ABDOMINAL PAIN

• One of the most common symptom in children. Pain may range from mild and temporary to severe and requiring emergency care
• About 1 out of 3 children is seen by a doctor for abdominal pain by the time they are age 15, but only a small number of these children have a serious problem
• Complaints of abdominal pain are more common in children younger than 11 years and are often caused by changes in eating and bowel habits. Most cases of abdominal pain are not serious and self limiting
• Acute pain: first episode of pain or recurrent with a history of repeated episodes of acute pain
• Chronic abdominal pain: recurrent or persistent bouts of abdominal pain occur over a minimum of 3 months

ANAEMIA

• Pallor generally indicates anaemia. Anaemia is defined as a decrease in the quantity of circulating red blood cells (RBC), represented by a reduction in hemoglobin concentration (Hb), hematocrit (Hct), or RBC count
• The 2005/06 National Family Health Survey (NFHS) in India revealed that at least 80% of children between 12 and 23 months were anaemic in India. And in children aged <5 years, 69.5% were anaemic. Unfortunately, recent economic development and the national anaemia-control programme have not translated to major reduction in the occurrence of anaemia in India as shown in the 2015 figures. The 2015 demographic health survey show only 11 percentage point decrease from 69.5% to 58.5% childhood anaemia in India, still making it endemic. The elimination of iron deficiency anaemia in children is a public-health priority, given the association of anaemia with impaired cognitive and psychomotor development

AUTISM SPECTRUM DISORDERS

• Autism spectrum disorder is a neurodevelopmental condition characterized by qualitative impairment in social interaction and communication as well as repetitive stereotyped behavior, interests, and activities
• Autism is Classified under pervasive developmental disorders. Pervasive developmental disorders have got the following types
  1. Autistic disorder or autism
  2. Asperger disorder
  3. Rett syndrome
  4. Childhood disintegrative disorder
  5. PDD not otherwise specified

• Triad of AUTISM

  • Impaired socialization
  • Impaired communication
  • Stereotypic behaviour

ATTENTION DEFICIT HYPERACTIVITY DISORDERS

• Attention Deficit Disorder: A relatively common neurodevelopmental disorder that presents in childhood with symptoms such as impulsivity, hyperactivity, and inattention. A core feature of this disorder is that symptoms must impair social, occupational, or academic performance. The onset occurs before the age of 7 years and a large majority of patients exhibit symptoms by the 4th year of age. Attention deficit disorder is of four clinical types, hyperactivity, without hyperactivity, residual type, and conduct disorder
• Attention deficit disorder with hyperactivity (Hyperkinetic disorder/ ADHD) is the commonest type
• Attention deficit disorder without hyperactivity is a rare disorder with similar features of ADHD without hyperactivity
• Residual type – Usually diagnosed in adulthood, with the presence of few residual features in adult life
• It occurs in about 3% of school-age children and males are 6-8 times more often affected

ATOPIC DERMATITIS

• Atopic Dermatitis is a common chronic or relapsing dermatitis characterized by severe pruritis, occurring primarily in infants and children. The age of onset is between 2 and 6 months in the majority of cases, but it may start at any age, even before the age of 2 months in some cases
• Although it often improves during adolescence, it may also become a chronic condition that extends into adulthood. Atopic dermatitis is often associated with atopic diseases such as asthma or allergic rhinitis 

COUGH

• A cough is a forceful expulsion of air from the lungs and a protective mechanism that serves to expel foreign matter inhaled by accident and to remove secretions from the air passage to keep it clear
• A most common symptom of respiratory disease
• It may be classified as acute (< 3 weeks), subacute (3–8 weeks), or chronic (> 8 weeks), as well as productive (with sputum/mucus expectoration) or dry
• Upper respiratory tract infections (URI) and acute bronchitis are the most common causes of acute cough
• Subacute cough is often a sequela of a URI (post-infectious cough) but can also be due to chronic bronchitis or pneumonia
• Chronic cough is often caused by rhinitis/sinusitis, asthma, GERD, and ACE inhibitors

