in hot water and machine dried using a hot dry cycle. All nonwashable items should be quarantined in a plastic bag for 2 weeks. Combs and brushes should be disinfected with hot water or alcohol.

Tongue`s surface in Prolonged antibiotic use

Which of the following conditions is the skin finding shown in the picture associated with?

  • A) Prolonged antibiotic use
  • B) Sj√∂gren's syndrome
  • C) Addison's disease
  • D) Chronic gastroesophageal reflux
  • E) Malignant melanoma

The answer is A. 
(Black tongue)  actually ...Black hairy tongue results from hyperplasia of the filiform papillae with deposition of keratin on the surface. The condition causes the tongue to have a dark, velvety, hairlike appearance.
Associated conditions include smoking, consumption of coffee, prolonged use of antibiotics, and possibly acquired immunodeficiency syndrome. Treatment involves using a toothbrush to scrape off the excess keratin that forms on the tongue's suface.

Photo illustration of Allen’s Test

Simply Allen`s test "named for Edgar Van Nuys Allen" is used to check the collateral circulation of the hand by evaluating the patency of the radial and ulnar arteries prior to perform radial arterial blood sampling or cannulation.

+ve Allen test :
When you occlude the radial artery for several minutes and compares the hand color to the other hand and you find that there is no change in color------>This hand is said to have sufficient collateral circulation through the ulnar artery .

Step 1 occlusion
Step 2 releasing

Modified Allen’s test :
Step 1 occlusion : With the same idea, Ask the patient to clench the hand into a tight fist and then apply pressure to both the radial and ulnar arteries, and ask the patient to relax their hand .The hand should appear somewhat white & blanched (if haven`t completely occluded the arteries with your fingers).

Step 2 releasing : When you Release the occlusive pressure on the ulnar artery it will result in the hand regaining its colour "flushing of the hand within 5 to 15 seconds"------> the ulnar collateral circulation is adequate, and it`s called positive modified Allen’s test
The test can be repeated, this time releasing the pressure on the radial artery, to assess radial collateral circulation.

Man with characteristic penis projections

A 41-year-old man complains of soft, raised, flesh-colored growths or projections on his glans penis,prepuce, and penile shaft. Several excisional biopsies are done to look for malignancy.the most likely diagnosis is?
  • a.Genital herpes
  • b.Condyloma acuminatum
  • c.Molluscum contagiosum
  • d.Condylomata lata
  • e.Peyronie’s disease

 The answer is:  ( b ).
The lesions of condyloma acuminatum or venereal warts are soft, flesh-colored (may also be pink or red) growths or projections that are found on various parts of the penis. The etiologic agent is human papilloma virus (HPV), which is associated with dysplasia (i.e., squamous cell carcinoma of the cervix, penis, anus, vagina, and vulva). Warts are sexually transmitted " it is the most common sexually transmitted disease in the United States " with an incubation period of 1–6 months.

Condylomata lata are the soft, flat-topped, moist, pale nodules and papules of secondary syphilis that appear 2–6 months after the primary chancre. These contagious lesions may be seen anywhere on the body, including the palms and soles. Peyronie’s disease is unilateral deviation of the penis caused by a fibrous band in the corpus cavernosum. It results in deviation (and often pain) of the penis during erection. Genital herpes is a sexually transmitted disease characterized by a painful group of vesicles on an erythematous base.

Surface Anatomy of the External Ear

The external ear consists of the auricle and the external auditory canal. The helix rim arises anteriorly and inferiorly from a crus extending horizontally above the external auditory meatus, thus creating the outer frame of the auricle. The helix merges inferiorly into the cauda helices and connects to the lobule.

The region located between the crura of the antihelix is referred to as the triangular fossa, while the scapha lies between the helix and antihelix. The antihelix borders medially to the rim of the concha and the concha proper. The concha is composed of the conchal cymba superiorly and the conchal cavum inferiorly, which are separated by the helical crus and meet the antihelix at the antihelical rim. The intertragic notch separates the tragus and antitragus. The lobule does not contain cartilage and displays a variety of shapes and attachments to the adjacent cheek and scalp.

-Arterial supply : The superficial temporal and posterior auricular arteries.
-Sensory innervation : Anterior and posterior branches of the greater auricular nerve and is reinforced by the auricular temporal and lesser occipital nerves. A portion of the posterior wall of the external auditory meatus is supplied by the auricular branch of the vagus nerve.

Anal Fistula

A fistula-in-ano is a hollow tract lined with granulation tissue connecting a primary opening inside the anal canal to a secondary opening in the perianal skin. Secondary tracts may be multiple and from the same primary opening

Fistula-In-Ano: External opening of fistulus tract is apparent in photo above. Proximal opening wouldbe at level of crypts, within the anal canal. Fistulas are frequently associated with perirectal abscesses,though none are present in this case.

Anatomy of the anal canal and perianal space: