临床，医学和实验图像杂志

ISSN:2573-7708

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一些临床重要性的观察

Syed Abdul Kader*

孟加拉国巴利萨尔Sher-e-bangla医学院内分泌与新陈代谢系助理教授

*Address for Correspondence:MBBS，医学博士Syed Abdul Kader博士，孟加拉国巴利萨尔的Sher-e-e-Bangla医学院内分泌与新陈代谢系助理教授，电子邮件：skdr0002@gmail.com

Dates:Submitted:2019年5月13日;得到正式认可的：2019年6月3日;Published:2019年6月4日

如何引用本文：Kader SA。一些临床重要性的观察。J Clin Med Exp图像。2019;3：002-008。doi：10.29328/journal.jcmei.1001011

版权许可证：©2019 Kader SA。这是根据Creativ必威体育西汉姆联e Commons归因许可分发的开放访问文章，该文章允许在任何媒介中不受限制地使用，分发和复制，前提是适当地引用了原始作品。

Keywords:Feet; Hyponatraemia; Bulla; Hoffman’s sign

医学方面的知识和最佳实践正在不断变化。随着新的研究和经验扩大我们的理解，可能有必要进行研究方法，专业实践或医疗的变化。从业者和研究人员必须依靠自己的经验和知识来评估和使用任何信息，方法，化合物或实验[1]。有两个步骤临床诊断，临床数据库的建立及其解释[2]。知识，常识和声音推理对于正确的临床诊断是必要的，而我们的前任医学先驱则更多地取决于后两者，因为它们创造了知识。

穆斯林祈祷的脚

在虔诚的穆斯林中，在“ salah”中祈祷的工人阶级宗教习惯[3]或“ waqts” [3] [3]所有“ rakats” [3,4]，包括强制性的，以及占领的人。其中许多脚在内侧偏离，以试图将脚趾引向“ Qiblah” [3,4]。他们中的大多数在左脚和额头的背上都有玉米和call骨。

脚部压力的程度，模式和持续时间很重要。我认为当时在清真寺的房屋中拍摄那些脚的照片是不合适的，但我在医院拍摄了两张类似脚的照片。

Though he was a younger person (Figure 1a) in his late thirties actually admitted with fever. We know about corns and callosities, but I have not heard of or read about this medial deviation of feet. I call it ‘Muslim Prayer’s feet’. The older person (Figure 1b) presented with stroke with cerebral acute infarction and haemrrahage at two different sites which seemed to be simultaneous (Figure 2).

低钠血囊

Figure 3 shows a clinical picture which I find often in the ward without any specific mention of this clinical association in the textbooks. I saw, many a times, chemosis, conjunctival and sometimes lower eyelid bullae in patients developing moderate to severe hyponatraemia, usually hypervovolaemic hyponatraemia, sometimes with hyponatraemia with myxoedema coma. The patients in the picture did not have much of facial oedema, but had bullous lower eyelids. He had, at that time, a serum sodium level of 105.46 meq/L. These bullae are very superficial. Probably, low concentration of hypontraemic serum provides a greater chance of fluid coming out of vessels to that superficial a space. I would like to call these lesions hypontraemic bullae. Figure 4 shows chemosis and conjunctival bulla in a different patient.

Hemi-Semi-Hoffman标志

图5中的患者在左手中表现出脖子和无力。她浪费了thenar的杰出。在X射线颈椎上，她具有狭窄的椎间空间，尤其是在C5和C6之间，并且可能在左侧相同水平的软组织反应。值得注意的是，霍夫曼（Hoffman）的反应[5]可以在左手的两根手指中引起，相反，左手的另一个手指和径向部分的较低运动标志。我们可以称其为Hemi-Semi-Hoffman标志。

PCV sign

Subdural haematoma when presented within 72 hours of occurrence is called acute subdural haematoma, when between 4 and 21 days subacute subdural haematoma, when after 21 days chronic subdural haematoma. In acute subdural haematoma unabsorbed blood crescentic hyperdensity on CT scan of brain, hypodensity of the same shape in chronic subdural haematoma. In subacute subdural haematoma density is in between hyper and hypodensity or isodense, but more often than not the blood cells settle down and separate from fluid portion in the same way it separates in ESR (Erythrocyte Sedimentation Rate) estimation to a much lesser extent in one hour or in PCV (Packed Cell Volume) estimation to a much similar extent in much quicker time with the help of rapid centrifugation. We can call it PCV sign (Figures 6-8).

Early signs of oedema

We all know where to see oedema, and in which condition where oedema develops first and preferentially. We can also notice the early signs of odema , gradual disappearance of skin creases over joints, gradual non-visualisation of veins in the limbs which are dependent, subcutaneous engorgement causing skin shininess, microvascular compromise and fall of hair, there might be leukonychia to indicate the cause(Figure 9).

