How to differentiate clinically between LTB (croup) and epiglottitis

Which of the following best differentiates, by history, LTB (croup) from epiglottitis?

• (A) Temperature
• (B) Presence of inspiratory stridor
• (C) Length of time from onset to defining symptom
• (D) Lung field auscultation
• (E) Presence or absence of dyspnea

The answer is C.
Croup, laryngeotrachiobronchitis, a viral illness with subglottic involvement, typically exhibits the symptoms of inspiratory stridor only after 12 to 24 hours of coryza, typical of a viral “cold.” Epiglottitis, which is a much more serious condition, begins suddenly. Epiglottitis is caused by bacterial infection with supraglottic involvement, classically by H.influenzae but also by S.aureus and Corynebacterium diphtheriae.

Although epiglottitis is characterized more by high fever than is croup, this appears to be a weak factor on which to base a preliminary diagnosis. Whereas croup virtually always includes a cough, epiglottitis rarely
does so. Epiglottitis typically includes dysphagia while croup does not. The child with croup is comfortable in all positions, whereas the patient with epiglottitis will be sitting forward with the mouth open. Both conditions are characterized by inspiratory dyspnea. Croup is benign and epiglottitis is potentially critical.

Associated conditions result in intestinal intussusception in children

An 8 year old boy is seen in the emergency room secondary to abdominal pain. Further evaluation confirms the presence of intussusception. The most likely precipitating cause for this intussusception is :

• A) colon polyp
• B) Meckel's diverticulum
• C) lymphoma
• D) parasite infection
• E) foreign body

The answer is C.

Intussusception is the most common cause of intestinal obstruction in the first 2 years of life. It is more common in males than in females. In most cases (85%) the cause is not apparent. Associated conditions that can result in intussusception include :
-polyps, Meckel's diverticulum, Henoch–Schonlein purpura, lymphoma, lipoma, parasites, foreign bodies, and viral enteritis with hypertrophy of Peyer patches.

Intussusception of the small intestine occurs in patients with celiac disease and cystic fibrosis—related to the bulk of stool in the terminal ileum. Henoch–Schonlein purpura may also cause isolated small-bowel intussusception. In children older than 6 years, lymphoma is the most common cause. Intermittent small-bowel intussusception is a rare cause of recurrent abdominal pain.

Hay WW Jr, Levin MJ, Sondheimer JM, et al., eds. Current pediatric diagnosis & treatment, 18th ed. New York: McGraw-Hill; 2007:616–617

Treating pressure ulcers

The case shown here in this picture was noted associated with an 89-year-old debilitated nursing home resident. He has no evidence of bacteremia or osteomyelitis. Which of the following is an acceptable treatment?

• A) application of povidone-iodine gauze two times per day
• B) application of hydrogen peroxide 3 times per day
• C) systemic antibiotics for 7 to 10 days
• D) keeping the area clean and dry until granulation tissue forms
• E) surgical debridement

 The answer is E. (Surgical débridement)

When treating this pressure ulcer, it is important to maintain a moist environment while keeping the surrounding skin dry. This can be accomplished by loosely packing the ulcer with saline-moistened gauze. Topical antimicrobials such as silver sulfadiazine cream may be helpful in ulcers that appear infected. Topical antiseptics such as povidone-iodine or hydrogen peroxide should be not be used in the treatment of pressure ulcers. Systemic antibiotics should be reserved for serious infections (e.g., bacteremia, osteomyelitis). A 2-week trial of topical antimicrobials may be considered for ulcers that do not appear infected but are not improving. Although most patients are successfully managed without surgery, procedures may be appropriate in patients whose quality of life would be markedly improved by rapid wound closure. Stage 3 and 4 ulcers with necrotic tissue should be débrided. Ulcers with minimal exudate that are not infected can be covered with an occlusive dressing to promote autolytic débridement. Ulcers with thick exudate, slough, or loose necrotic tissue should undergo mechanical débridement. Options include wet-to-dry dressings, hydrotherapy, wound irrigation, and scrubbing the wound with gauze. Ulcers with evidence of cellulitis or deep infection should undergo sharp débridement with a scalpel or scissors. Ulcers with a thick eschar or extensive necrotic tissue should undergo sharp débridement as well. However, a thick, dry eschar covering a heel ulcer should generally be left intact. Patients without access to surgical inter-ventions (such as in a long-term care setting) or those who may not be acceptable surgery candidates can be treated with enzymatic débriding agents. Wound débridement should stop once necrotic tissue has been removed and granulation tissue is present.

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.

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) Sjögren'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.

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.