Graves Disease

GRAVES DISEASE

The hyperthyroidism of Graves’ disease is the result of circulating IgG antibodies that bind to and activate the G-protein–coupled thyrotropin receptor.This activation stimulates follicular hypertrophy and hyperplasia, causing thyroid enlargement, as well as increases in thyroid hormone production and the fraction of triiodothyronine (T3) relative to thyroxine (T4) in thyroid secretion (from approximately 20% to as high as 30%). Thyroid-function testing in Graves’ disease typically reveals a suppressed serum thyrotropin level and elevated levels of serum T4 and T3. A suppressed serum thyrotropin level with normal serum levels of T4 and T3 is referred to as subclinical hyperthyroidism. Graves’ ophthalmopathy is clinically apparent in approximately 30 to 50% of patients with Graves’ disease, but it is detected in more than 80% of patients who undergo assessment by means of orbital imaging. Manifestations of ophthalmopathy, which vary in severity and have a course that is typically independent of the thyroid disease, can include proptosis, periorbital edema and inflammation, exposure keratitis, photophobia, extraocular muscle infiltration, and eyelid lag - Von graeffe sign (which can also occur with augmented adrenergic stimulation).

Panel A shows a man with bilateral exophthalmos and marked retraction of the upper eyelid. Panel B shows a woman with mild inflammatory signs and hypotropia in the right eye. Panel C shows a woman with marked edema and redness in the upper eyelid, redness of the conjunctiva, and severe chemosis in the left eye. Panel D shows a man with marked edema and retraction of the eyelid and exophthalmos. Panel E shows a woman with marked redness of the conjunctiva and chemosis. There is marked impairment of movement of the globes, which are unable to follow the examiner's finger; this patient had severe dysthyroid optic neuropathy, which responded dramatically to intravenous glucocorticoids (Cortesy of NEJM)

Clinical manifestations

Semiology Apart


This patient has a lot of graves signs: first et all, a big difuse goiter, probably exophtalmos, eyelid lag ( Von graeffe Sign), Pemberton sign ( yugular ingurgitation when rise up her arms due obstruction) and binocular vision impairment (Moebius sign).

The female-to-male ratio among patients with Graves’ disease is between 5:1 and 10:1. The peak incidence is between 40 and 60 years of age, although the disease can occur at any age.

Tests for Graves’ disease–associated antibodies are useful in the evaluation of some conditions, but they are not usually required for diagnosis or to monitor disease activity

IMAGING

A radioiodine-uptake study should be performed in patients in whom painless thyroiditis is considered to be a diagnostic possibility and in patients with an irregular or nodular thyroid gland.

CT is not needed for ophtalmopathy for primary care, and EKG should be performed.

THERAPY

The treatment options for Graves’ disease include antithyroid drugs (propylthiouracil and methimazole), radioiodine, and surgery.

References

- Graves DIsease Review - NEJM

Diarrhea

Diarrhea

Is defined as three or more depositions on a day, or consistence changes making the depositions more fluid and take the recipient form. This last definition is not very useful in clinical practice, so is more common the first one.

Can be classificated according to:

Evolution

Acute: < 2 weeks
Persistent: between 2-4 weeks
Chronic: > 4 weeks

Mechanism

• Osmotic
• Secretory
• Inflammatory
• Malabsortive

Osmotic: Is an acuose diarrhea, very voluminouse, is usually painless, and the most important thing stops in fasting because the causal agent is not being eaten. The most usual agents are cations and anions that can't be taken up by the mucose and causes osmosis with ana elevation of the luminal osmotic presion that elicit diarrhea. The anti-acids ion-containers like phosphates, sulphates and magnesium. Otherway, people with lactase deficiency have abdominal distention, meteorism and diarrhea.

Secretory: Is an acuose diarrhea, very voluminouse, is usually painless and do not stops in fasting. Is caused due to mucose alteration with proteins damage. Is caused by medicaments like AINE's, ACEI, tricyclic anti-depressive's and others. Also is caused by neuroendocrinal tumoration like VIPoma's, Zollinger-Ellison syndrome, carcinoid syndrome. Lastly, bowel disection's like gastrectomy can elicit a secretory diarrhea due to decrease of absortive surface.

Malabsortive: Is steatorrheic, fetid, abdominal distention, and causes nutritional and vitaminic deficiencies. There is three types of diarrhea with malabsortion:

Luminal: in this type, there is deficiency of enzymes or bile acids and digestion is defective. This occurs in pancreatic insuficiency, cyrrhosis and coledocolithiasis.

Mucose: In this type, there is mucose alteration like epitellium atrophy due Celiac Sprue or tropical sprue. Also in Wipple's syndrome there is an infection with t. wipplei that causes absortive epitellium atrophy.

Pos-mucose: is due to lymphatic obstruction in congenital diseases, or tumorations or infections.

in malabsortion, the nutriotional deficiency can reflect as glositis, angular cheilitis, ecchymosis, blur vision, ascites, edema's.

Inflammatory: is a diarrhea accompanied of fever, malaise, abdominal pain, and depositions can be: hematic or not; with mucoid component or not.