Ups and downs with Down’s

In the mid-August 2015 a young gentleman with Down syndrome got admitted to medicine ward of SBMCH with urinary retention and sonographic evidence of bilateral hydronephrosis. Retention was relieved by catheterization, and he was sent to one of the urology beds of surgery ward. He looked quite jovial throughout the proceeding with smile on his face, with his hand gently placed on mine, with his small hand showing clear signs of clinodactyly of little finger and simian crease (Figure 10). How much he felt the agony of retention? We know that Down syndrome may be associated with non-neurogenic neurogenic bladder. Could it be it? Could it be complicated by hydronephrosis? Associations with hypothyroidism and diabetes mellitus are quite common in these patients, so are congenital heart diseases and different types of leukaemia. We should watch out for these conditions to give somewhat longer and more comfortable life of these patients.

鱼霉菌的代谢面

Ichthyosis patients present with dry, thick, fish like scaly skin, the commonest congenital form being autosomal dominant ichthyosis vulgaris. The patients with this disease cannot sweat well. However rare it may be, it doesn’t seem so rare among beggars in the streets of Dhaka. I interviewed one of them whose brother had the same condition (Figure 11). Severest form of the congenital disease, along with loss of temperature regulation and water loss, has severe vitamin-D deficiency. I saw a few of the ichthyosis patients with bent legs. I saw one of such patients repeatedly pouring water on his body to keep the skin moist. Weather temperature approximating body temperature means less heat loss. The greater humidity of weather leads to less evaporation from the body, and skin taking up the humidity from the atmosphere becoming less dry. So, ironically, hot and humid weather suits ichtyosis patients’ comfort.

Mass hysteria

What we know about mass hysteria, mass psychogenic illness or mass epidemic illness is that it manifests as a collection of symptoms, typically, nausea, muscle weakness, fits or headache which begins in one individual and spread to others, usually of the same group of people, who has seen the symptoms of index or subsequent cases. In the last week of August 2015, this happened in Barisal. A lot of school students rushed to hospitals with mass hysteria ringing an alarm bell in the population and medical personnel in the area. Rush of patients was so much they had to find their place in the space between the wards in SBMCH. Incidence of mass hysteria has been noticeable in Bangladesh in increasing frequency and intensity in the recent years. This time, probably, junior school certificate examination worked as a trigger factor. Community psychiatrist could be employed particularly in the schools and other vulnerable institutions to prevent this problem (Figure 12).

Broadened and lengthened intercostal space in massive pleural effusion and reduction by thoracentesis

可以在胸腔积液中拓宽和延长肋间空间（图13），可以在胸部X射线和palpation上观察到。胸腔穿刺带来了这些空间的膨胀以及纵隔到对面的偏差以及第一个肋骨升高的偏离（图14（a）之前和（b）胸腔化后，（b））。

临床体征的谬误

有趣的是，身体，生计，周围和身体的其他条件如何影响临床体征的解释。次大陆人用裸手取辣，姜黄且干辣椒粉的食物。家庭主妇和厨师用裸露的手和基本的石头用姜黄制成糊状物。在评估这些人的黄疸时只相信巩膜。黄光，黄色的窗台，墙壁上的深黄色反射光，耐心在反射射线中，可能会使黄疸的解释变得困难。一侧掉下的牙齿使舌头的突出舌头更容易模仿那一侧的下腹神经麻痹。一侧重叠的牙齿可能会导致类似于面部麻痹的不对称的唇粘附。单侧疼痛的刺激只能在模仿偏瘫的失去知觉患者中产生运动和鬼脸。明智的做法是在观察细节的组成部分的相关性上是系统的。在2015年的一轮比赛中，我看到一名呼吸困难的患者在他身后有超过30年的吸烟史。 His chest X-ray showed two big partially emptied abscess cavities in the lower zone of the right lung field. Interestingly, he didn’t cough out as much sputum as expected of a typical lung abscess patient. There were no amphoric or bronchial breath sound, no increase in vocal fremitus and resonance over the lesions. It seemed something is hindering the patency of bronchus proximal to the abscesses with their aeration and drainage being impaired. A directed and informed look could delineate a bulge from the right hilum. So, it could be bronchogenic carcinoma in the setting of clinical scenario. Multiple abscesses in the same region of the same lung add to the set of information that gives clue to the diagnosis. Here is the importance of ‘check, think, recheck’ approach. This case could give rise to clinical pearl – ‘radiological appearance, if the patient comes with an X-ray, of abscess in the lung which is not producing much sputum can have a cancer as its cause’, a clinician should suspect it, and check if the history and examination support it.

在我们的病房中，我们听到并看到有时会听到并看到标准认可教科书中未提及的症状和体征。我们看到与疾病古典图片的偏差。我们大多数人没有足够的信心，无法根据自己的经验来写下其他临床医生的审查和看法。这篇简短的文章是一项谦虚的尝试，反映了我的一些临床经历的意见。