S K Mathur and colleagues have done some excellent case report
tracking a very rare syndrome Fahr's Syndrome is a rare, genetically
dominant, inherited neurological disorder characterized by abnormal
deposits of calcium in areas of the brain that control movement, including
the basal ganglia and the cerebral cortex. First described in 1930 by
German neurologist Karl Fahr .The basal ganglia calcification may occur
as...
S K Mathur and colleagues have done some excellent case report
tracking a very rare syndrome Fahr's Syndrome is a rare, genetically
dominant, inherited neurological disorder characterized by abnormal
deposits of calcium in areas of the brain that control movement, including
the basal ganglia and the cerebral cortex. First described in 1930 by
German neurologist Karl Fahr .The basal ganglia calcification may occur
as a consequence of several known genetic conditions affecting locus at
14q, chromosome 8 and chromosome 2.
It usually manifests itself in the third to fifth decade of life but may
appear in childhood or later in life. It is usually identified on CT scan
but may be visible on plain films of the skull. Making a clinical
diagnosis of Fahr's disease relies on the combination of clinical
features, brain imaging, and exclusion of other causes of intracranial
calcification.
It usually presents with Neuropsychiatric symptoms manifestations includes
clumsiness, fatigability, unsteady gait, slow or slurred speech,
dysphagia, involuntary movements or muscle cramping. Seizures of various
types are common. Fahr's disease is a differential diagnosis of frontal
lobe syndrome.
The available treatment is directed symptomatic control. Currently no
standard course of treatment available. Genetic counseling may be helpful.
References
1.
http://rarediseases.info.nih.gov/GARD/Disease.aspx?PageID=4&diseaseID=8272
2. JNNP - Sign In Page
3. T. Fahr: Idiopathische Verkalkung der Hirngef?sse. Zentralblatt f?r
allgemeine Pathologie und pathologische Anatomie, 1930-1931, 50: 129-133.
4. http://www.whonamedit.com/synd.cfm/451.
5.Dr Osama Hammer MBBch.,MSc.,MRCPsych
When I was in medical school, my lecturers used to say that Lues is
the chameleon among diseases. The presentation of this case is another
fine example why this description seems appropriate.
Inam Ulhaq and Adam Abba-Aji have done an excellent case report which it has obvious strengths, it employs the effect of conventional antipsychotic medications (haloperidol )in induction of OCD .Obsessive-compulsive disorder (OCD)-is a neuropsychiatric condition that affects 1-2% of the population and often has an early age at onset of symptoms. OCD has been shown to be familial, and a major gene effect has been reported.( Grad...
Inam Ulhaq and Adam Abba-Aji have done an excellent case report which it has obvious strengths, it employs the effect of conventional antipsychotic medications (haloperidol )in induction of OCD .Obsessive-compulsive disorder (OCD)-is a neuropsychiatric condition that affects 1-2% of the population and often has an early age at onset of symptoms. OCD has been shown to be familial, and a major gene effect has been reported.( Grados MA, Walkup J, Walford S.) . Obsessive-compulsive symptoms (OCS) are common and clinically significant phenomena in schizophrenia patients and bipolar affective disorders .OCS might modify the expression of psychotic symptoms and bring about complex psychopathological phenomena, psychotic in content and obsessive in form. The relationship between the obsessive compulsive symptoms induced by haloperidol treatment it raise the possibility that it could be related to the effect of the glutamatergic system. Giegling I et al reported that Glutamatergic gene variants impact the clinical profile of efficacy and side effects of haloperidol. The brain network which mediates this complex psychopathological effect despite it is rare but it cause clinical significances which stopped only after removing the triggered medications .There is a need for additional research and increased awareness of clinicians for this phenomenon.
I read this well presented case report with a great interest. This
manuscript highlights the difficulties and challenges regarding the
management of the critically ill polytrauma patients which are recognised
worldwide. It also emphasises the role of the initial pre Intensive Care
Unit (ICU) resuscitation, which is essential not only in reducing the
physiological insult from trauma, but more impor...
I read this well presented case report with a great interest. This
manuscript highlights the difficulties and challenges regarding the
management of the critically ill polytrauma patients which are recognised
worldwide. It also emphasises the role of the initial pre Intensive Care
Unit (ICU) resuscitation, which is essential not only in reducing the
physiological insult from trauma, but more importantly it influences
subsequent clinical course and overall outcome for the trauma patient.