CONSTIPATION

• A frequent problem in infants and children
• Definition of constipation is relative and depends on stool consistency, stool frequency, and difficulty in passing stools.
• Normal bowel frequency varies widely
  • On an average baby passes 3 to 6 stools per day in the neonatal period
  • 1-2 stools per day at 1 year of life
  • 1 stool per day or every other day in preschool years

• Thus constipation can be defined as delay or difficulty in defecation that has been present for 2 weeks or longer
• Absolute constipation: Absence of evacuation of faeces and flatus and is due to intestinal obstruction from congenital or acquired conditions. This is a surgical emergency and needs urgent attention. The most common symptom of absolute constipation is vomiting with abdominal distension

CEREBRAL PALSY

• Cerebral Palsy is a non-progressive motor disorder affecting movement or posture caused by an insult to the developing brain during infantile development up to the age of 3 years
• Depending on the affected brain area, spastic, ataxic, or dyskinetic cerebral palsy develops. While, in many cases, there is no identifiable cause, risk factors for cerebral palsy are prematurity, perinatal complications such as chorioamnionitis, birth trauma with intracerebral haemorrhage, or postnatal infections such as meningitis

INADEQUATE WEIGHT GAIN

• Inadequate weight gain in children caused by failure to thrive is indicated when a child's weight is consistently lower than the third to fifth percentile for his or her age- or when a child loses weight and remains at or below the third percentile. Another indicator is when a child slows down in two or more major growth parameters.

OBESITY

• Obesity is defined as BMI > 95th percentile for age and sex or body weight > 120 % of ideal.
• Childhood obesity is now an epidemic in India. With 14.4 million obese children, India has the second-highest number of obese children in the world, next to China. The prevalence of overweight and obesity in children is 15%. In private schools catering to upper-income families, the incidence has shot up to 35-40%, indicating a worrying upward trend.

DUCHENNE MUSCULAR DYSTROPHY

• An X linked recessive genetic disease in which mutations in the dystrophin gene results in a defective protein product
• Characterized by the ongoing destruction of muscle. It is progressive and is not limited to muscle and other system involvement may also be there
• Degeneration of muscle fibers causing proximal muscle weakness along with cardiomyopathy and bone fragility
• It progresses rapidly and most patients become dependent in late childhood and die during or before the second or third decade of life due to respiratory insufficiency or cardiomyopathy

RICKETS

• Rickets is the failure of mineralization of growing bones, caused by a lack of vitamin D, calcium, or phosphate. These nutrients are important for making healthy bones, thus resulting in delayed growth and softening and weakening of bones
• Occurs only in children( growth plates have not fused)

VOMITING IN NEWBORN

Common symptom in infant and children.

• Vomiting: forceful expulsion of gastric contents through the mouth and is usually accompanied by vigorous contractions of abdominal muscles and descent of diaphragm.
• Regurgitation: non- forceful, expulsion of food and secretions from the esophagus or stomach through the mouth not accompanied by nausea or forceful contractions.
• Nausea: feeling of inclination to vomit
• Retching: effort to vomit, short of expulsion of gastric contents
• Rumination: habit of bringing up semi digested food and chewing it again

Majority of neonates vomit without a pathological cause. Vomiting become pathological only if

• it is bilious
• hemorrhagic
• nonbilious but projectile and persistent
• associated with failure to thrive

VOMITING IN INFANTS AND CHILDREN

• As age advances, possibilities of vomiting as a symptom of congenital obstructive anomalies diminishes. Etiologic spectrum now widens and shifts to acquired conditions
• Vomiting is a common symptom of numerous underlying conditions for which children frequently present for healthcare. Although vomiting can originate from the gastrointestinal (GI) tract itself, it can also signal more generalized, systemic disorders. Vomiting in children is often benign and can be managed with supportive measures only. Still, clinicians must be able to recognize life-threatening causes of vomiting and to avoid serious associated complications, including electrolyte abnormalities, dehydration, or even bowel necrosis.

