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OTTAWA ANKLE RULE


The Ottawa ankle rules are a clinical decision-making strategy for determining which patients require radiographic imaging for ankle and midfoot injuries. Proper application has high (97.5%) sensitivity and reduces the need for radiographs by ~35%

 

The Ottawa Ankle Rules are guidelines indicating that x-ray studies should be obtained if there is a pain in the malleolar zone and 

A) bony tenderness at the distal 6 cm of the fibula –or– 

B) bony tenderness at the distal 6 cm of the tibia –or– inability to take 4 steps immediately after injury. 


The Ottawa Foot Rules indicate that x-rays should be obtained if there is a pain in the midfoot zone and: 

C) bony tenderness at the base of the fifth metatarsal –or– 

D) bony tenderness at the navicular bone tibia –or– inability to take 4 steps immediately after injury

 

Satyendra Dhar MD, @DharSaty




 


 Thrombocytopenia 

Work up, differential diagnosis, and management.


 

Satyendra Dhar MD, 


 Goodsall's Rule states that 

Fistulas can be described as anterior or posterior relating to a line drawn in the coronal plane across the anus, the so-called transverse anal line. Anterior fistulas will have a direct track into the anal canal. Posterior fistulas will have a curved track with their internal opening lying in the posterior midline of the anal canal. An exception to the rule is anterior fistulas lying more than 3 cm. from the anus, which may open in the anterior midline of the anal canal.

Successful treatment of an anal fistula requires correct identification of the internal opening and accurate delineation of the course of the fistula in relation to the anal sphincters. 

Goodsall’s rule is of limited use in predicting the site of the internal opening of a fistula. The closer the external opening is to the anal verge, the more likely a fistula conforms to the rule. The further a fistula is away from the anal verge, the more likely it follows a horseshoe course and less likely to conform to Goodsall’s rule.


The predictive accuracy of Goodsall’s rule was found to be 84.6% in the case of a fistula with an anterior external opening. While in the case of a fistula with a posterior external opening this found to be 69.1%. Overall predictive accuracy of Goodsall’s rule is 77%. 

 

Satyendra Dhar MD,


 Electrolyte imbalances are common findings in many diseases. The kidney is a principally responsible organ for the retention and excretion of electrolytes and fluids. But other mechanisms like hormonal interactions of antidiuretic hormone, aldosterone, and parathyroid hormone, and factors such as physiological stress play important roles in regulating fluid and electrolyte balance.

Electrolyte imbalances have a very broad range of signs and symptoms, from being completely asymptomatic to having fatal arrhythmias. The coexistence of one or more electrolyte imbalances in individuals with mixed medical conditions can create a complex clinical presentation. However, typically, each electrolyte imbalance presents with signs and symptoms that are more indicative of the specific imbalance.

 

 

Satyendra Dhar MD, 

 



 THYROID EMERGENCIES 

Emergencies related to thyroid gland diseases are infrequently observed in clinical practice. They are caused by either overt dysfunction or marked enlargement of the gland that jeopardizes the life of patients and require admission to intensive care units (ICU) in most cases.

 

The first description of thyroid diseases as they are known today was that of Graves’ disease by Caleb Parry in 1786, but the pathogenesis of thyroid disease was not discovered until 1882-86. Thyroidectomy for hyperthyroidism was first performed in 1880, and antithyroid drugs and radioiodine therapy were developed in the early 1940s. Thomas Curling first described hypothyroidism (myxedema) in 1850 and the cause and suitable treatment were established after 1883. 

 

Thyroid-related emergencies are caused by overt dysfunction of the gland which is so severe that requires admission to intensive care units (ICU) frequently. 

 

Severe excess or defect of thyroid hormone is a rare condition, which jeopardizes the life of patients in most cases. Both hypothyroid coma (HC) and thyrotoxic storm (TS) are triggered by precipitating factors, which occur in patients with severe hypothyroidism or thyrotoxicosis, respectively. The pillars of HC therapy are high-dose L-thyroxine and/or tri-iodothyroinine; IV glucocorticoids; treatment of hydro-electrolyte imbalance (mainly, hyponatremia); treatment of hypothermia; often, endotracheal intubation and assisted mechanic ventilation are needed. Therapy of TS is based on beta-blockers, thyrostatics, and IV glucocorticoids; eventually, a high dose of iodide compounds or lithium carbonate may be of benefit. Surgery represents the gold standard treatment in patients with euthyroid massive nodular goiter, although new techniques – e.g., percutaneous laser ablation – are helpful in subjects at high surgical risk or refusing operation.

 

Satyendra Dhar MD, 


 INCIDENTALOMAS

Once incidentalomas  are detected, appropriate management is dependent on an informed patient's wishes and the clinical situation.

•      Patients presenting with pituitary incidentalomas should undergo pituitary-specific magnetic resonance imaging if the lesion is 1 cm or larger, or if it abuts the optic chiasm.

•       Thyroid incidentalomas are ubiquitous, but nodules larger than 1 to 2 cm are of greater concern.

•       Worrisome pulmonary incidentalomas are those larger than 8 mm or those with irregular borders, eccentric calcifications, or low density. However, current guidelines recommend that even pulmonary incidentalomas as small as 4 mm be followed.

•       Solid hepatic incidentalomas 5 mm or larger should be monitored closely, and multiphasic scanning is helpful.

•       Pancreatic cystic neoplasms have malignant potential, and surgery is recommended for pancreatic cysts larger than 3 cm with suspicious features.

•       Adrenal lesions larger than 4 cm are usually biopsied.

•       The Bosniak classification is a well-accepted means of triaging renal incidentalomas. Lesions at category IIF or greater require serial monitoring or surgery.

•       Benign or probably benign ovarian cysts 3 cm or smaller in premenopausal women or 1 cm or smaller in postmenopausal women do not require follow-up. Ovarian cysts with thickened walls or septa, or solid components with blood flow, should be managed closely.

 

 

Satyendra Dhar MD,


 Albuminuria is a major risk factor for progressive renal function decline and is believed to be the initial step in an inevitable progression to proteinuria and renal failure in humans. Thus, reduction of albuminuria is a major target for Reno protective therapy in CKD.

 

Moderately increased albuminuria (previously microalbuminuria) is arbitrarily defined as excretion of 30 to 300 mg albumin/24 h in at least two of three consecutive urine samples. At a concentration of 30 to 300 mg/24 h, albumin is normally not detected by nonspecific tests for protein (e.g., Biuret reaction). Albumin can be detected, however, by use of specific techniques such as dipstick, enzyme-linked immunosorbent assay, nephelometry, and radioimmunoassay. Instead of difficult-to-obtain 24-hour urine collections, the albumin concentration can be determined in spot urine or, better, first-void morning urine samples. The normal range is less than 20 µg/ml.

 

Satyendra Dhar MD,

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