Once the lethal triad (acidosis, hypothermia and coagulopathy) develops,
even the best therapy in the Intensive Care Unit (ICU) cannot restore
basic physiologic and immunologic functions(1,3). In addition, the
delivery of prompt and definitive treatment has been directly linked with
the improved survival rates after trauma all over the world.
However, there are few points regarding the management of this case,
which I would like the challenge. Firstly, I would like comment on the
Diagnostic Peritoneal Lavage (DPL) and subsequently discuss the general
principles of the damage control resuscitation and damage control surgery.
I note that on arrival this haemodynamically unstable polytrauma
patient undergone the DPL. The DPL is sensitive in detecting blood in the
peritoneal cavity, but lacks the specificity and more importantly is
unable to identify the injury to retroperitoneal structures(2). For those
reasons, the DPL has been abandoned many years back in the United Kingdom
when faced with trauma cases. Also one of the absolute contraindications
to DPL is "an existing indication for laparotomy", which I believe was
present in this case(2). The mechanism of injury provides invaluable
information to the clinicians regarding the energy transfer. It allows
anticipating the injuries and planning the immediate treatment. Such
polytrauma scenario clearly indicates the enormous energy transfer and
very likely rapid deceleration mechanism. All above suggest the
possibility of any bony, visceral, soft tissue and vascular injuries.
Therefore, based on this information and haemodynamic parameters either an
immediate laparotomy or head to pelvis computed tomography (CT) should be
performed. Currently, level one trauma centres provide a multidetecor CT
(MD-CT) which allows to perform full body scan for the trauma victims
within 5 seconds(4). MD-CT is for quite some time a vital part of the
primary survey which allows for rapid radiological and clinical evaluation
of the trauma patients regarding the decision making process: ICU
admission, laparotomy/thoracotomy or interventional radiology procedures.
Of most interest to me is the timing of the Above Knee Amputation
(AKA), which was performed on day 32 of the hospitalisation. It is well
recognised that following traumatic "first hit" disturbed immune and
coagulation systems make trauma patients susceptible to a "second hit"
insult related to surgical procedures. Aggressive and prolonged surgical
interventions in such circumstances exacerbate shock induced inflammatory
response leading to profound systemic and cellular complications, which
causes Systemic Inflammatory Response Syndrome (SIRS), Adult Respiratory
Distress Syndrome (ARDS), Multi Organ Dysfunction Syndrome (MODS) and
death(5). In such scenarios the polytrauma patients benefit from the
damage control concept, which can be in the form of a primary AKA. The
Damage Control (DC) is based on the two principles: damage control
resuscitation (DCR) and damage control surgery (DCS). The first one
utilises three key concepts: permissive hypotension, early use of blood
products as primary resuscitation fluids, early and rapid correction of
the coagulopathy(6).
The DCS concept is applicable to any of the major body compartments.
The objectives of DCS are always the same and they aim at haemorrhage
control and correction of the coagulopathy, limitation of the
contamination and inflammatory response(1). It enables the salvage of
critically ill trauma patients with exhausted physiology by breaking the
lethal triad (hypothermia, coagulopathy, and acidosis) with aggressive
resuscitation of patients on the ICU with subsequent definitive repairs at
the later stage(3).
Most commonly DCS is utilised in the form of Damage Control Laparotomy
(DCL) and Damage Control Orthopaedics (DCO). These two procedures are
performed at the same time and should take at maximum in the experienced
hands about 20-30 minutes. Therefore the primary AKA would have been a
perfect example of the DC principles in this case if performed at the same
time as laparotomy. But the decision whether and when to amputate is not
an easy one and must be a matter of clinical judgement based on each case,
and it must always involve a consensus of the entire health care team and
the patient. Unfortunately, the discussion with the patient very often is
not possible in an acute trauma scenario. In such circumstances, the
decision regarding the amputation can be delayed and made once the patient
is awake. The advantages of an early amputation include quicker recovery,
shorter hospitalisation and lower costs and morbidity(7). However, it's
tiring being an amputee, because the energy costs needed in walking
increases with the proximal level of amputation, with bilateral limb loss
and age(8,9).
It appears to me that in this case the decision was made to salvage
the limb, therefore few principles should follow. In theatre, adequate
debridement and lavage are crucial, because if performed inappropriately
they will impact on the patient's subsequent treatment options and
outcome.