IBD (inflammatory bowel disease) is caused principally by Chron's disease and ulcerative colitis. Ulcerative colitis cause edema, erythema and ulceration of the mucose down below right colon, with sigmoid and rectal compromise. Chron's disease cause inflammation since mouth till rectus, with transmural compromise, diferent from ulcerative colitis that only affect the mucose and submucose. Chron's disease can elicit uveitis, arthalgias and aphtas. A classical sign is leukocits present on the coprologic test.

ACUTE ABDOMINAL PAIN

ACUTE ABDOMINAL PAIN

Is an unconfortable pain with onset six hours left, that brings general manifestations in the patient.

Types of pain

Visceral: Is a difuse pain, heavy and can have sympathetic sypmtoms concomitant.
Somatic: Is a localized pain, ellicited with compresion ansd is due to parietal peritoneum inflamation.
Refered: Is a refered pain that occurs in a distal zone from origin, is caused by dermatoma's inervation.
- Shoulder: biliar ways and diapragm.
- Subscapular: Gallblader
- Back: pancreas, gut, peptic ulcer and intestinal obstruction.
- Inguinal and perineal: Nephroplitiasys.

Cholic: Intermitent like cramping, can be urinary or gallblader stones. Peptic ulcer.
Heartbreaking: Very hard pain, can be abdominal arterial disection .
Burning: peptic ulcer, peritonitis and nephrolithiasis.
Alodinia: cutaneous pain with normal stimule. vertebral arthropathy and Herpes zoster.

If there is vomit concomitant:

Bilious vomit: is due to obstruction after the vater ampulla.
Transparent vomit: is due to obstruction before the vater ampulla.
fecaloid: smells, is very dark and is due to intestinal obstruction.
Coffee bar: Is bilious with food remainings, is due to ulcer and tumor.
Food vomit: with food intact is due to pyloric obstruction.
Hematemesis: Is due to esophageal varices and ulceration.

According localization

Epigastrium: pancreatitis, duodenitis, gastritis, peptic ulcer.
Mesogastrium: early appendicitis, pancreatitis, gastroenteritis.
Hipogastrium: Cystitis, prostatitis, diverticulitis.
Right hypochondrium: hepatitis, hepatic abscess, cholangitis, choledocolithiasis, cholecystitis, pancreatitis, peptic ulcer.
Left hypochondrium: Hypersplenism, splenic rupture, splenic infarction, diverticulitis.
Right iliac cavity: appendicitis, pyelonephritis, diverticulitis, Colon CA, salpyngitis, ovaric cyst, endometriosis, ectopic pregnance.
Lef iliac cavity: the same in the right cavity but appendicitis.

Pain characteristics:

• - If there is remision of the pain when vomiting occurs --> peptic ulcer and intestinal obstruction.
• - If the pain is worst during inspiration --> gallblader disease
• - If there is remision of the pain sitting or in mahometan position --> pancretitis
• - If the pain is worst when cought --> inflamation
• - If the food ingest makes worse the pain --> gastric ulcer, if the pain gets better--> duodenal ulcer.
• - If the respiratory movements makes worse the pain--> hepatic abscess, pneumonia, pleuresy.

Rheumatoid Arthritis

Diagnostic Criteria for Rheumatoid Arthritis




Morning Stifness: morning stifness lasting at least 1h since the start of the stifness till the complete remision.

Arthritis in three or more joints: Arthritis in three or more joints regions of the fourteen following: metacarpophalageal, proximal interphalageal, wrists, eldbow, knees, anckles and metatarsophalangeal.

Arthritis in the hand: arthritis in the wrist, metacarpophalangeal and proximal interpahlangeal joints.

Symetric Arthritis: The arthritis is symetric and do not affect the lumbar region except the cervical region.

To this part of the list the symptoms has long at least six months.

Rheumatoid Nodules: Subcutaneous nodules in the joints or over bony prominences.

Rheumatic Factor: Rheumatic factor positive and Anti-CCP

Radiographs: Imaging tests indicating rheumatoid arthritis.

If > or = 4 there is Rheumatoid Arthritis diagnose and if the result is 2 the physician cannotexclude the diagnose.

Clinical aspects

There is historical description for rheumatoid arthritis and several presentation forms.

Z deformity: deviation at the wrist with ulnar deviation of the digits, often with palmar subluxation of the proximal phalanges.



Swan-Neck deformity: Flexion of distal interphalangeal joints and extension of metacarpophalangeal joints.

Boutoniere deformity: Extension of the distal interphalangeal joint and flexion of the proximal metacarpophalangeal joint.

Mallet finger: is a swan-neck deformity of the finger with loss of movility and pinch.



Hallux Valgus: is a foot deformity in which the toe has a lateral deviation.




Baker cyst: Is due to accumulation of sinovial fluid of the knee joint in the popliteal region.

SLE - Systemic Lupus Erythematosous

Diagnostic Criteria SLE

Malar Rash: Is a fixed erythema, flat or raised, over the nose, cheeks or forehead.



Discoid rash: Are an erythematous central patches normally raised with keratotic and scaly rims, atrophy scarring may occur.