WORM INFESTATION

• Worm infestation is referred to as an infestation of the host by Helminth. The high prevalence of worm infestation is an indicator of poor living conditions and low standards of sanitation in a society
• Worms of various species, such as nematodes( roundworms), cestodes (or tapeworms e.g. taenia), or trematodes can cause infection

URINARY TRACT INFECTIONS

• An infection in any part of the urinary system, the kidneys, Bladder,or Urethra. Most infections involve the lower urinary tract i.e. Bladder and Urethra 

• Common among preschool and school-going children. More among girls

JOINT PAIN

• Pain over joints is now becoming a common condition especially due to the changing lifestyle in children. The manifestations of this pain may be diverse and needs a thorough evaluation for the same

SCABIES

• Scabies is a parasitic skin infestation caused by the Sarcoptes scabiei var. hominis (S. scabiei) mite, which is primarily transmitted via close personal contact but may be transmitted through clothing or towels
• The female scabies mite burrows into the stratum corneum, causing severe pruritus, particularly at night. Primary lesions commonly include erythematous papules, vesicles, or burrows

DENGUE FEVER

• Dengue fever is caused by dengue viruses and transmitted by the Aedes aegypti mosquito
• Dengue classically presents with high fever, headache, body aches, exanthem, and generalized lymphadenopathy. Symptoms usually subside within one week
• Some cases progress to the more severe dengue hemorrhagic fever (DHF) with thrombocytopenia, spontaneous bleeding, and potentially shock (dengue shock syndrome)

MUMPS

• Mumps is a contagious viral infection transmitted via airborne droplets, affecting salivary glands and it is easily preventable by a vaccine 
• The organism involved is a single-stranded RNA virus of the paramixovirus family, which has only one serotype. The infection or immunization provides lifelong immunity in the majority of people 

MEASLES( RUBEOLA)

• Measles (Rubeola) is an infectious disease caused by the measles virus
• It has no extra-human reservoir, vectors, or carrier state, thus making it a potentially eradicable disease and is caused by an RNA virus belonging to the Paramyxovirus family
• There are two phases of disease- a catarrhal (prodromal) stage and an exanthem stage
• The catarrhal stage is characterized by fever with conjunctivitis, coryza, cough, and pathognomonic Koplik spots on the buccal mucosa
• The exanthem stage is typically characterized by an erythematous maculopapular rash that originates behind the ears and spreads to the rest of the body towards the feet

VARICELLA

• Chickenpox (Varicella) is an infection with the varicella-zoster virus that occurs most frequently during childhood and causes a characteristic itchy rash with macules that rapidly develop into papules and then vesicles
• It is highly contagious, with transmission taking place via airborne droplets or, less frequently, through direct skin contact with vesicle fluid
• In addition to fever, patients present with a highly pruritic rash covering the entire body (including the scalp). The rash is characterized by macules that rapidly develop into papules and then vesicles with an erythematous base before forming crusts. The simultaneous manifestation of the exanthem's different stages is a hallmark of the disease

AGE RELATED MACULAR DEGENERATION

• A degenerative disease of the retina typically leading to central vision impairment caused by deposits under the retinal pigment epithelium( in dry AMD) or neurovascularization in the subretinal space (in wet AMD) and in rare cases leads to complete blindness 
• Age-related macular degeneration (ARMD), also called senile macular degeneration, is a bilateral disease of persons over 50 years of age. It is a leading cause of blindness in developed countries, in population above the age of 65 years. It is of two types non exudative and exudative

ASTIGMATISM

• Astigmatism (from the Greek, "a" meaning absence and "stigma" meaning point) is a refractive error (ametropia) that occurs when parallel rays of light entering the non-accommodating eye are not focused on the retina
• Astigmatism is a condition in which uneven curvature of the cornea hinders even refraction. Leads to the placement of the focal point anterior or posterior to the retina, which causes unclear vision at all distances
• The cornea of the normal eye has a uniform curvature, with resulting equal refracting power over its entire surface. In some individuals, the cornea is not uniform and the curvature is greater in one meridian (plane) than another, much like a football as a rugby ball. Light rays refracted by this cornea are not brought to a single point focus, and retinal images from objects (both distant and near) are blurred and may appear broadened or elongated. This refractive error is called astigmatism