Of a major concern to me is the Figure 3 showing "Wound condition
after surgical debridement", which is clearly inadequate. It shows
malalignment of the limb with bare, exposed bone and doubtful viability of
the surrounding skin. The general principles of the debridement are well
described by the Nanchahal and co-authors in the "Standards for the
management of open fractures of the lower limbs" and they include(10):
1. Irrespective of the wound size careful assessment from superficial
to deep tissues is essential and all non viable tissues (skin, fascia,
bone, muscles) have to be excised. We should aim to be reasonably
conservative with the skin and as radical as possible with the muscles.
2. Large volumes of low pressure lavage (Normal Saline) should be
used which is safe and effective in reducing the infection rate.
3. There is no doubt that broad spectrum antibiotics should be
administered as soon as possible because they are the most important
factor in decreasing the infection rate.
4. External fixation is part of Damage Control Orthopaedics and is
preferred when rapid stabilisation is necessary in open comminuted
fractures Gustilo IIIB like in this case. Ones again application of an
external fixator can be performed alongside with the laparotomy and should
take no longer then 30 minutes. Conversion to internal fixation ideally
should be achieved within 72 hours of primary debridement, but the surgeon
is the one who is best placed to understand the best window of opportunity
for the trauma patient to return to theatre for definitive surgery.
5. Soft tissue cover can only take place when appropriate skeletal
stabilisation is achieved. Extensive evidence supports the early use of
soft tissue cover for the injured area, because it is associated with an
increased rate of fracture union and decreased deep infection rates, flap
failures and length of hospital stay(11,12). Gopal described an
innovative approach to Gustilo IIIB or IIIC fractures, which includes
radical debridement and soft tissue cover with muscle flap within 72
hours, but this "fix and flap" technique may not be achievable in smaller
centres without 24 hour dedicated teams of plastic surgeons(13). In cases
when temporary wound cover is required, Vaccum Assisted Closure dressing
or antibiotic beads pouch (as part of the dressing), allow Plastic surgeon
to plan for a definite bone or soft tissue cover(10). Depending on the
extent of the soft tissue damage, skin grafts, local flaps or free flaps
can be used. Traumatic wound, with an exposed bone which is left without
soft tissue envelope is without a doubt a gate for subsequent sepsis
development.
The trauma victims represent the most vulnerable group of patients
who should be looked after by a dedicated trauma surgeon who is
responsible for taking the patient through all phases of the "trauma
disease" pathway. Had this AKA been performed within first hours or days
of admission this case may have had a very different outcome. Trauma
surgeons must make quick and correct decisions, remembering that "life
comes before limb" and those aggressive limb reconstruction efforts may
harm patients leading to prolonged hospitalisation, rehabilitation,
greater costs, as well as increased sepsis and death(7).
References
1. Moore EE, Burch JM, Franciose RJ, et al. Staged physiologic
restoration and damage control surgery. World J Surg 1998;22:1184-1191.
2. American College of Surgeons . ATLS manual 7th edition. Chicago:
American College of Surgeons, 2004.
3. Stahel PF, Smith WR, Moore EE. Current trends in resuscitation strategy
for the multiply injured patient. Injury 2009;40S4: 27-35.
4. Chan O. Primary computed tomography survey for major trauma. Br J
Surg 2009; 96: 1377-1378.
5. Moore FA, McKinley BA, Moore EE. The next generation in shock
resuscitation. Lancet, 2004;12;363(9425):1988-96.
6. Duchesne JC, McSwain NE Jr, Cotton BA, et al. Damage control
resuscitation: the new face of damage control. J Trauma 2010;69(4):976-90.
7. Busse JW, Jacobs CL, Swiontowski MF, et al. Complex Limb Salvage
or Early Amputation for severe Lower-Limb Injury: A Meta-Analysis of
Observational Studies. J Orthop Trauma 2007;21(1):70-76.
8. Taghipour H, Moharamzad Y, Mafi AR, et al. Quality of Life Among
Veterans with war-related unilateral lower extremity amputation: a long
term survey in a prosthesis centre in Iran. J Orthop Trauma 2009;23 (7):
525-530.
9. Dougherty PJ. Transtibial amputees from the Vietnam War. J Bone
Joint Surg 2001;83-A (3):383-389.
