Legg-Calve-Perthes

Disease

DEFINITION
is a childhood hip disorder initiated by a disruption of
blood flow to the ball of the femur called thefemoral
head
it is a condition common in childhood that affects the
hip, where the thighbone (femur) and pelvis meet in a
ball-and-socket joint.

PATHOLOGY
4 STAGES on the basis of the evolution of the disease
1. Avascular Necrosis
2.Revascularization/Fragmentation
3.Ossification/Healing
4.Remodelling

PATHOLOGY
1. Avascular Necrosis-(ischemia) without enough blood in the area, the
bone will die
2. Revascularization/Fragmentation- at this stage there is collapse and
loss of structural integrity of the femoral head as it is sort of softened
due to bone resorption, collapse of necrotic bone and persistence of
fibro-vascular tissue leading to deformation of epiphysis
3. Ossification/Healing- New bone starts forming and epiphyseal density
increases in the lucent portions of the femoral head
4. Remodeling- the stage of remodeling and there is no additional change
in the density of the femoral head. Depending of on the severity of the
disease the residual shape of the head may be spherical or distorted

ETIOLOGY
Idiopathic/unknown cause
Proposed theories
-inherited protein C and/or S deficiency
-venous thrombosis
-arterial occlusion
-synovitis of hip joint
-generalized skeletal disorder

INCIDENCE
Common in Central Europe, less common in blacks,
Chinese and Indians
Sex: Males are affected 4-5 times more often in females
Age: most commonly seen in aged 5-10 yrs.
New cases of Perthes' disease rarely occur after age 14
years (if diagnosed after 14 years of age, then it is
usually old disease from early in childhood or avascular
necrosis from an alternative cause)

CLINICAL MANIFESTATION
The first symptom is often limping, which is usually painless.
Sometimes there may be mild pain that comes and goes.
Other symptoms may include:
-Hip stiffnessthatlimits hipmovement
-Knee pain
-Limited range of motion( Abduction and Internal Rot. are nearly
always limited)
-Thigh or groin pain that does not go away
-Shortening of the leg, or legs of unequal length
-Muscle lossin the upper thigh

ANATOMY

DIAGNOSIS
Imaging Test
- X-ray
- Magnetic Resonance Imaging(MRI)
- Bone Scan
Physical Examination
-health care provider will look for a loss in hip
motion(ROM) and a typical limp.

TREATMENT
Medical management : Medications include nonsteroidal anti-inflammatory
medication (NSAIDs) for pain and/or inflammation
THERAPY

-Physical Therapy
-Crutches
-Traction
-Cast
SURGICAL
-Contracture Release
-Joint Alignment
-Removal of Excess bones or loose bodies
-Joint Replacement

COMPLICATIONS
Hip Arthritis (osteoarthritis)

DIFFERENTIAL DIAGNOSIS
Slipped Capital Femoral Epiphysis
Osteomyelitis
Synovitis

Pneumonia

neumonia
Out lines

Definition
Pathology
Etiology
Incidence
Clinical manifestation
Pertinent anatomy
Differential diagnosis
Treatment
Complication

Pneumonia
definition
Lung inflammation caused by bacterial or
viral infection, in which the air sacs fill
with pus and may become solid.
Inflammation may affect both lungs .

Pneumonia
pathology

The streptococci reach the alveoli and lead to inflammation

and pouring of an exudates into the air spaces.
WBCs migrates to alveoli, the alveoli become more thick
due to its filling consolidation, involved areas by
inflammation are not adequately ventilated, due to
secretion and edema. This will lead to partial occlusion of
alveoli and bronchi causing a decrease in alveolar oxygen
content.