Types

• Astigmatism can be described as regular or irregular

Regular astigmatism

• A more common form, the cornea would resemble a football or a rugby ball standing on one end or its side, or less often, tipped to one side
• In regular astigmatism, there are two principal meridians separated by 90 degrees

Irregular astigmatism

• Less common, the corneal “rugby ball” would appear out of its customary shape and/or bumpy
• It is described as a refractive state in which “refraction in different meridians confirms to no geometrical plane and the refracted rays have no planes of symmetry

BLEPHAROSPASM

• Blepharospasm is a type of focal dystonia in which there is an involuntary contraction of the muscles of the eyelids causing the closure of the lids
• It is generally due to spasm of the orbicularis oculi (OO) muscles and occurs in a variety of disorders of the CNS, or may occur secondarily to ocular disorders
• Peak age of onset is between the fifth and the seventh decade
• Greater tendency to spread to adjacent body parts (usually within the first 5 years of history) than cervical and upper limb dystonia

CENTRAL SEROUS RETINOPATHY

• Central Serous Chorio Retinopathy (CSCR) is serous retinal detachment at the posterior pole of the eyeball (macula or in the perimacular region) due to a defect in the pigment epithelium
• It is due to a defect in the pigment epithelium that leads to fluid leakage from the sclera into the subretinal space and cause serous retinal detachment 
• CSCR is an idiopathic, self limiting but recurrent condition which occur suddenly, more likely to Men than women in their 30s to 50s. Central Serous Retinopathy does not always produce symptoms and usually affects just one eye at a time

CHALAZION

• Chalazion, also called a tarsal or meibomian cyst, is a chronic non-infective (non-suppurative) lipogranulomatous inflammation of the meibomian gland primarily caused by obstruction of the glands
• A chalazion mimics a stye for the first few days and then turns into a painless hard, round bump later on

CORNEAL OPACITY

• ‘Corneal opacification’ literally means loss of normal transparency of cornea, which can occur in many conditions. Therefore, the term Corneal opacity' is used particularly for the loss of transparency of cornea due to scarring
• A corneal opacity or scar will prevent the light and the image from being properly transmitted to the retina. Images can become distorted, leading to decreased vision
• Corneal diseases represent the second leading cause of blindness in most developing world countries. Nearly 80% of all corneal blindness is avoidable

Types

• Nebula – Faint opacity, Involves Bowman’s layer and superficial stroma
• Macula- Semi dense opacity, ½ of Corneal stroma involved
• Leucoma- Dense white, More than ½ of stroma involved

CORNEAL ULCER

• A corneal ulcer may be defined as a discontinuation of the normal epithelial surface of cornea associated with necrosis of the surrounding corneal tissue
• Pathologically, it is characterised by oedema and cellular infiltration
• Inflammation of the cornea (keratitis) is characterised by corneal oedema, cellular infiltration and ciliary congestion

Etiological classification

• Infective keratitis
• Allergic keratitis
• Trophic keratitis
• Keratitis associated with diseases of the skin and mucous membrane
• Keratitis associated with systemic collagen vascular disorders
• Traumatic keratitis
• Idiopathic keratitis

CONJUNCTIVITIS

• Inflammation of the conjunctiva (conjunctivitis) is classically defined as conjunctival hyperaemia associated with a discharge which may be watery, mucoid, mucopurulent or purulent. It is most commonly caused by viruses or bacteria but can also have non infectious (allergic) causes
• A person experiencing the following features can be suggestive of conjunctivitis (pink eye)
  • A gritty feeling in one or both eyes
  • Itching or burning sensation
  • Excessive tearing
  • Discharge
  • Swollen eyelids
  • Pink discolouration to the whites of one or both eyes
  • Increased sensitivity to light

CYSTOID MACULAR EDEMA

• Cystoid Macular Oedema refers to collection of fluid in the outer plexiform (Henle's layer) and the inner nuclear layer of the retina, centred around the foveola
• It might be asymptomatic in several cases and diagnosed during a routine eye check-up

