Congenital Pyloric Stenois - Important Signs

1.  String sign: thin column of barium leaking through the tightened muscle
2. Shoulder sign: filling defect in the antrum due to prolapse of muscle inward
3.  Mushroom sign: hypertrophic pylorus against the duodenum
4. Railroad track sign: excess mucosa in the pyloric lumen resulting in 2 columns of barium.

Abnormal Pulses and Possible Etiologies

Abnormal Pulses 

Pulsus alternans: sign of left ventricular systolic dysfunction

Pulsus bigeminus: sign of hypertrophic obstructive cardiomyopathy
(HOCM)

Pulsus bisferiens: in aortic regurgitation

Pulsus tardus et parvus: aortic stenosis

Pulsus paradoxus: cardiac tamponade and tension pneumothorax

Irregularly irregular: atrial fibrillation

Referred Pain and Pain location

Hypercalcemia of malignancy

Hypercalcemia of malignancy

Paraneoplastic Syndromes

Cancer

Metastasis :  PTH low , High Ca , High Phosphate

(Squamous cell )PTH-rp in Lung : PTH low , High PTH r-p , High Ca , low Phosphate

Amyloidosis

Epidemiology

• Extracellular deposit of insoluble polymeric protein fibrils in tissue & organs
• Can be primary (AL type) or secondary (AA) to chronic inflammatory conditions such as:
• Inflammatory arthritis (e.g RA)
• Chronic infections (e.g bronchiectasis, tuberculosis, osteomyelitis)
• Inflammatory bowel disease (e.g Crohn's disease)
• Malignancy (e.g. lymphoma)
• Vasculitis

Clinical presentation

• Asymptomatic proteinuria or nephrotic syndrome 
• Restrictive cardiomyopathy
• Hepatomegaly
• Peripheral neuropathy &/or autonomic neuropathy
• Visible organ enlargement (e.g. macroglossia)
• Bleeding diathesis
• Waxy thickening, easy bruising of skin

Diagnosis 

• Tissue biopsy (e.g. abdominal fat pad)

Congo red stain shows amyloid deposits within vessel walls. 

Congo red stain shows apple green birefringence under polarized light.

List of Granulomatous diseases

• Bartonella henselae(cat scratch disease)
• Berylliosis
• Churg-Strauss syndrome
• Crohn disease
• Francisella tularensis
• Fungal infections (e.g., histoplasmosis, 
• blastomycosis)
• Granulomatosis with polyangiitis (Wegener)
• Listeria monocytogenes(granulomatosis 
• infantiseptica)
• M. leprae(leprosy; Hansen disease)
• M. tuberculosis
• Treponema pallidum(tertiary syphilis)
• Sarcoidosis 
• Schistosomiasis

Th1cells secrete γ-interferon, activating macrophages. TNF-αfrom macrophages 

induce and maintain granuloma formation. Anti-TNF drugs can, as a side effect, cause 

sequestering granulomas to breakdown, leading to disseminated disease. Always test for 

latent TB before starting anti-TNF therapy.

Features of constrictive pericarditis

Features of constrictive pericarditis

Etiology 

• Idiopathic or viral pericarditis
• Cardiac surgery or radiation therapy
• Tuberculous pericarditis (in endemic areas)

Clinical presentation

• Fatigue and dyspnea on exertion
• Peripheral edema and ascites
• Increased JVP
• Pericardial knock may be heard
• Pulsus paradoxus
• Kussmaul's sign

Diagnostic findings

• ECG may be nonspecific or show atrial fibrillation or low voltage QRS complex
• Imaging shows pericardial thickening and calcification
• Jugular venous pulse tracing shows prominent x and y decents.