Pneumonia

PATHOLOGY (CONT..)
Venous blood that goes to affected areas without being
oxygenated and returns to the heart. This will lead to
arterial hypoxemia and even death due to interference
with ventilation.

neumonia
kinds of Pneumonia
Community-Acquired Pneumonia
Hospital-Acquired Pneumonia
Health Care-Associated Pneumonia

Pneumonia
etiology

Streptococcus pneumoniae is recognized as an important

cause of pediatric pneumonia regardless of age in both
the inpatient and outpatient setting. In developed
countries S. pneumoniae probably accounts for 25 to 30%
of cases of pediatric community-acquired pneumonia.
Viruses (mostly respiratory syncytial virus) are
responsible for approximately 20% of cases, and
Chlamydia pneumoniae and Mycoplasma pneumoniae
occur commonly in older children.

3 common types
of Pneumonia
A) Bacterial pneumonia
present in many throats

4 causative Agents
Streptococcus pneumonia
resulting in lobar pneumonia

4 causative Agents
hemophilus influenza
resulting in bronchopneumonia
Legionella pneumophilia
resulting to legionnaires disease
Staphylococcus aureus
is a type of bacteria that about 30% of people carry on
their noses

 B ) viral pneumonia
Half of all pneumonias are believed to be cause by virus,
such as:
influenza
adenovirus
coxsackievirus
chickenpox
measles
cytomegalovirus

 C) mycoplasmal pneumonia
A.K.A walking pneumonia
The mycoplasmas multiply and spread causing infection

Pneumonia
incidence

According to department of health year 2010 the rate of

pneumonia became the first leading causes of child mortality age
group (1-4, 5-9, 10-14) & Sex No. & Rate/100,000 population
Male

1-4 Years
Pneumonia
5-9 Years
Pneumonia
10-14 Years Pneumonia

1,073
334
233

Female

978
282
195

Both Sexes

2,051
616
428

Rate

223.3
5.9
4.4

Pneumonia
clinical manifestation
Shaking chills
Rapidly rising fever ( 39.5 to 40.5 degree)
Stabbing chest pain aggravated by respiration and coughing
Tachypnea, nasal flaring
Patient is very ill and lies on the affected side to decrease pain
Use of accessory muscles of respiration e.g. abdomen and intercostals muscles
Cough with purulent, blood tinged, rusty sputum
Shortness of breath
Flushed cheeks
Loss of appetite, low energy, and fatigue
Cyanosed lips and nail beds

Differential Diagnosis
Asthma
Atelectasis
Bronchiectasis
Bronchiolitis
Bronchitis
Chronic Obstructive Pulmonary Disease
Foreign Body Aspiration
Lung Abscess
Pneumocystis Carinii Pneumonia
Pneumonia, Fungal
Pneumonia, Viral
Respiratory Failure

Diagnostic test
History taking
Physical examination
Chest x-ray
Blood test
Sputum culture

 Medical treatment
Most cases of pneumonia can be treated at home. However
babies, children, and people with severe pneumonia may
need to be admitted to hospital for treatment.
Pneumonia is usually treated with antibiotics, even if viral
pneumonia is suspected as there may be a degree of bacterial
infection as well. The type of antibiotic used and the way it is
given will be determined by the severity and cause of the
pneumonia.

 Antibiotics - given by mouth as tablets or liquid

Pain relieving medications
Paracetamol to reduce fever
Rest.
Antibiotics given intravenously (via a drip into a vein)
Oxygen therapy - to ensure the body gets the oxygen it needs
Intravenous fluids - to correct dehydration or if the person is too
unwell to eat or drink

 Physical therapy treatment

Modified postural
Shaking and vibes
Coughing and huffing exercises
Breathing exercises
IPPB administration
obilization of the patient

Complication
Pleural effusion
When fluid accumulates between the pleura and the chest wall due to the
large amount of fluid already present in the lungs.

Empyema
Pus may be present in the lungs due to the infection.

Lung abscess
A lung abscess develops when the infection has destroyed lung tissue and a
pus is formed

cavity filled with

Bacteremia
This occurs when the infection is no longer contained within the lungs and moves into the
bloodstream, thus the blood is infected

BELLS PALSY

BELLS PALSY
Is a form of temporary facial paralysis resulting from
damage or trauma to the facial nerves
Always unilateral
This condition comes on suddenly, often overnight, and
usually gets better on its own within a few weeks

WHAT CAUSES BELLS PALSY?