DACRYOCYSTITIS

• Dacryocystitis means the inflammation of the lacrimal sac. It may occur in two forms- Congenital and Adult Dacryocystitis
• Congenital Dacryocystitis is an inflammation of the lacrimal sac occurring in newborn infants
• Adult Dacryocystitis may occur in an acute or a chronic form. It is an acute suppurative inflammation of the lacrimal sac, characterised by the presence of painful swelling in the region of the sac

DRY EYE

• People with dry eyes may experience irritated, gritty, scratchy or burning eyes; excess watering; and blurred vision. Advanced dry eyes may damage the front surface of the eye and impair vision
• Dry eye is a disease of the eye surface caused by underproduction or changes in the lacrimal fluid, when the eyes does not produce tears properly, or when the tears are not of the correct consistency and evaporate too quickly

DIABETIC RETINOPATHY

• Diabetic retinopathy (DR) is a vascular disease of the retina affecting individuals with long standing diabetes mellitus. Diabetic retinopathy is a leading cause of blindness
• Loss of vision is typically insidious and occurs in most patients 20-30 years after the onset of DM, but acute loss of vision may occasionally occur as a result of retinal detachment, vitreous haemorrhage, or macular oedema

Classification

Non-proliferative diabetic retinopathy (NPDR)

• Mild NPDR
• Moderate NPDR
• Severe NPDR
• Very severe NPDR

Proliferative diabetic retinopathy (PDR)

Diabetic maculopathy

Advanced diabetic eye disease (ADED)

EPISCLERITIS

• Episcleritis is a benign recurrent inflammation of the episclera, involving the overlying Tenon's capsule but not the underlying sclera
• It typically affects young adults, being twice as common in women than men

EXTERNAL HORDEOLUM

• It is a common acute suppurative inflammation of lash follicle and its associated glands of Zeis or Moll
• Red, swollen lumps that form along the edge of the eyelid, close to the lashes, usually affecting unilaterally at a time may be a stye

INTERNAL HORDEOLUM

• It is a suppurative inflammation of the meibomian gland, usually visible at the palpebral conjunctiva

HYPERMETROPIA (FARSIGHTEDNESS)

• Hypermetropia (hyperopia) or long-sightedness is a refractive error in which objects placed at a closer distance appears blurry while distant objects appear normal
• It is the refractive state of the eye wherein parallel rays of light coming from infinity are focused behind the retina with accommodation being at rest

Clinical types of hypermetropia:

Simple hypermetropia: It includes axial and curvature hypermetropia. It may be hereditary.

Pathological hypermetropia: due to congenital or acquired conditions. It may be

• Senile or acquired hypermetropia:It occurs in old age due to
• Curvature hypermetropia:There is decreased curvature of the outer lens fibres with ageing
• Index hypermetropia: due to acquired sclerosis of the cortex (outer part) of the crystalline lens
• Positional hypermetropia:due to posterior subluxation of the lens
• Aphakic hypermetropia:Aphakia is the displacement of the lens from its normal pupillary position in the eye. It may be congenital or acquired condition
• Consecutive hypermetropia:- Due to surgically overcorrected myopia or pseudo-phakia with under-correction

Functional hypermetropia: Results from paralysis of accommodation as is seen in patients with third intracranial nerve palsy

MACULAR HOLE

• Macular hole refers to a partial thickness or full-thickness hole in the neurosensory retina in the foveal region
• Straight lines or objects can begin to look bent or wave. A slight distortion or blurriness in their straight-ahead vision, which are gradually increasing are some common symptoms of macular hole

MYOPIA(SHORT-SIGHTEDNESS)

• Myopia is a condition of near sightedness that causes blurred distance vision. Typically affects children and young adults but can arise in adults especially those who spend extensive time reading or working on a computer
• Myopia occurs if the eyeball is too long or the cornea is too curved. As a result, the light entering the eye isn't focused correctly, and distant objects look blurred
• It is a refractive error in which parallel rays of light coming from infinity are focused in front of the retina when accommodation is at rest

