10 Benefits of Lemon Juice

You don’t have to waste money on toxic chemicals to clean your home, treat a cold, or pamper your skin. Lemon juice is a simple, natural alternative that can replace countless bottles of over-priced chemicals.

10 creative ways to use lemon juice:

1.Grease removal-A mixture of plain water and lemon juice is tough enough to bust through any grease on your kitchen appliances and counter tops.
2.Disinfect and deodorize your kitchen- Is your refrigerator or cutting boardreallyclean? Surfaces where we prepare and store food need to be clean, but this is also exactly where we don’t want to use toxic chemical cleaners. Lemon juice is excellent for disinfecting these surfaces, and will also remove unpleasant stains and odors.
3.Sooth a cough- Mix some raw honey with an equal amount of lemon juice to ease your coughing. This also works well for a sore throat.
4.Enhance digestion- Fresh lemon juice in water can aid digestion during meals. It’s also a great way to hydrate in the morning when you first wake up.
5.Tone your skin- Use a cotton ball to apply a light layer of diluted lemon juice to your skin. Let it sit for ten minutes and then rinse away with cool water. The lemon juice will naturally exfoliate your skin, and can also lighten dark spots and scars.
6.Clean glass- Lemon juice is just what you need to bring the sparkle back to that dull vase, coffee pot or decanter. You can also use one part lemon juice in ten parts water to shine your windows.
7.Clean and soften your hands- Lemon juice is excellent for removing stains and odors left on your hands. Lightly scrub the lemon juice into your hands with a sponge, then rinse and moisturize as usual. Your hands will feel clean, soft and fresh.
8.Remove tarnish- A simple paste of table salt and lemon juice can make tarnished copper, chrome and brass gleam again. Apply the mixture, allow it to sit for ten minutes, then rinse with warm water and buff gently to shine.
9.Get sun-kissed hair highlights -Chemicals used to lighten hair can be highly toxic. Get natural highlights by spritzing your hair with lemon juice before you go out in the sun. As an added bonus, rinsing your hair with lemon juice removes build-up and gives your locks incredible shine.
10.Clean your toilet- Toilet cleaning products are harsh and unnecessary. A mixture of borax powder and lemon juice will leave your toilet looking (and smelling) as good as new.

Axillary Lymph Nodes

Identifying Sites for Heart Auscultation

Right Hemicolectomy Surgery

Inguinal Lymph Nodes

General Pulsation

The Golden 5 Tips TO Save Your Kids from Alzheimer’s Now

impact on his or her likelihood of Alzheimer’s many decades later.
Here are five things you can do now to help save your child from Alzheimer’s and memory loss later in life, according to the latest research.

1. Prevent head blows:

Insist your child wear a helmet during biking, skating, skiing, baseball, football, hockey, and all contact sports. A major blow as well as tiny repetitive unnoticed concussions can cause damage, leading to memory loss andAlzheimer’s years later.

2 Encourage language skills:

A teenage girl who is a superior writer is eight times more likely to escape Alzheimer’s in late life than a teen with poor linguistic skills. Teaching young children to be fluent in two or more languages makes them less vulnerable to Alzheimer’s.

3. Insist your child go to college: Education is a powerful Alzheimer’s deterrent.

The more years of formal schooling, the lower the odds. Most Alzheimer’s prone: teenage drop outs. For each year of education, your risk of dementia drops 11%, says a recent University of Cambridge study.

4. Provide stimulation:

Keep your child’s brain busy with physical, mental and social activities and novel experiences. All these contribute to a bigger, better functioning brain with more so-called ‘cognitive reserve.’ High cognitive reserve protects against memory decline and Alzheimer’s.

5. Spare the junk food:

Lab animals raised on berries, spinach and high omega-3 fish have great memories in old age.
Those overfed sugar, especially high fructose in soft drinks, saturated fat and trans fats become overweight and diabetic, with smaller brains and impaired memories as they age, a prelude to Alzheimer’s.