10. Nanchahal J, Nayagam S, Khan U, et al. Standards for the
management of open fractures of the lower limb. London: Royal Society of
Medicine Press Ltd, 2009.
11. Caudle RJ, Stern PJ. Sever open fractures of tibia. J Bone Joint
Surg Am 1987;69:801-7.
12. Gopal S, Majumder S, Batchelor AGB, et al. Fix and flap: the
radical orthopaedic and plastic treatment of severe open fractures of the
tibia. J Bone Joint Surg 2000;82-B (7): 959-966.
13. Gopal S, Giannoudis PV, Murray A, et al. The functional outcome
of sever, open tibial fractures managed with early fixation and flap
coverage. J Bone Joint Surg Br 2004;86-B (6): 861-867.
Great case report. Atracurium has a problem. Its been so long that we
have used SUX and Ro--cuim.
Our muscle relaxant of choice is Cista---cium.
This is how we do our shoulder open or scopes--
Interscalene brachial plexus block followed by
LMA after propofol..
Works great...
Don't need to intubate ALL pts. except intra-abdominal ,hx,lx or
prone position etc.etc.
Great case report. Atracurium has a problem. Its been so long that we
have used SUX and Ro--cuim.
Our muscle relaxant of choice is Cista---cium.
This is how we do our shoulder open or scopes--
Interscalene brachial plexus block followed by
LMA after propofol..
Works great...
Don't need to intubate ALL pts. except intra-abdominal ,hx,lx or
prone position etc.etc.
We commend the authors for highlighting a difficult clinical scenario. We read the article with interest and would like to share a small thought of ours. The possibility of the tumour's origin being the underlying pectoralis muscles can not be discounted. The appearance on the CT scan does suggest a breast lesion, which appears to be inseparable from the muscle underneath. Moreover, another point which prompted us to feel so was t...
We commend the authors for highlighting a difficult clinical scenario. We read the article with interest and would like to share a small thought of ours. The possibility of the tumour's origin being the underlying pectoralis muscles can not be discounted. The appearance on the CT scan does suggest a breast lesion, which appears to be inseparable from the muscle underneath. Moreover, another point which prompted us to feel so was that no axillary nodes were involved inspite of the 'T' stage being T4.
We believe this case is of high educational potential, and hence additional histopathological processing should not be neglected.
Sarcoidosis most of the times mimics tuberculosis symptomatically as
well as radiologically and poses diagnostic dilemma. It is nice to see
case report on Sarcoidosis with caseating granuloma as biopsy usually
differentiate it from tuberculosis as tuberculosis produces caseating
granuloma and sarcoidosis non caseating type. Anergy produced by
sarcoidosis can lead to loss of induration in PPD testing. As bronchoscopy
was...
Sarcoidosis most of the times mimics tuberculosis symptomatically as
well as radiologically and poses diagnostic dilemma. It is nice to see
case report on Sarcoidosis with caseating granuloma as biopsy usually
differentiate it from tuberculosis as tuberculosis produces caseating
granuloma and sarcoidosis non caseating type. Anergy produced by
sarcoidosis can lead to loss of induration in PPD testing. As bronchoscopy
was done in this patient all the investigations were done including
mycobacterial culture but status of CD4 and CD8 and there ratio is not
mentioned. This CD4/CD8 ratio reverses in bronchoalveolar lavage in
sarcoidosis and disregulation leads to Immune paradox leading to anergy
responsible for no induration in PPD testing1. ACE levels are elevated in
60% of patients with sarcoidosis as Sarcoidal granuloma produce
angiotensin-converting enzyme (ACE). Effective antitubercular treatment
can lead to improvement in symptoms within 2-4 weeks so it was not needed
to follow the patient for 6 months. Hypercalcemia, hypercalciurea usually
occurs in sarcoidosis so 24 hours urinary calcium analysis was indicated
in this patient2. Spontaneous remission occurs in two third of the
patients and in half of the patients remission occurs within three years.
However as patient responded very well to steroid diagnosis of necrotising
sarcoid granuloma is justifiable and further research is needed to
establish a definitive diagnosis as sarcoidosis is still not very well
understood and still it is diagnosed by exclusion.
References:-
1. Miyara M, Amoura Z, Parizot C, et al. The immune paradox of sarcoidosis
and regulatory T cells. J Exp Med 2006;203:359-370[Erratum, J Exp Med
2006;203:477.]
