Author Archives: zlahlou42

About zlahlou42

Dr. Lahlou is the former founding Dean of Health Sciences of Larkin Community Hospital, a Statutory Teaching Hospitals in Florida and the largest Osteopathic Teaching Hospital in the United States. He has experience teaching at several universities in South Florida, where his main expertise is in the teaching of basic science covering courses making up the fundamentals to the study of medicine. Zachary was part of the founding team responsible for the IMPLEMENTATION OF A NEW PROGRAM- MASTER OF SCIENCE IN PHYSICIAN ASSISTANT PROGRAM strategic planning, development and design, which lead to the implementation of a new physician assistant program on Fort Lauderdale Campus January 2010. His was instrumental in the program's accreditation process: ARC-PA CONTINUING ACCREDITATION SITE VISIT, Self-study and application document preparation, KEISER UNIVERSITY– Fort Lauderdale March 2011 site visit. Dr. Lahlou has extensive experience in Institutional Research and effectiveness. His work was fundamental to the collection, analysis and interpretation of institutional data to help support planning and decision-making. The data was used for easy access and analysis, and was instrumental for Keiser University in analyzing and projecting the Masters in Physician assistant program effectiveness/improvement and for the documentation of the ongoing self-study process required for accreditation purposes. Zachary own cultural competency is built on a lifetime of international experiences. He grew up and went to high school in Morocco, later attended university in France, Canada, California, the Netherlands Antilles and Ireland. He obtained his B.A. in Political Science at the University Of Ottawa, Canada in 1985, his MBA from San Francisco State University College of Business in 1990, and his Doctorate in Medicine from The American University of the Caribbean School of Medicine in 2000, where his clinical studies were conducted at the University Hospital Waterford Ireland.

Spontaneous Intracerebral Hemorrhage & Saccular “Berry” Aneurysms

Spontaneous Intracerebral Hemorrhage

  • Sites
    • Basal ganglia > thalamus > white matter > pons > cerebellum
  • Morphology
    • No large areas of necrosis (vs. infarcts)
    • May dissect into ventricles, subarachnoid space
    • Duret hemorrhage if herniation occurs

Ultimately resorbed leaving fluid filled cavity

Hemorrhage_GR

Saccular “Berry” Aneurysms

  • Less common than ICH
  • Most common cause of spontaneous subarachnoid hemorrhage
  • Affects 1% of population
    • Polycystic kidney disease, fibromuscular dysplasia, coarctation of aorta, arteriovenous malformation
  • Congenital defect of arterial wall (media) at branch points (80%)
  • Site
    • 80% at bifurcations of anterior circulation
    • 15-20% posterior circulation
    • 25% multiple
  • Manifestations
    • Local mass effect
    • Rupture into subarachnoid space
    • Rupture into brain
    • Secondary infarcts due to arterial spasm
  • Presentation
    • Younger females (< 50)
    • Abrupt onset of signs of raised intracranial pressure
    • Meningeal signs (bloody CSF)
  • Complications
    • 50% die within days
    • Infarcts after 4-9 days
    • Herniation
    • Hydrocephalus (organization may cause obstruction)

aneurysmpict  cirwillis02

APPENDICITIS

 

  • Inflammation of the appendix that lead to infection (abscess) and/or perforation if not recognized and treated appropriately

ETIOLOGY/ PATHOGENESIS

**Most common abdominal surgical emergency**

  • Most common in ages between 10 – 30

Causes incude:

  • lymphoid hyperplasia,
  • fecalith obstruction (hardening of feces into lumps of varying size inside)
  • Perforation occurs in about 20%

CLINICAL SYMPTOMS

  • Initial symptom is intermittent periumbilical or epigastric pain.
  • Then localizes to the RLQ (McBurney’s point) and becomes constant
  • Pain is worsened by movement
  • Nausea and anorexia
  • Low-grade fever

Specific localization of tenderness to McBurney’s point indicates that inflammation is no longer limited to the lumen of the bowel (which localizes pain poorly), and is irritating the lining of the peritoneum at the place where the peritoneum comes into contact with the appendix.