The Golden 8 Tips To Lower Your Blood Pressure

While high blood pressure (also know as hypertension) is a serious health problem, there’s good news. No matter what your age or physical condition, there are things you can do to prevent high blood pressure.
The U.S. Department of Health and Human Services offers these 8 tips to help you prevent high blood pressure, or reduce your blood pressure if it’s already a problem.

Are you overweight? Lose weight:

Maintaining a healthy weight (see your doctor about this) will help prevent high blood pressure. Getting back to a healthy weight is not as hard as it sounds. You can start by limiting the portion size of your meals and snacks, and cut way back on high calorie foods. If you eat as many calories as you burn each day, you’ll maintain your weight. Eating fewer calories than you burn will help you lose weight. And losing weight will help lower your blood pressure.

When you plan meals, think of your heart:

Choose a diet that includes plenty of fruits and vegetables. Keep total fat low and avoid foods that are high in saturated fats and cholesterol. Having a healthy heart will help prevent blood pressure.

Eat less salt and sodium:

Salt and sodium can increase blood pressure, so it’s important to read food labels. The U.S. guidelines suggest limiting sodium intake to no more than 2,400 mg, or about 1 teaspoon of salt each day. If you eat canned, processed, and convenience foods, buy the brands that are lower in sodium.If you salt your food at the table, try using less, or none. It may take a little while to get used to the new flavors, but you may find that food tastes better when you use less salt. Fast food can contain a lot of sodium, so if you eat fast food choose items that are lower in salt and sodium. Reducing your salt intake will help to prevent high blood pressure.

If you drink alcohol, practice moderation:

The U.S. guidelines recommend that men have no more than 2 drinks per day, and women have no more than one alcoholic beverage per day.

Increase your physical activity:

Exercise is a key factor in preventing high blood pressure. If you get very little exercise now, start slowly and work your way up to at least 30 minutes of a moderate-level activity, such as brisk walking or bicycling, each day. If time is a factor, you’ll still benefit by breaking the 30 minute daily exercise periods into 10 or 15 minute sessions.

Stop smoking:

Research shows that smoking increases your chances of developing a heart disease, stroke, stroke, peripheral arterial disease, and several forms of cancer.

Talk with your doctor or health care professional:

Learn what your blood pressure reading means to your health, and if medication is recommended for you to treat or prevent high blood pressure.

If your doctor prescribes medication, take it:

It’s important to understand:

• what your blood pressure medication is expected to do for you
• how to take your medication, and when
• if your blood pressure medication has any side effects
• if the blood pressure medication is safe to take with any other prescriptions or vitamins you are already taking

If you have high blood pressure and treatment is prescribed, don’t be afraid to ask questions or get another medical opinion. Once you understand why you’re taking the medication, follow the recommended dose.
But the best way to treat high blood pressure is to prevent high blood pressure from becoming a problem. These 8 tips, plus advice from your health care provider, can help you keep your blood pressure at a healthy level.