Renal disorder: Proteinuria > 0.5 g/d, >3+ or cells casts.

Arthralgia: Joint pain in two or more peripheral joints, with tenderness, swelling or effusion.

Photophobia: Rash due UV rays.

Oral ulcers: Oral ulcers usually in the nasopharigeal region or in the oral mucose. Apthous like lessions.

Neurologic Disorder: Seizures or psychosis. Mood change.

Serositis: Pericarditis or pleuritis with effusion.

Cytopenias: Anemia, leukopenia, lymphopenia or thrombocytopenia.

ANA's: Antinuclear antibodies in serum tests or in immunofluorescence test.

Antibodies: Anti-dsDNA, Anti-SM and/or Anti-phospholipids.

If > or = 4 there is high probability to be a SLE patient with 95% sensibility and 75% specifity.

Note: the signs and symptoms could appear at any time of a well documented patient's history.

References

Harrison - Internal Medicine 17º Edition

STREPTOCOCCUS PNEUMONIE

STREPTOCOCCUS PNEUMONIE

Morphology

Is gram + coccus, facultative anaerobic, encapsulated, catalase -, alpha hemoliticus, has no movility, is no spore former, grows in chocolate agar and has 90 serotypes.

Colonies

This bacteria formes a mucose colonia, umbilicated ( with a central depretion) and do viridans hemolysis.

Virulence Factors

Adherence: the adherence to epitellium is mediated by surface proteins.
Capsule: Allow him to elude the immune response. is the most important virulence factor.
Peptidoglicane: Lipoteicoic and teicoic acid allows to ellicit immune response and make bigger inflamation due TLR5.
Coline Phosphate: links to PAF-R and allows the cell enter into the epitellium and elude opsonization and phagocitosis.
Pneumolisine: Is a citotoxic toxine, links to cholesterol and formes pores in the membrane of PMN, monocytes and lymphocites.
Autolisine: Is a protein that clives the peptidoglicane and bring outside the Hypometylated-DNA to performe a immune response due TLR9.

Clinical Manifestations

Neumonie: It's the princiapl manifestation in children and less prevalent in adults. The symptoms include fevere, dispnea, pleuritic pain, chills, night sweat, mucopurulent spute.

Another manifestations: Meningitis, Middle otitis, osteomielitis, sinusitis.

Dx

The diagnostic is performed with clinical manifestations, X-ray and laboratory tests.

Laboratory Tests

Gram Dyeing: With the well taken sputum of the patient, the sample is carried to the laboratory, and the best sample will be the one with: many bacterias, few epitellium and very immune complexes. The culture is only performed in the gram dyeing with mored than 25 bacterias and less than 10 epitellium cells.

Culture: Is performed in chocolate, blood and Mckonkey agar; in sterile recipient.

Antibiograme: Is very useful because of penicilline resistance. Also is very useful to confirme the bacteria with the optoquidine test.

Treatment: 3d generation Cephalosporine (e.g. Ceftriaxone). In resistent infections is useful a macrolide (e.g. Azytromicine) or a quinolone (e.g. levofloxacine)

ABDOMINAL INSPECTION

ABDOMINAL INSPECTION

The following images are an exposition part that i'd do.

When the doctor is doing the abdominal inspection, there are certain cases in which is possible speculate the diagnosis.

Courvoisier-Terrier Sign

If a patient had a visible and palpable gallblader and jaundice, the physician can think in pancreas head carcinoma with a 95% specifity. This is due to biliary duct obstruction by a mass.


Cullen Sign

If a patient has a periumbilical ecchymosis, got Cullen sign due to retroperitoneal bleeding that goes thorugh the falciform ligament, and pass till subcutaneus tissue due to conective tissue of the redondus ligament. This is unusual but indicate an acute pancreatitis.

Turner Sign

If a patient has a flank ecchymosis got the turner sign (also called Grey-turner). This happens due to para-renal space bleeding that goes with the quadratus lumborum muscle and pass through the flank muscle fascia, probably for a defect of the fascia. Lastly, the blood pass through the subcutaneous tissue. This is also unusual and indicate acute pancreatitis.


Erythema Ab igne

If a patient has a brown livedo reticularis-like pigmentation, the doctor could think in two possible options: a physical damage of the skin (e.g. heat exposure) and a chronic pancreatitis.




Sister Mary Joseph's Nodule

Metastasic cancer of the umbilillicus associated with gastrointestinal and ovarian tumors. This condition was named for Sister Mary Joseph (1856–1939), a surgical assistant for Dr. William
Mayo, who noted the association between paraumbilical nodules observed during skin
preparation for surgery and metastatic intraabdominal cancer confirmed at surgery.



References

- Sopeña Bernardo et all; Visible gallbladder. Medical images; 2007

- Mok Daniel H M et all; Erythema Ab igne in chronic pancreatitis: a diagnostic sign; Journal of royal society of medicine; 1984

- Mookadam Farouk et all; Cullen’s and turner’s signs; NEJM; 2005

- Kanter, Judith et all. Sister Mary Joseph's Nodule - NEJM