Clinical varieties of myopia

• Congenital myopia
• Simple or Developmental myopia
• Pathological or Degenerative myopia

Acquired or Secondary myopia which occurs secondary to some other disease/factors

PRESBYOPIA

• Presbyopia (eyesight of old age) is not an error of refraction but a condition of physiological insufficiency of accommodation leading to a progressive fall in near vision
• After the age of 40, the lens becomes more rigid. Because the lens can’t change shape as easily as it once did, it is more difficult to read at close range. This normal condition is called presbyopia

PTERYGIUM

Pterygium is a wing-shaped fold of conjunctiva encroaching upon the cornea from either side within the interpalpebral fissure. Usually seen in old age and is more common in males doing outdoor work. It may be unilateral or bilateral. Usually present on the nasal side but may also occur on the temporal side.

Often a person with pterygium (surfer's eye) may notice the formation of growth in the eye but may not experience any other symptoms. If other symptoms are experienced, they may include: 

• A gritty feeling in the eye
• Foreign body sensation
• Eye redness and inflammation
• Dryness of the eye due to reduced tear production
• Blurring of vision if the corneal surface is altered or “warped”
• Obscuring of vision if growth encroaches across the pupil.

PTOSIS

• Abnormal drooping of the upper eyelid is called ptosis
• It is derived from an ancient Greek word, which means “to fall”
• Other related complaints include difficult vision due to the attendant visual field obstruction and prefrontal headaches due to chronic use of the frontalis muscle in an attempt to lift the eyelids
• Normally, upper lid covers about upper one-sixth of the cornea, i.e., about 2 mm. In ptosis, it covers more than 2 mm

RETINAL ARTERY OCCLUSION

• Retinal artery occlusion refers to occlusion of the central retinal artery and/or its branches, usually as a result of thrombo embolic phenomena
• Central retinal artery occlusion is characterized by sudden painless loss of vision and a relative afferent papillary defect
• Branch retinal occlusion present with specific patterns of visual field defects depending on the branch involved
• Common age of onset is > 60 years , It is more common in males than in females and is usually unilateral but rarely may be bilateral

RETINAL VEIN OCCLUSION

• An occlusion of the Retinal vein, usually by a thrombus. Retinal vein occlusions are more common than artery occlusions. These typically affect elderly patients in the sixth or seventh decade of life.
• Painless blurring or loss of vision which gets worse over the next few hours or days usually happens in just one eye indicates retinal vein occlusions. Sometimes there is a complete loss of vision almost immediately
• Central retinal vein occlusion can either be non ischaemic or ischaemic
• Branched retinal vein occlusion is more common and is usually asymptomatic unless the macula is involved

RETINITIS PIGMENTOSA

• Retinitis pigmentosa or primary pigmentary retinal dystrophy is a progressive hereditary dystrophy of the retina or of the photoreceptors and the retinal pigment epithelium
• It is a hereditary disorder predominantly affecting the rods more than the cones
• Difficulty with night vision, slow adaptation to the dark, and gradual loss of peripheral vision (tunnel vision) which often begin in childhood, but commonly diagnosed during adolescence with a positive family history is characteristic of RP

SCLERITIS

• Scleritis refers to an inflammation of the sclera proper. Scleritis causes piercing eye pain typically worse at night and with eye movement
• It is a comparatively serious disease which may cause visual impairment and even loss of the eye if treated inadequately
• Very painful, causing a deep 'boring' kind of a pain in or around the eye, redness, tearing, light sensitivity (photophobia), with decreased visual acuity is likely to be scleritis

Classification

Non-infectious Scleritis

Anterior scleritis(98%)

Non-necrotizing Scleritis (85%)

• Nodular
• Diffuse

Necrotizing scleritis (13%)

• Without inflammation 
• With inflammation

Posterior Scleritis(2%)

Infectious Scleritis

UVEITIS

• The term uveitis strictly means inflammation of the uveal tissue only. Clinically there is always some associated inflammation of the adjacent structures such as the retina, vitreous, sclera and cornea.
• Severe redness, pain, light sensitivity, blurred vision and dark floating spots in the field of vision are the warning signs of uveitis and can be associated with ocular inflammation alone or in association with systemic disease