Drug of Choice for Different Diseases

For MRSA Infection-Vancomycin
For Malaria in Pregnancy-Chloroquine

For Whooping Cough or Perteusis- Erythromycin
For Kawasaki disease-IV Ig
For Warferin Overdose-Vit-K
For Heparin Overdose-Protamine
For hairy Cell Leukemia-Cladirabine
For Multiple Myeloma- Melphalan
For CML-Imatinib
For Wegner's granulomatosis-Cyclophosphamide
For HOCM- Propranolol
For Delirium Tremens-Diazepam
For Drug Induced Parkinsonism-Benzhexol
For Diacumarol Poisoning-Vit-K
For Type-1 Lepra Reaction-Steroids
For Type- 2 Lepra Reaction-Thalidomide
For Allergic Contect Dermatitis-Steroids
For PSVT- 1st-Adenosine, 2nd-Verapamil, 3rd-Digoxin
For Z-E Syndrome- Proton Pump Inhibitor
For Chancroid-Cotrimoxazole
For Dermatitis Herpetiformis-Dapsone
For Spastic Type of Cerebral Palsy-Diazepam
For Herpis Simplex Keratitis-Trifluridine
For Herpes Simplex Orolabialis-Pancyclovir
For Neonatal Herpes Simplex-Acyclovir
For Pneumocystis carinii Pneumonia- CotrimoxazoleFor Nodulo Cystic Acne-Retinoic acid
For Trigeminal Neuralgia-Carbamezapine
For Actinomycosis-Penicillin
For Plague- Streptomycin
For Opioid Withdrawal- Methadone 2nd-Clonidine
For Alcohol Withdrawal- Chlordiazepoxide 2nd-Diazepam
For Post Herpetic Neuralgia- Fluphenazine
For WEST Syndrome-ACTH
For Diabetic Diarrhoea- Clonidine
For Lithium Induced Neuropathy-Amiloride

Mechanical Cardiopulmonary Resuscitation

Lund University cardiac arrest System (LUCAS)

The latest AHA 2010 guidelines on CPR has changed it’s sequence from ABC to CAB and stressed on the importance of effective chest compression. While there are still many debates exist in this sequence as the ATLS protocol and Neonatal Resus Protocol still maintaining it’s ABC sequences, the message is clear that chest compression should be done as effective as possible in order for the patient to achieve Return of Spontaneous Circulation. (ROSC)

The AHA guidelines defines the High Quality and Effective CPR through the criteria of 1) Rate is at least 100 compression per minute, 2) Depth of compression is 2 inches/5 cm in adult and 1 ½ inches in infants, 3) Minimal interruption as possible and it should be less than 10 seconds, 4) Avoiding excessive hyperventilation, and 5) Allow the chest wall to fully recoil in between compression.

In order to achieve that, the guidelines suggest that the rescuer taking turn every two minutes in performing CPR in order to minimize fatigue, do not stop the CPR while attaching the AED machine until the rhythm is being analyzed and less than 10 seconds should be use in checking the pulse.

However, we as a human still bound to the weakness and inconsistencies despite of many measures that we take. Besides, other issue also arise like should we do the CPR in ambulance? Will it still be effective, remain as a high quality CPR and the most importantly, will it guarantee the safeness of the healthcare provider?  

Autopulse - load distributing band (LDB) CPR

While it is still relatively new in Malaysia, the usage of the mechanical CPR devices has actually being practices around the world for a long time. The history itself begin from research in 1960’s and continues until now. 

From my personal opinion, this invention is indeed a genius art despite of conflicting study result regarding the usage of this device. For me, this device is a practical practice especially in continuation of CPR in the ambulance or when the CPR providers are getting tired.

The Conchrane Review 2011 found that there is insufficient evidence from human RCT's to conclude that mechanical chest compression is associated with benefit or harm. Ong et al (2012) in their review of 88 articles identify 10 studies that meet their inclusion criteria and finally draw a conclusion that that there are insufficient evidence to support or refute the use of mechanical CPR devices in setting of out hospital cardiac arrest and during ambulance transport. They further add that there is some low quality evidence suggesting that mechanical CPR  can improve consistency and reduce interruptions in chest compression. However, there is no evidence that mechanical CPR devices improve survival, to the contrary they may worsen neurological outcome.

Furthermore, the cost of implementing this procedure is very expensive compared to the traditional CPR which is of course free of charge. Therefore, i think that the usage of this device should be justified in context of physician preferences for now until there is a well establish study on this aspect.

Reference

Steven C Brooks, Blair L Bigham, Laurie J Morrison, "Mechanical versus Manual Chest Compression for Cardiac Arrest", Conchrane Database, 2011

Ong et al, "Mechanical CPR Devices Compared to Manual CPR During Out-of-hospital Cardiac Arrest and Ambulance Transport: A Systemic Review", Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2012, 20:39.