2. Berliner AR, Haas M, Choi MJ. Sarcoidosis: the nephrologist's
perspective. Am J Kidney Dis 2006;48:856-870
I read with interest the case report on complications of trans
thoracic lung biopsy. Only a few studies have systematically evaluated
risk factors for pneumothorax and pulmonary haemorrhage in computed
tomographically (CT)-guided transthoracic lung biopsy (TLB). One study
looking into the factors affecting diagnostic yield and complication
rates, by Heyer CM and colleagues in 2008, showed that the...
I read with interest the case report on complications of trans
thoracic lung biopsy. Only a few studies have systematically evaluated
risk factors for pneumothorax and pulmonary haemorrhage in computed
tomographically (CT)-guided transthoracic lung biopsy (TLB). One study
looking into the factors affecting diagnostic yield and complication
rates, by Heyer CM and colleagues in 2008, showed that the rate of
pneumothorax was influenced by the size and depth of the lesion. This
study was done on 172 CT guided TLBs which were performed on 159 patients
using a 16 gauge core biopsy needle. There was higher frequency of
pneumothorax in smaller lesions and of greater depth. Haemorrhage was
associated with CT signs of emphysema. The high diagnostic yield of CT-
guided TLB was not affected by lesion characteristics or emphysema.
Another study on CT-guided transthoracic fine needle aspiration of
pulmonary lesions: accuracy and complications in 134 cases by Uskul BT and
colleagues in 2009 suggested that the most important factor increasing the
risk of pneumothorax is an increase in the depth of aerated lung traversed
for sampling.
These population-based data should help patients and physicians make
more informed choices about whether to perform biopsy of a pulmonary
lesion.
References
1.Acad Radiol. 2008 Aug;15(8):1017-26.
Computed tomography-navigated transthoracic core biopsy of pulmonary
lesions: which factors affect diagnostic yield and complication rates?
Heyer CM, Reichelt S, Peters SA, Walther JW, M?ller KM, Nicolas V.
2. CT- guided transthoracic fine needle aspiration of pulmonary
lesions: accuracy and complications in 294 patients.
Arslan S, Yilmaz A, Bayramg?rler B, Uzman O, Nver E, Akkaya E.
Med Sci Monit. 2002 Jul;8(7):CR493-7.
3 Accuracy and complications in computed tomography fluoroscopy-guided
needle biopsies of lung masses. Eur Radiol. 2006 Jun;16(6):1387-92. Epub
2006 Mar 16.
Heck SL, Blom P, Berstad A.
Eur Radiol. 2006 Jun;16(6):1387-92. Epub 2006 Mar 16.
4 CT-guided transthoracic fine needle aspiration of pulmonary lesions:
accuracy and complications in 134 cases.
Usk?l BT, T?rker H, G?k?e M, Kant A, Arslan S, Turan FE.
To the Editor: I read with interest the article by Liu A et al (1). The authors have described the management of asymptomatic patient with electrocardiographic (ECG) evidence of pre-excitation. Certain aspects of this report needs to be highlighted.
Asymptomatic patients with ECG evidence of pre-excitation of the ventricles are labelled as Wolf-Parkinson-White (WPW) pattern. On the contrary patients with documented tachyarrhythmia...
To the Editor: I read with interest the article by Liu A et al (1). The authors have described the management of asymptomatic patient with electrocardiographic (ECG) evidence of pre-excitation. Certain aspects of this report needs to be highlighted.
Asymptomatic patients with ECG evidence of pre-excitation of the ventricles are labelled as Wolf-Parkinson-White (WPW) pattern. On the contrary patients with documented tachyarrhythmias with pre-excited ECG are diagnosed as WPW syndrome (2). It is preferable to use these terminologies which are recommended by European society of cardiology.
The crucial factor which determines the risk of developing tachyarrhythmias in patients with WPW pattern is the refractory period of the accessory pathway. If the refractory period of the accessory pathway exceeds 250 ms, the risk of tachyarrhythmias is extremely low (2). Pointers to significantly prolonged refractory period of accessory pathway are abrupt disappearance of delta wave on the surface ECG at rest or during exercise stress test (3). Though the guidelines do not recommend non-invasive risk stratification, exercise testing is a simple, non-invasive tool to identify low risk individuals. In patients with WPW ECG pattern who are not ready to undergo EPS, exercise test may identify individuals at low risk of precipitating ventricular fibrillation. This can be reassuring to both the asymptomatic patient and treating physician.