CLASSIFICATION

Uveitis is often grouped by the part of the uvea it affects. There are four types of uveitis:

• Anterior uveitis
• Intermediate uveitis
• Posterior uveitis
• Panuveitis

In Anterior uveitis

• Inflammation involves the iris(iritis)
• The anterior ciliary body(cyclitis)
• Both (iridocyclitis)

Posterior uveitis

• Inflammation involving the choroid(choroiditis)
• Retina (retinitis)
• Both( chorioretinitis)
• Retinal vessels(retinal vasculitis)

Panuveitis involves all three parts of the uvea

Uveitis may extend to involve the cornea (keratouveitis) or sclera (sclerouveitis)

DEVIATED NASAL SEPTUM (DNS)

• A deviation of the nasal septum from midline which can lead to difficulty breathing( typically in only one nostril) , nasal congestion,(usually one side more than the other, recurrent sinus infections, nose bleeds, sleep apnea

Types of DNS

• Anterior dislocation- Septal cartilage may be dislocated into one of the nasal chambers
• C-shaped deformity- Septum is deviated in a simple curve to one side
• S-shaped deformity - Such a deformity may cause bilateral nasal obstruction
• Spurs- A spur is a shelf-like projection often found at the junction of bone and cartilage. Spur may gives rise to headache and also predispose to repeated epistaxis
• Thickening

EPISTAXIS

• The term epistaxis is derived from the Greek word epistazein (epi –above,over ; stazein– to drip)
• It is defined as the bleeding from the nasal cavity. Epistaxis is a common symptom of diverse conditions which may present as mild recurrent bleeds or severe life threatening rhinological emergency
• Epistaxis appears to occur more often in males than in females

Classification:

Epistaxis can be classified by its anatomical location into anterior & posterior

Anterior epistaxis

• is more common 
• More than 90% of episodes of epistaxis occur along the anterior nasal septum, which is supplied by Keisselbach’s plexus in a site known as the Little’s area
• Bleeding causes blood to flow out through the nsotrils

Posterior epistaxis

• Approximately 10% of episodes of epistaxis are posterior
• Generally arises from the posterior nasal cavity via branches of the sphenopalatine arteries
• Blood runs down the throat

Epistaxis can also be divided into primary or secondary

• Primary causes account for 85% of episodes and are idiopathic, spontaneous bleeds without any notable precipitant
• Bleeds are considered secondary if there is a clear and definite cause (e.g. trauma, anticoagulant use, post surgical)

HEARING LOSS

• Loss of the ability to hear sound frequencies in the normal range of hearing is called hearing impairment
• Frequencies capable of being heard by humans are called audio or sonic. The range is typically considered to be between 20 Hz and 20,000 Hz (Hertz)

Types

• Conductive hearing loss– Results from any disruption in the passage of sound from the external ear to the oval window. It can be caused by pathologies involving the external and middle ear (external auditory meatus, tympanic membrane, ossicular chain)
• Sensorineural hearing loss- Results from disruption of the passage of sound beyond the oval window. Such pathologies can be located to the auditory receptor cells of the cochlea and the eighth cranial nerve
• Mixed hearing loss – Represents a mixture of both conductive and sensorineural hearing loss

Classification

• Normal Hearing -10 to 15 dBHL
• Slight Hearing Loss-16 to 25 dBHL
• Mild Hearing Loss-26 to 45 dBHL
• Moderate Hearing Loss-46 to 55 dBHL
• Moderately-severe Hearing Loss- 56 to 70 dBHL
• Severe Hearing Loss-71 to 90 dBHL
• Profound Hearing Loss-91 and more dBHL

HAIR LOSS

• Hair loss is a common condition. It can be caused by variety of disorders that can be congenital or acquired. Hair disorders are divided into scarring (cicatricial) and non-scarring (non-cicatricial) hair loss
• If the area is devoid of hair orifices and associated with atrophy then it is a scarring alopecia .If hair orifices are preserved then it is considered as a non-scarring hair loss