Types and Causes of Hydrocephalus

Types and Causes of Hydrocephalus

What is hydrocephalus?

The term hydrocephalus is derived from the Greek words "hydro" meaning water and "cephalus" meaning head. As its name implies, it is a condition in which the primary characteristic is excessive accumulation of fluid in the brain. Although hydrocephalus was once known as "water on the brain," the "water" is actually cerebrospinal fluid (CSF) - a clear fluid surrounding the brain and spinal cord. The excessive accumulation of CSF results in an abnormal dilation of the spaces in the brain called ventricles. This dilation causes potentially harmful pressure on the tissues of the brain.

The ventricular system is made up of four ventricles connected by narrow pathways. Normally, CSF flows through the ventricles, exits into cisterns (closed spaces that serve as reservoirs) at the base of the brain, bathes the surfaces of the brain and spinal cord, and then is absorbed into the bloodstream.

CSF has three important life-sustaining functions: 1) to keep the brain tissue buoyant, acting as a cushion or "shock absorber"; 2) to act as the vehicle for delivering nutrients to the brain and removing waste; and 3) to flow between the cranium and spine to compensate for changes in intracranial blood volume (the amount of blood within the brain).

The balance between production and absorption of CSF is critically important. Ideally, the fluid is almost completely absorbed into the bloodstream as it circulates; however, there are circumstances which, when present, will prevent or disturb the production or absorption of CSF, or which will inhibit its normal flow. When this balance is disturbed, hydrocephalus is the result.

What are the different types of hydrocephalus?

Hydrocephalus may be congenital or acquired. Congenital hydrocephalus is present at birth, and may be caused by either environmental influences during fetal development or genetic predisposition. Acquired hydrocephalus develops at the time of birth or at some point afterward. This type of hydrocephalus can affect individuals of all ages and may be caused by injury or disease.

Hydrocephalus may also be communicating or non-communicating. Communicating hydrocephalus occurs when the flow of CSF is blocked after it exits from the ventricles. This form is called communicating because the CSF can still flow between the ventricles, which remain open. Non-communicating hydrocephalus - also called "obstructive" hydrocephalus - occurs when the flow of CSF is blocked along one or more of the narrow pathways connecting the ventricles. One of the most common causes of hydrocephalus is "aqueductal stenosis." In this case, hydrocephalus results from a narrowing of the aqueduct of Sylvius, a small passageway between the third and fourth ventricles in the middle of the brain. There are two other forms of hydrocephalus which do not fit distinctly into the categories mentioned above and primarily affect adults: hydrocephalus ex-vacuo and normal pressure hydrocephalus.

Hydrocephalus ex-vacuo occurs when there is damage to the brain caused by stroke or traumatic injury. In these cases, there may be actual shrinkage (atrophy or wasting) of brain tissue. Normal pressure hydrocephalus commonly occurs in the elderly and is characterized by many of the same symptoms associated with other conditions that occur more often in the elderly, such as memory loss, dementia, gait disorder, urinary incontinence, and a general slowing of activity.

Who gets this disorder?

Incidence and prevalence data are difficult to establish as there is no existing national registry or database of people with hydrocephalus and closely associated disorders; however, hydrocephalus is believed to affect approximately 1 in every 500 children. At present, most of these cases are diagnosed prenatally, at the time of delivery, or in early childhood. Advances in diagnostic imaging technology allow more accurate diagnoses in individuals with atypical presentations, including adults with conditions such as normal pressure hydrocephalus.

What causes hydrocephalus?

The causes of hydrocephalus are not all well understood. Hydrocephalus may result from genetic inheritance (aqueductal stenosis) or developmental disorders such as those associated with neural tube defects including spina bifida and encephalocele. Other possible causes include complications of premature birth such as intraventricular hemorrhage, diseases such as meningitis, tumors, traumatic head injury, or subarachnoid hemorrhage blocking the exit from the ventricles to the cisterns and eliminating the cisterns themselves.