The cause of Bell's palsy is not clear. Most cases are
thought to be caused by the herpes virusthat
causescold sores
In most cases of Bell's palsy, the nerve that controls
muscles on one side of the face is damaged
byinflammation
Many health problems can cause weakness or paralysis
of the face. If a specific reason cannot be found for the
weakness, the condition is called Bell's palsy.

PATHOLOGY
Bell's palsy occurs due to a malfunction of thefacial nerve(VIIcranial
nerve), which controls themuscles of the face.
Facial palsy is typified by inability to control movement in the facial
muscles. The paralysis is of the infranuclear/lower motor neuron type.
It is thought that as a result ofinflammation of the facial nerve, pressure
is produced on the nerve where it exits the skull within its bony canal,
blocking the transmission of neural signals or damaging the nerve.
Possible causes includetumor, meningitis,stroke,diabetes
mellitus,head traumaand inflammatory diseases of the cranial nerves
(sarcoidosis,brucellosis, etc.). In these conditions, the neurologic findings
are rarely restricted to the facial nerve. Babies can be born with facial
palsy. In a few cases, bilateral facial palsy has been associated withacute
HIV infection.

INCIDENCE
Affects men and women equally , all ages ,all times of
the year.
Increased occurrence in the elderly diabetics,
hypertensives than in the common people.
Increased incidence in women during the third trimester
of pregnancy 2 weeks preceding delivery ,first two
weeks postpartum.

CLINICAL MANIFESTAION
Rapid onset of mild weakness to total paralysis on one side of
the face- occurring within hours to days- making it difficult to
smile or close the eye on the affected side
Facial droop and difficulty making facial expressions
Pain around the jaw or in or behind the ear on the affected
side
Increased sensitivity to sound on the affected side
Headache
Decreased ability to taste
Changes in the amount of tears and saliva production

DIFFERENTIAL DIAGNOSIS
stroke
Infections with herpes zoster virus
Ramsay hunt syndrome
Lyme disease

TREATMENT
In mild cases, it do not require treatment as the symptoms
usually subside on their own within 2 weeks
Use of corticosteroids such as prednisone to reduce
inflammation and swelling
Other drugs such as acyclovir -- used to fight viral herpes
infections -- may also have some benefit in shortening the
course of the disease.
Analgesics such as aspirin, acetaminophen, or ibuprofen may
relieve pain
Lubricating eye drops, such as artificial tears or eye ointments
or gels, and eye patches are also effective

 Physical therapy to stimulate the facial nerve and help

maintain muscle tone may be beneficial to some
individuals.
Facial massage and exercises may help prevent permanent
contractures of the paralyzed muscles before recovery
takes place
Other therapies that may be useful for some individuals
include relaxation techniques, acupuncture, electrical
stimulation, biofeedback training, and vitamin therapy
(including vitamin B12, B6, and zinc), which may help
restore nerve function.

COMPLICATIONS
Contracture- It can lead to facial disfigurement such as
the eye becoming smaller, the cheek becoming more
bulky, or the line between the nose and the mouth
becoming deeper.
Loss or reduced sense of taste
Speech problems
Eye-mouth synkinesias
Eye drying and corneal ulceration
Crocodile tear syndrome

Cirrhosis

Definition
Cirrhosis is a late stage of scarring (fibrosis) of the liver caused
by many forms of liver diseases and conditions, such as
hepatitis and chronic alcohol abuse.

Pathology
Consequence of chronic liver
disease characterized by
replacement of liver tissue by
fibrosis, scar tissue and
regenerative nodules leading
to progressive loss of liver
function

Pathology
cirrhosis is defined by its pathological features on microscopy:
the presence of regenerating nodules of hepatocytes
the presence of fibrosis, or the deposition of connective tissue between these
nodules

Pathology
MICRONODULAR
CIRRHOSIS
Uniform, small nodules up
to 3 mm in diameter
Often caused by alcohol
damage

Pathology
MACRONODULAR
CIRRHOSIS
Large nodules
Often seen following
hepatitis B infection