References:
1. Liu A, Pusalkar P. Asymptomatic Wolff-Parkinson-White syndrome: incidental ECG diagnosis and a review of literature regarding current treatment. BMJ Case Reports 2011;10.1136
2. Blomstrom-Lundqvist C, Scheinman MM, Aliot E, e t al. Supraventricular Arrhythmias (ACC/AHA/ESC Guidelines for the Management of Patients with) ESC Clinical Practice Guidelines EHJ 2003;24:1857 - 97
3. Jezior MR, Kent SM, Atwood JE Exercise testing in Wolff-Parkinson-White syndrome: case report with ECG and literature review Chest 2005;127:1454-7
A very interesting case report but a common omission seen again
in this report as is seen in real life in the wards . Any x -ray for an
acute abdomen should always include both the domes of diaphragm which I
cannot see in the AP view in figure A (only left dome visible) as
compared to B where both domes are clearly visible ( unless it was done
originally but cut off in the view shown here in this report) whic...
A very interesting case report but a common omission seen again
in this report as is seen in real life in the wards . Any x -ray for an
acute abdomen should always include both the domes of diaphragm which I
cannot see in the AP view in figure A (only left dome visible) as
compared to B where both domes are clearly visible ( unless it was done
originally but cut off in the view shown here in this report) which may
lead to loss of very valuable sign of gas under the diaphragm . A
decubitus film is a valuable view but if both domes of diaphragm
specially the right are visible in an AP view , it could avoid a
decubitus view specially in a very sick patient ( as in ventilated sick
newborn babies ) where it may not be possible. A lateral 'shoot
through' is done to diagnose perforation in such cases if needed,
specially if the air leak is not a lot which can even easily disappear
in a repeat x ray after few hours or at laparotomy.
So the take home message is to always insist on complete view of both
domes of diaphragm in an abdominal x ray for acute abdomen by clearly
mentioning on the request form otherwise it does not happen ( as in
this case reported ), resulting in repeat x rays or additional views on
some occasions.
S K Mathur and colleagues have done some excellent case report tracking a very rare syndrome Fahr's Syndrome is a rare, genetically dominant, inherited neurological disorder characterized by abnormal deposits of calcium in areas of the brain that control movement, including the basal ganglia and the cerebral cortex. First described in 1930 by German neurologist Karl Fahr .The basal ganglia calcification may occur as...
When I was in medical school, my lecturers used to say that Lues is the chameleon among diseases. The presentation of this case is another fine example why this description seems appropriate.
Conflict of Interest:
None declared
Dear Authors,
I read this well presented case report with a great interest. This manuscript highlights the difficulties and challenges regarding the management of the critically ill polytrauma patients which are recognised worldwide. It also emphasises the role of the initial pre Intensive Care Unit (ICU) resuscitation, which is essential not only in reducing the physiological insult from trauma, but more impor...
Great case report. Atracurium has a problem. Its been so long that we have used SUX and Ro--cuim. Our muscle relaxant of choice is Cista---cium. This is how we do our shoulder open or scopes-- Interscalene brachial plexus block followed by LMA after propofol..
Works great...
Don't need to intubate ALL pts. except intra-abdominal ,hx,lx or prone position etc.etc.
Conflict of Interest:
...Sarcoidosis most of the times mimics tuberculosis symptomatically as well as radiologically and poses diagnostic dilemma. It is nice to see case report on Sarcoidosis with caseating granuloma as biopsy usually differentiate it from tuberculosis as tuberculosis produces caseating granuloma and sarcoidosis non caseating type. Anergy produced by sarcoidosis can lead to loss of induration in PPD testing. As bronchoscopy was...
Dear Editors,
I read with interest the case report on complications of trans thoracic lung biopsy. Only a few studies have systematically evaluated risk factors for pneumothorax and pulmonary haemorrhage in computed tomographically (CT)-guided transthoracic lung biopsy (TLB). One study looking into the factors affecting diagnostic yield and complication rates, by Heyer CM and colleagues in 2008, showed that the...
A very interesting case report but a common omission seen again in this report as is seen in real life in the wards . Any x -ray for an acute abdomen should always include both the domes of diaphragm which I cannot see in the AP view in figure A (only left dome visible) as compared to B where both domes are clearly visible ( unless it was done originally but cut off in the view shown here in this report) whic...
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