9 Ways to Burn Fat

Everyone's metabolism naturally slows down with age. At 40, you could be burning 100 to 300 

fewer calories a day than you did at 30, says Pamela M. Peeke, M.D., author of Body for Life for Women and assistant professor of medicine at the University of Maryland in Baltimore. That can translate into a 10-25-pound weight gain in a year. But you can counteract that slowdown and boost your body's fat-burning capabilities by making just a few tweaks to your daily routine. The following strategies will help you bust out of a weight-loss plateau and burn even more fat.

:Take five

Do five minutes of exercise each morning. We all have a metabolic thermostat, called the 

metastat, that can be turned up or down, and morning is the best time to activate it. Each day, your metastat is waiting for signals to rev up, so the more signals you can send it, the better. Your best bet is a light, full-body activity like walking orpush-ups.

:Fuel up in the morning

Numerous studies have found that regular breakfast eaters are often leaner than breakfast skippers. "Your metabolism naturally slows at night, but you can jump-start it in the morning by eating breakfast," says Tammy Lakatos Shames, R.D., C.D.N., co-author of Fire Up Your Metabolism. And because both your activity level and metabolism decrease later in the day, it's a good idea to make breakfast or lunch your largest meal.

:Fill up on good grains

Whole grains such as brown rice, wheat germ, dark bread, whole-grain cereal, oatmeal and bran leave you feeling full because they take longer to digest than simple carbohydrates. In a study from The American Journal of Clinical Nutrition, researchers at Brigham and Women's Hospital and Harvard Medical School evaluated the dietary intake of more than 74,000 women for 12 years. Overall, women who regularly ate the most whole-grain foods — about 1.5 servings a day — gained less weight than women who ate the least.

:Pump yourself up

Muscle burns more calories than fat does, and decreased muscle mass can be one of the main 

reasons metabolism slows. Disuse can cause women to drop as much as 10 pounds of muscle between the ages of 30 and 50. Losing that much muscle means you'll burn 350 to 500 fewer calories a day. To build and maintain muscle mass, aim for two to three strength-training workouts a week. If you don't belong to a gym, try push-ups, squats, abdominal crunches and tricep dips off a chair.

:Power on with protein 

Add a little high-quality, lowfat protein, such as chicken, fish and egg whites, to your meals, and you'll help your body burn fat faster. "Because protein requires more energy to digest, it speeds up your metabolism, and protein is necessary to ensure against loss of muscle tissue," says Michael Thurmond, author of 6 Day Body Makeover.

:Get your vitamin "I"

That's "I" for intensity. You love to walk, but if that usually means strolling along at a snail's pace, your waistline will pay little attention. Instead, put intensity, or "vitamin I," into your stride. Pick up your pace so you're walking at 4 mph, or one mile per 15 minutes. Once you build up your cardiovascular fitness level, you can even alternate between walking and jogging. The key is to get your heart rate up and keep your workouts challenging.

:Say yes to yogurt

In a recent study from the International Journal of Obesity, women who ate three daily servings of lowfat yogurt lost 60 percent more fat than women who didn't. In another study, participants who ate three daily servings of dairy lost more than twice as much fat as those who ate less than that. "Calcium-rich diets reduce fat-producing enzymes and increase enzymes that break down fat," says Michael B. Zemel, Ph.D., lead author of both studies and director of the Nutrition Institute at the University of Tennessee in Knoxville. Eat three servings of lowfat dairy a day, like milk, yogurt and hard cheeses (Gouda, Cheddar and Monterey Jack).

:Get active after eating

Your body's metabolic rate increases 10 percent after eating, and just a few minutes of activity could double that boost for up to three hours. Within 15 to 30 minutes of eating a snack or meal, do five or 10 minutes of light activity. Take the dog for a walk, climb stairs in your house or do some basic strength exercises.