Etiology
Alcoholic liver disease once was considered to be
the predominant source of cirrhosis in the United
States, but hepatitis C has emerged as the
nation's leading cause of chronic hepatitis and
cirrhosis.
Alcohol liver disease (21%)
Hepatitis B May be coincident with hepatitis
D (15%)
Hepatitis C (26%)
Hepatitis C plus alcoholic liver disease (15%)
Cryptogenic causes (18%) - Many cases actually
are due to NAFLD

Etiology
It's important to determine the cause of cirrhosis because
treating that underlying cause can help prevent further liver
damage. A wide range of diseases and conditions can damage
the liver and lead to cirrhosis

Incidence
According to the National Institutes of Health (NIH) cirrhosis is
the 12th leading cause of death due to disease in America. It is
more likely to affect men than women.
The overall incidence of cirrhosis in the US is approximately
360 per 100,000 population, or approximately 900,000 total
individuals ("Cirrhosis of the Liver").

Clinical Manifestation
There may be no symptoms, or symptoms may come on slowly,
depending on how well the liver is working.
Early symptoms include:

Fatigue and loss of energy

Poor appetite and weight loss
Nausea or belly pain
Small, red spider-like blood vessels on the skin

Clinical Manifestation

As liver function worsens, symptoms may

include:
Fluid buildup of the legs (edema) and in the abdomen
(ascites)
Yellow color in the skin, mucus membranes, or eyes
(jaundice)
Redness on the palms of the hands
In men, impotence, shrinking of the testicles, and breast
swelling
Easy bruising and abnormal bleeding
Confusion or problems thinking
Pale or clay-colored stools

Differential Diagnosis

Differential Diagnosis

Exams and Tests

Your doctor will do a physical exam to look for:

An enlarged liver or spleen

Excess breast tissue
Swollen abdomen, as a result of too much fluid
Reddened palms
Red spider-like blood vessels on the skin
Small testicles
Widened veins in the abdomen wall
Yellow eyes or skin (jaundice)

Exams and Tests

You may have the following tests to measure liver function:

Complete blood count

Prothrombin time
Liver function tests
Blood albumin level

Exams and Tests

Other tests to check for liver damage include:

Computed tomography (CT) of the abdomen

Magnetic resonance imaging (MRI) of the abdomen
Endoscopy to check for abnormal veins in the esophagus or stomach
Ultrasound of the abdomen

You will need a liver biopsy to confirm the diagnosis.

Treatment
LIFESTYLE CHANGES
Limiting alcohol
Eating a healthy diet that is low in salt
Getting vaccinated for diseases such as influenza, hepatitis A and hepatitis B,
and pneumococcal pneumonia
Talking to your doctor about all medicines you take including herbs and
supplements and over-the-counter medicines

Treatment
MEDICINES FROM YOUR DOCTOR
"Water pills" (diuretics) to get rid of fluid build-up
Vitamin K or blood products to prevent excess bleeding
Antibiotics for infections

OTHER TREATMENTS
Endoscopic treatments for enlarged veins in the throat
(bleeding varicies)
Removal of fluid from the abdomen (paracentesis)
Placement of a transjugular intrahepatic portosystemic shunt
(TIPS) to repair blood flow in the liver

Treatment
Liver transplant surgery
Your liver may stop functioning if it's severely damaged by scarring. In
this situation, a liver transplant is the only option. This is a major
procedure that involves removing your diseased liver and replacing it
with a healthy donor liver.

Complications
Bleeding disorders (coagulopathy)
Buildup of fluid in the abdomen (ascites) and infection of the fluid
(bacterial peritonitis)
Enlarged veins in the esophagus, stomach, or intestines that bleed
easily (esophageal varices)
Increased pressure in the blood vessels of the liver (portal hypertension)
Kidney failure (hepatorenal syndrome)
Liver cancer (hepatocellular carcinoma)
Mental confusion, change in the level of consciousness, or coma
(hepatic encephalopathy)

Hypothyroidism
A condition, where the thyroid has become under- active
and is producing low levels of one or both of the thyroid
hormones
T3 ( triiodothyronine)
T4 ( thyroxine)

