March, 2012 | Master Of Medicine

Monthly Archives: March 2012

Why does nocturia occur in heartfailure?

While taking case history in a cardiac failure patient, one of the most important points to be enquired is whether there is a history of nocturia in the patient.

What is nocturia?

The tendency of the patient to urinate excessively during night is called nocturia.Nocturia can be very distressing as the patient having heart failure(before being admitted and catheterised) is unable to walk to the toilet for urination hence may result in bedwetting.Usually patient doesn’t mention this due to embarrassment, so a doctor has to ask specifically about nocturia to extract this precious information.

Why does nocturia occur?

In cardiac failure, the heart is not able to meet the needs of organs which include kidneys due to failure of heart to pump out blood.Due to the failure of heart to pump out blood, it pools in the extremities leading to edema of legs and face. At night when the patient lies down, the blood that had been accumulated in the extremities returns to the heart, hence the cardiac output during the night is slightly increased compared during the day time.This increased cardiac output perfuses kidneys, which in turn produces more urine to decrease the workload of heart resulting in nocturia.

What is syphilis?

Syphilis is a sexually transmitted disease(STD) affecting the genital organs.Syphilis is transmitted by a spirochete bacterium named Treponema pallidum.It is most often transmitted by sexual contact, but it can also be transmitted from mother to fetus by placental route.When transmission occurs from mother to baby and when syphilis is present in an infant it is called congenital syphilis.

Syphilis has been called ” the great imitator” due to its frequent atypical features.Usually after sexual contact with an infected individual, syphilis takes about 9-90 days to establish in a new individual.This period is known as the incubation period of syphilis.During this period the signs and symptoms of the disease are not present.Syphilis passes through different stages in an individual.It can be primary, secondary,tertiary and latent syphilis.

Symptoms of syphilis

Syphilis usually presents as painless ulcer on the glans penis or in the vulval region with painless rubbery lymphadenopathy. The ulcer is described as painless punched out non bleeding ulcer.This painless feature of syphilitic ulcer is the main symptom which helps to differentiate between syphilis and other genital infections like chancroid,LGV etc.The lymphadenopathy is usually bilateral.This stage is known as primary syphilis.

In secondary syphilis, there may be bilaterally symmetrical asymptomatic skin rash on palms and soles which is the most common finding.There may be loss of hair, described as moth eaten alopecia.Arthritis and proteinuria may also be present along with condyloma lata.

In tertiary syphilis,syphilitic gumma is present.This is the phase where syphilis affects the nervous system.Neurosyphilis has two components, general paresis and tabes dorsalis.

Argyll Robertson’s pupil is another feature of syphilis.In this condition, accomodation reflex is present, but pupillary reflex is absent.

Diagnosis of syphilis

There are several tests to diagnose syphilis.They are TPHA,VDRL,TPA etc.VDRL is used for the prognosis of syphilis.

Treatment of syphilis

Penicillin is the drug of choice for the treatment of syphilis.

Classification of surgical wounds

Surgical wounds are classified based on the presumed magnitude of the bacterial load at the time of surgery.

Class I-Clean Wounds

Clean wounds are those wounds in which no infection is present.Only skin microflora contaminate the wound and no hollow viscus which contains microbes is entered.Infection rate is 1-5.4%

Eg: Hernia repair,breast biopsy

Class II – Clean contaminated wounds

Clean contaminated wounds are those wounds in which a hollow viscus such as respiratory, alimentary or genitourinary tracts with indigenous bacterial flora is opened under controlled conditions without significant spillage of contents.Infection rate is 2.1-9.5%

Eg:Cholecystectomy,Elective GI surgery

Class III -Contaminated wounds

Includes open accidental wounds encountered early after injury, those with extensive introduction of bacteria into normally sterile area of body due to major breaks in sterile technique(open cardiac massage),gross spillage of contents of viscus,incision through inflamed non purulent tissue.Infection rate  is 3.4-13.2% can be in 15-20% range.

Eg:Penetrating abdominal trauma,large tissue injury,enterotomy during bowel obstruction.

Class IV -Dirty wounds

Dirty wounds include traumatic wounds in which a significant delay in treatment has occurred and in which necrotic tissue is present ,overt infection evidenced by presence of purulent material and those created to access a perforated viscus accompanied by high degree of contamination.Expected infection rate is 3.1-12.1%.

Eg:Perforated diverticulitis,necrotizing soft tissue infections.

How to do phalens test for carpal tunnel syndrome

Carpal tunnel syndrome is due to the compression of median nerve in the carpal tunnel at the wrist.It usually occurs in a middle aged female,hypothyroidism,diabetes etc.In Carpal tunnel syndrome there is paraesthesia of lateral 31/2 fingers.Phalens test is a provocative test to produce the symptoms of median nerve compression in a patient who presents to the OPD.

How to perform Phalens test

Place the backs of both  hands of the patient together and hold the wrists in forced flexion for a full minute. (Stop at once if sharp pain occurs) . If this produces numbness or “pins and needles” along the thumb side half of the hand, the patient most likely have Median nerve entrapment (Carpal Tunnel Syndrome).


Initial treatment is analgesics, if not relieved steroid injections are given into the carpal tunnel.If the symptoms are not relieved still,the definitive treatment is surgical release flexor retinaculum to decompress the carpal tunnel.

Development of genital structures in males and females

Genital structures in males

  1. Genital tubercle -Glans penis
  2. Urogenital sinus  -Corpus spongiosum,Bulbourethral glands(Cowpers),Prostrate
  3. Urogenital folds -Ventral shaft of penis
  4. Labioscrotal swelling -Scrotum
  5. Gubernaculum -Gubernaculum testis
  6. Mesonephric/Wolffian duct -Epididymis,Ejaculatory duct,Ductus deferens
  7. Paramesonephric/Mullerian duct -Appendix of testis,prostatic utricle

Genital structures in females

  1. Genital tubercle – Glans clitoris
  2. Urogenital sinus -Greater vestibular glands of bartholin,Urethral and paraurethral glands of skene
  3. Urogenital folds -Labia minora
  4. Labioscrotal swelling -Labia majora
  5. Gubernaculum – Ovarian ligament and round ligament
  6. Wolffian duct – Duct of epoophoron
  7. Mullerian duct -Uterus,Fallopian tube,upper part of vagina


Derivatives of dorsal and ventral mesogastrium

The derivatives of dorsal and ventral mesogastrium are

Dorsal mesogastrium

  1. Greater omentum
  2. Gastrosplenic ligament
  3. Gastrophrenic ligament
  4. Lienorenal ligament

Ventral mesogastrium

  1. Lesser omentum
  2. Falciform ligament
  3. Coronary ligament
  4. Right and left triangular ligament

PGI november 2010 questions

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