:Sip green tea

You might love your lattes, but if you switch to green tea, not only will you get a healthy dose of disease-fighting compounds, you'll also cut body fat. In a study from The American Journal of Clinical Nutrition, people who drank a bottle of tea fortified with green tea extract every day for three months lost more body fat than people who drank black tea. Researchers at a health care lab in Tokyo believe disease-fighting antioxidants called catechins in green tea may help decrease body fat.

source

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Trauma in pregnancy

Trauma in Pregnancy remains the leading cause of non O. morbidity & Mort. accounting for 46 % of fatalities in pregnant women.
Since women remains active during preg it is reported that 6-7 % of them will have trauma.
The major cause of maternal death are the same as those in non pregnant; head injuries and hypovolemia.
Injury in pregnant women may be intentional or unintentional.
MVC & falls are most common cause of injury.
However, homicide and suicide accounts for 1/3 of cases.
In one study domestic violence occurred in at least 8-17 % of cases during pregnancy. Single kick to abdomen in late preg. is associated with abruption placentae and fetal loss.
In one series, 57% of the maternal deaths were due to homicides and 7% due to suicides.
Causes of traumatic injury roughly parallel those seen in the general population, blunt being more common.
10% of maternal deaths from trauma are due to head injury, like the general population.
Maternal death rate is not statistically different from the general matched population.
Trauma, however, does seem to raise the rate of fetal loss and placental abruption over baseline rates in pregnant population.

Physiological Changes During Pregnancy
Each system of the mother undergoes changes to compensate for the growing metabolic demand and load
of the new fetus.
The cardiovascular and hematopoetic changes include those noted above.
Additionally, there are increased amounts of thrombolytic factors present in the placenta, although systemic measurements of coagulation are normal.
The placental vascular system is exquisitely sensitive to circulating catacholamines which may result in intense vasoconstriction.
Maternal shock may result in 85% fetal mortality.

Cardiovascular
Total blood volume increases by 50%
Shock-like changes
Up to 20% acute and 30-35% gradual blood loss may show no sign of instability
Normal baseline heart rate is increased up by 10-15 bpm
Diastolic BP is decreased by 5-15 mmHg...

Injuries unique to pregnancy
Premature Contractions
Rarely progress to preterm delivery
Tocolysis is not proven in trauma.(1)

Abruptio Placentae
Different elastic properties in uterus & placenta “shearing”
3 % of minor trauma and upto 50 % in severe trauma

Uterine Rupture
Rare, 0.6 % of severe abdominal trauma (1)
Direct trauma after 12 wks of gestation
Prior Surgery (C/S or Myomec.) the risk

Maternal-Fetal Hemorrhage
Trimesters:T1 3%, T2 12%, T3 45%
4-5 X more common in injured pregnant women
Causes isoimmunization & fetal death
Kleihauer-Betke test - volume of fetal blood

Trauma in pregnancy ppt

Atrial Septal Defects(ASD)

An atrial septal defect (ASD) is a deficiency of the atrial septum. ASDs account for about 10-15% of all congenital cardiac anomalies .
Types of ASDs:
1-Ostium secundum defect→70% of ASDs.
2-Ostum primum defect→20% of ASDs.
3-sinus venosus defect.→10%of ASDs.
4-coronary sinus septal defect→ < 1% of ASDs .

Cardiac Development:
Cardiac tissues are first detectable on the 18th or 19th day of fetal life. Cardiac development continues for the next several weeks. The atrial septum begins to form during the fourth week and is complete by the end of the fifth week.

Frequency:
Research indicates that the incidence of congenital heart disease (CHD) is 0.8% of the US population. Approximately 7% of these individuals, or about 1 in 1500 live births, have an ASD. An estimated 15-30% of healthy adults have an unfused foramen ovale in which the valve functions normally but has failed to fuse. I
PFO is of no haemodynamic significant and not considered as ASD. Does not need surgical repair but increase risk of paradoxical syst. embolization.