The Thyroid
Gland that regulates
metabolism
Located in the front of the
neck just below the voice box
(larynx)
The thyroid gland releases two
hormones: thyroxine (T4) and
triioxdothyronine (T3)
The thyroid gland, as well as
the pituitary gland and
hypothalamus, control how
much of these hormones are
produced
There are three types of
hypothyroidism: primary,
secondary, and tertiary

PATHOPHYSIOLOGY

Primary Hypothyroidism
Due to a defect in the gland, the thyroid cannot make enough T3 and
T4
The most common cause of primary hypothyroidism in the United
States is the destruction of the thyroid gland by the immune system
(Hashimotos thyroiditis)
Other causes of primary hypothyroidism include:
certain drugs such as lithium
radiation exposure to the neck
radioactive iodine used for treatment of hyperthyroidism
special x-ray dyes
surgical removal of part or all of the thyroid gland
some women develop after pregnancy (postpartum thyroiditis)

Secondary & Tertiary

Hypothyroidism
In secondary hypothyroidism the thyroid gland produces too
little hormone due to disorders of the pituitary gland (i.e.
pituitary hypothyroidism)
Tertiary hypothyroidism is caused by disorders of the
hypothalamus

Risk Factors
Age (older than 50)
Female gender
Obesity
Thyroid surgery
X-ray or radiation treatments to the neck

Early Symptoms
Cold intolerance
Constipation
Depression
Fatigue
Weakness
Muscle or joint pain
Paleness
Thin, brittle hair and fingernails
Dry, itchy skin
Weight gain and water retention

Late Symptoms
Decreased sense of taste and smell
Dry flaky skin
Hoarseness
Menstrual disorders
Puffy face, hands, and feet
Slow speech
Thickening of skin
Thinning of eyebrows

Exams and Tests

Physical examination may reveal:
Smaller than normal thyroid gland (but sometimes may also be normal in
size or enlarged)
Coarse facial features
Firm swelling of arms and legs
Loss of the edges of eyebrows
Low blood pressure
Slow heart rate
Low temperature
Pale, yellow, and dry skin
Slow muscle relaxation when reflexes are tested
Thin, brittle hair

Chest x-ray may show enlarged heart

More Exams and Tests

Laboratory tests include:

High levels of thyroid stimulating hormone (TSH) indicate that

the thyroid is not producing sufficient levels of thyroid
hormone (mainly T4). TSH does not diagnose secondary and
tertiary hypothyroidism.
Low free T3 and T4
Total T3 and T4
Anemia on a complete blood count
Increased cholesterol levels
Increased liver enzymes
Increased serum prolactin
Low serum sodium

Treatment
Treatment is to replace the thyroid hormone that is
lacking
T4 is used most often, but a combination of T4 and T3 is also
used
Receive the lowest dose that relieves symptoms and brings
blood tests to a normal range

Periodic monitoring of TSH levels Requires life-long

therapy, can be completely controlled with early
treatment

Related Complications
Myxedema coma, the most severe from of hypothyroidism
(rare)
Signs and symptoms include: low temperature, decreased
breathing, low blood pressure, low blood sugar, and
unresponsiveness

Depression
Heart disease
Increased risk for infection
Infertility
Miscarriage
Pituitary tumors
Complications from too much thyroid hormone replacement:
Atrial fibrillation
Osteoporosis
Symptoms of hyperthyroidism

Differential diagnosis
Depression
Alzheimer dementia
Anemia

References
Holt, Elizabeth H. "Hypothyroidism - primary." Medline Plus N.p., 17 June 2008.
Web. 4 Dec. 2009.
<http://www.nlm.nih.gov/medlineplus/ency/article/000367.htm>.
"Hypothyroidism." American Association of Clinical Endocrinologists N.p., 2006.
Web. 4 Dec. 2009.
<http://www.aace.com/pub/thyroidbrochures/pdfs/Hypothyroidism.pdf>.
"Hypothyroidism." Wikipedia N.p., 21 Nov. 2009. Web. 3 Dec. 2009.
<http://en.wikipedia.org/wiki/Hypothyroidism#cite_ref-nlm_6-0>.
Simon, Harvey. "Hypothyroidism." University of Maryland Medical Center N.p.,
21 May 2009. Web. 4 Dec. 2009.
<http://www.umm.edu/patiented/articles/what_causes_hypothyroidism_00003
8_2.htm>.