Location of McBurney’s point (1), located two thirds the distance from the umbilicus (2) to the anterior superior iliac spine (3).

McBurney

PHYSICAL EXAM FINDINGS

  • Abdominal rebound tenderness and guarding
  • Positive Psoas sign (pain with raising a straight leg with resistance)
  • Positive Obturator’s sign (pain with flexed right hip rotation)
  • Sometimes pt may have RLQ pain on palpation of LLQ

Psoas Sign

Pain is elicited by performing the psoas test by passively extending the thigh of a patient lying on his side with knees extended, or asking the patient to actively flex his thigh at the hip.[1] If abdominal pain results, it is a “positive psoas sign“.

The pain results because the psoas borders the peritoneal cavity, so stretching (by hyperextension at the hip) or contraction (by flexion of the hip) of the muscles causes friction against nearby inflamed tissues. In particular, the right iliopsoas muscle lies under the appendix when the patient is supine, so a positive psoas sign on the right may suggest appendicitis. A positive psoas sign may also be present in a patient with a psoas abscess

Obturator's Sign

Obturator’s sign: If an inflamed appendix is in contact with the obturator internus, spasm of the muscle can be demonstrated by flexing and internal rotation of the hip. This maneuver will cause pain in the vagina hypogastrium.

DIFFERENTIAL DIAGNOSIS

  • Gastroenteritis
  • Gynecologic Disorders
  • Ectopic pregnancy
  • Kidney stones
  • Mechanical obstruction
  • Diverticulitis

DIAGNOSTIC EVALUATIONS

CT is choice diagnostic test***

  • Leukocytosis
  • Microscopic hematuria and pyuria may be seen
  • Radiographic finding of free air suggests perforation

SURGICAL MANAGEMENT

  • Appendectomylaparoscopic – longer surgery time than open surgery, shorter recovery time, and less infectious complication
  • Antibiotics may be indicated prior to surgery

 

IDIOPATHIC THROMBOCYTOPENIC PURPURA

ITP is a disorder of increased platelet destruction caused by the development of platelet autoantibodies.

ETIOLOGY/ PATHOGENESIS

  • Also known as isolated thrombocytopenia, ITP is a diagnosis of exclusion.
  • It occurs in children as acute ITP, typically follows an acute viral or upper respiratory infection, and resolves spontaneously within several months.
  • In adults it occurs as chronic ITP and affects more women than men in a 3:1 ratio.
  • Spontaneous remission in adults is rare.
  • Intracranial hemorrhage is the most significant complication.

CLINICAL SYMPTOMS

  • Children often present with sudden onset of bruising and petechiae
  • Adults may have history of easy bruising
  • Women may have history of menometrorrhagia

PHYSICAL EXAM FINDINGS

  • In adults physical exam is usually normal.
  • Patients may present with epistaxis, gingival bleeding or ecchymosis

DIFFERENTIAL DIAGNOSIS

  • TTP
  • SLE
  • Myelodysplastic diseases
  • Lymphoproliferative diseases

DIAGNOSTIC EVALUATIONS

  • Complete blood count: thrombocytopenia; large platelets on peripheral smear
  • PT/aPTT: normal
  • Bone marrow examination in chronic ITP
  • ANA in patients with chronic TTP to rule out SLE
  • Platelet count is often less than 30×109/L at the time of diagnosis.
  • In chronic ITP a bone marrow examination is performed to rule out other causes of thrombocytopenia. In ITP the bone marrow has increased numbers of megakaryocytes.

MEDICAL MANAGEMENT

  • Treatment is not usually initiated unless platelet count is <20,000/µL except in cases of hemorrhage.
  • Prednisone will increase platelet count and possibly decrease autoantibody production
  • Splenectomy in patients not responsive to prednisone
  • Immunosuppressive drugs in patients not responding after splenectomy or in relapse after initial therapy
  • IV gamma globulin (IVIgG) is known to temporarily increase platelet counts

PATIENT EDUCATION/ MAINTENANCE – PREVENTION

  • Avoid contact sports/activities associated with high incidence of trauma

Avoid ASA products