Age of presentation:
ASD, is present at birth; however, in most cases, a murmur is not audible until the child is a few months old. Symptoms usually do not occur in individuals with ASD until late childhood, adolescence, or adulthood.
Secundum type, sinus venosus, and unroofed coronary sinus defects sometimes are not diagnosed until the third decade of life.
Ostium primum ASDs usually are diagnosed in the first few years of life because of the presence of a mitral regurgitation murmur.

Ostium Secundum:
A defect in the region of the fossa ovalis
The most common form of ASD
Associated with structurally normal AV valves.
It may be single or multiple ( fenestrated atrial septum)
Female: male 3:1 incidence.
Associated lesions :partially anomalous pulmonary venous return .& Holt- Oram-syndrome.

Holt-Oram syndrome:
Holt-Oram syndrome (HOS) is a heart–upper limb malformation complex with an autosomal dominant inheritance.
Musculoskeletal defects:
    ♦Upper limbs are affected. The most severe form is phocomelia with rudimentary limbs.
     ♦Hypoplasia of the radius , The most common defects are radial thumb anomalies ranging from absent thumbs to displaced (distally placed), duplicated, or triphalangeal thumbs.
Atrial Septal Defects(ASD) ppt

Cutaneous Manifestations of Hepatitis C

The hepatitis C is an RNA virus.It is a major cause of both acute and chronic hepatitis. Persons become infected mainly through parenteral exposure to infected material by blood transfusions or injections with nonsterile needles. Persons who inject illegal drugs, people who snort cocaine with shared straws, and health care workers who are at risk for needlestick and other exposures are at highest risk for HCV infection. Another major risk factor for HCV is high-risk sexual behavior.

Most patients with acute and chronic infection are asymptomatic.However, chronic hepatitis C infection and chronic active hepatitis are slowly progressive diseases and result in severe morbidity in 20-30% of infected persons.

Cutaneous symptoms relevant to HCV infection manifest in 20-40% of patients presenting to dermatologists and in a significant percentage (15-20%) of general patients.

HCV is a major public health problem because it causes chronic hepatitis, cirrhosis, and hepatocellular carcinoma (HCC).Extrahepatic manifestations of hepatitis C virus are numerous.The most prevalent and most closely linked with HCV is essential mixed cryoglobulins with dermatologic, neurologic, renal, and rheumatologic complications. A less definite relationship to HCV is observed with systemic vasculitis, porphyria cutanea tarda, and the sicca syndromes.Extrahepatic manifestations include mixed cryoglobulinemia, porphyria cutanea tarda, leukocytoclastic vasculitis, lichen planus (LP), and sicca syndrome, all of which should be regarded as early markers of a potentially fatal chronic liver disease.

Case 3 Ear

Case 3: A 10 year old child complained of a right mucopurulent otorhea for the last 2 years. He suddenly became feverish and this was associated with diminution of the ear discharge. There was also tenderness on pressure behind the auricle. The retroauricular sulcus was preserved. There was no retroauricular fluctuation.

CASE 3
Diagnosis & reasons	Right chronic suppurative otitis media (mucopurulent discharge of 2 years duration) complicated by mastoiditis (fever with decreased ear discharge, tenderness behind the auricle with preservation of retroauricular sulcus; it is not an abscess because there is no retroauricular fluctuation).
Explain the following manifestations	Diminution of ear discharge: reservoir sign dischrge decreases but is still there and whenever discharge decreases fever and other constitutional symptoms increase in intensity Tenderness behind the auricle: due to inflammation of the bone of the mastoid process and its overlying periosteum Retroauricular sulcus preserve: as the inflammatory process is subperioteal No retroauricular fluctuation: it is mastoiditis and so is not a mastoid abscess yet
Further examination &/or investigations	Otoscopic examination of the ear possible finding of a cholesteatoma Look for the rest of the manifestations of mastoiditis as sagging of the posterosuperior wall of the bony external auditory canal CT scan of the ear to show opacity in the mastoid bone Complete blood picture
Treatment	Medical treatment in the form of antibiotics and Drainage of the ear through myringotomy and Mastoidectomy is essential to remove all disease from the ear