CEREBRAL PALSY

What is a cerebral Palsy?

Cerebral palsy is a name given to a group of
different nervous system disorders that are
present at birth or appear in the first 3 years of
life
Neurological condition that cause physical
disability in human development

 Collection of diverse syndrome

Disorder of movements and posture
Non progressive injury
Immature brain

Epidemiology
One of the most common disabilities affecting children
CP is more prevalent in more deprived socio-economic
populations.

Factors
Gestational age <32 weeks
Maternal mental retardation
Maternal seizure disorder
Hyperthyroidism
Two or more prior fetal deaths
A sibling with motor deficit
3rd trimester bleeding
Fetal bradycardia

 Chorionitis
Low placental weight
Fetal malformations
Neonatal seizures

Etiology
Premature delivery: Most common Cause
- Combination of immaturity, fragile brain vasculature,
physical stresses
Injury in the prenatal, perinatal and post natal
Perinatal injuries resulting to CP: severe anoxic
ischemic brain injury

Post natal: any type of brain injury

Prenatal Factors
Hereditary factors
-familial athetosis, congenital tremors, familial spastic
paraplegia, atonic diplegias and famil
-basic pathology being genetically transmitted to
developmental defects in the basal nuclei or in their
tracts

 Acquired during gestation

Irradiation
Maternal infection
Prenatal anoxia
Haemorrhage during pregnancy
Fetal cerebral haemorrhage
Kernicterus
Prematurity
Metabolic disturbance during pregnancy

Perinatal Factors
Mechanical cause
birth trauma
Prolonged labor

Fetal asphyxia - lack of oxygen or excess carbon dioxide

Post Natal Factors

Traumatic injuries
Infection
Toxic factors
Vascular accidents
Cerebral anoxia
Tumor

Classification
Tone abnormalities
Spastic
Dyskinetic
-Athetoid
-choreiform
-ballistic ataxic
Hypotonic
Mixed
Body parts involved
Diplegia

Spastic
Due to a cortical/pyramidal lesion
Augmented response with clonus and an abnormal EMG
record
Greater tendency towards contractures

Spastic
Spastic Hemiplegia

Present with a typical hemiplegic posture

Delayed milestone
Impaired sensation
Limb impairment
May have a moderate intelligence impairment or can be
normal

Spastic
Spastic Diplegia

Starbismus
Bunny hopping
Toe walking/ scissoring gait
Normal or near normal intelligence

Dyskinetic
Presence of involuntary abnormal movements in the
arms, legs, face, and trunk.
2 Types of Dyskinetic
Athetoid
Ataxic

Athetoid
Normal reflexes, normal EMG
Affects subcortical structures and the basal ganglia
Charecterized by abnormal and involuntary movements
With high intelligence

Ataxic
Primary in coordination due to the disturbance of
kinaesthetic or balance sense
Affection of the cerebellum and cranail nerve VIII
Hypotonic with normal or decreased DTRs
With equilibrium olyssynergias and nystagmus

Mixed
Most common combination of mixed cerebral palsy
involves both spasticity and athetoid movements

Associated abnormalities
Oral disabilities
Dysphagia
Bruxism
Dental carries

Speech
Maldevelopment of oropharyngeal structures
Oral-motor incoordination
Defective control of respiratory muscle

Associated abnormalities
Vision and extra ocular movements
Strabismus
mystagmus

Hand astereognosis
Seizure
Behavior disorders
Mental retardation
Perceptual dysfunction

Diagnosis
Early signs and symptoms
Testing the infant's motor skills
Magnetic resonance imaging (MRI)

Treatment
Surgery
Medication
Physical therapist