Case 4: A 9 year old child has been complaining of right continuous offensive ear discharge for the last 3 years. A month ago he began to suffer from headache, fever and some vomiting for which he received symptomatic treatment. The patient’s condition was stable for a while, then after 2 weeks he started to suffer from severe headache and drowsiness. The patient also noticed difficulty going up and down the stairs. A week later, he developed weakness in the left arm and left leg, and became markedly drowsy. He became comatose the next day.

Case 2 Ear

Case 2: A 50 year old male patient complained of right earache of 2 days duration. The pain was especially severe on chewing food and during speech. There was also marked edema of the right side of the face. On examination, pressure on the tragus was painful; and there was a small red swelling arising from the anterior external auditory meatal wall. Rinne test was positive in the right ear. The patient gave a history of 2 previous similar attacks in the same ear during the last six months but less severe.

CASE 2
Diagnosis & reasons	Recurrent furunculosis of the right external auditory canal (pain in the ear with movements of the temporomandibular joint or pressure on the tragus, edema of the face and a small red swelling in the anterior wall of the external auditory canal)
Explain the following manifestations	Severe pain on chewing food: movements of the temporomandibular joint lead to movements of the cartilaginous external auditory canal that is lined by skin containing hair follicles from which the furuncle arises. Edema of the right side of the face: extension of the inflammatory edema to the face in severe cases Rinne positive: means normal hearing and NO conductive hearing loss because when air conduction is better than bone conduction it is called Rinne positive Previous similar attacks: recurrence the most probable cause is Diabetes mellitus
Further examination &/or investigations	Otoscopic examination of the tympanic membrane if possible Blood glucose analysis to discover diabetes
Treatment	Antibiotics Analgesics Never incise or excise for fear of perichondritis Local antibiotic or glycerine icthyol ointment Proper control of diabetes if discovered

Case 1 Ear

Case 1: A 10 year old child was having a right mucopurulent otorhea for the last 4 years. A week ago he became dizzy with a whirling sensation, nausea, vomiting and nystagmus to the opposite side; his deafness became complete and his temperature was normal. Three days later he became feverish, irritable and continuously crying apparently from severe headache. Also he had some neck retraction. The child was not managed properly and died by the end of the week.

CASE 1
Diagnosis & reasons	Right chronic suppurative otitis media (mucopurulent otorhea of 4 years duration) complicated by suppurative labyrinthitis (dizziness, nausea and vomiting with nystagmus to the opposite side and complete loss of hearing) and then complicated by meningitis (fever, severe headache and neck retraction).
Explain the following manifestations	Whirling sensation: vertigo due to inner ear inflammation Nystagmus to the opposite side: suppurative labyrinthitis leading to fast phase of eye movement to the opposite ear and slow phase to the diseased ear nystagmus direction is called according to the fast phase. In serous labyrinthitis with no inner ear cell destruction the direction of nystagmus is toward the diseased ear. Severe headache: increased intracranial pressure due to meningitis Neck retraction: due to meningeal inflammation
Further examination &/or investigations	Otologic examination possible finding of a marginal perforation of atticoantral CSOM (cholesteatoma) Audiogram to reveal SNHL in the affected ear Kernig's and Brudzinski's signs Fundus examination to show papilledema Lumbar puncture: turbid high pressure CSF with pus rich in proteins Complete blood picture
Treatment	Antibiotics that cross the blood brain barrier Analgesics Repeated lumbar puncture to drain infected CSF and to relieve symptoms and to inject antibiotics Treaetment of the underlying otitis media appropriately according to its type