MIGRAINE

• Neurobiologically based, common clinical syndrome characterized by recurrent episodic attacks of head pain
• The core features of migraine is headache, which is usually throbbing and often unilateral, and associated with nausea, vomiting, sensitivity to light, sound, and exacerbation with head movement
• Migraine has long been regarded as a vascular disorder because of the throbbing nature of the pain
• Migraine headaches tend to first appear between the ages of 10 and 45. Sometimes, they begin earlier or later. Migraines may run in families. It occurs more often in women than men
• In approximately 25% of cases, patients experience an aura preceding the headache, which involves reversible focal neurologic abnormalities, e.g., visual field defects (scotomas) or paresis lasting less than an hour

MENIERE’S DISEASE

• Meniere’s disease, also called endolymphatic hydrops, is a disorder of the inner ear caused by impaired endolymph resorption. Usually presents with episodes of Vertigo, sensorineural hearing loss ,tinnitus and aural fullness
• The episode fluctuates in severity, typically lasting from 20 minutes to 12 hours
• Most commonly manifests in adults between 40 – 50 years of age

NASAL POLYP

• Nasal polyps are non- neoplastic masses of oedematous nasalor sinus mucosa. It typically presents with postnasal drip, bilateral nasal obstruction, and impaired olfactory function
• Persistent stuffy or blocked nose, nasal congestion, loss of smell or decrease in sense of smelltogether with snoring is indicative of nasal polyps
• They are divided into two main varieties - Ethmoidal polyp and Antrochoanal polyp
• Ethmoidal polyp – in the ethmoidal sinuses
• Antrochoanal polyp (Killian’s polyp) - arises from the mucosa of maxillary antrum near its accessory ostium, comes out of it and grows in the choana and nasal cavity. It has three parts- Antral, which is a thin stalk; Choanal, which is round and globular ; Nasal, which is flat from side to side

OTALGIA

• Otalgia, or pain localised to the ear
• Various diseases can cause otalgia because the ear has rich sensory innervations through many cranial (V, VII, IX, and X) and cervical (2 and 3) nerves
• Otalgia can be classified as primary or referred
• Otogenic otalgia originates from diseases of the external, middle and inner ear
• Referred otalgia arises from pathologies outside the ear

OTITIS EXTERNA

• Otitis externa is a condition of inflammation of the external auditory canal due to infection of the cutis and subcutis, possibly involving the tympanic membrane and the pinna. It is also known as swimmer's ear and it often occurs during the summer and in tropical climates
• The most characteristic symptom is discomfort that is limited to the external auditory canal, and the most characteristic signs are erythema and swelling of the canal with variable discharge
• Diffuse Otitis Externa - diffuse inflammation of meatal skin which may spread to involve the pinna and epidermal layer of tympanic membrane
• Furuncle (localized Acute Otitis Externa) - Staphylococcal infection of the hair follicle. Patient usually presents with severe pain and tenderness which are out of proportion to the size of the furuncle. Movements of the pinna are painful. Jaw movements, as in chewing, also cause pain in the ear
• Malignant (Necrotizing) Otitis Externa -Inflammatory condition caused by pseudomonas infection, usually in the elderly diabetics, or in those on immunosuppressive drugs
• Otomycosis - Fungal infection of the ear canal that often occurs due to Aspergillus Niger, Fumigates or Candida Albicans

RHINITIS

• Rhinitis is inflammation and swelling of the mucous membrane of the nose, characterized by a runny nose and stuffiness and usually caused by common cold or a seasonal allergy
• Acute (short-lived) - Acute rhinitis commonly results from viral infections but may also be a result of allergies, bacteria, or other causes. Types of acute rhinitis- a)Viral rhinitis b)Bacterial rhinitis c) Irritative rhinitis
• Chronic (long-standing)- recurrent attacks of acute rhinitis in the presence of predisposing factors results in chronicity
• Chronic simple rhinitis : early stage of hypertrophic rhinitis, where swollen turbinates do not have permanent hypertrophic changes
• Hypertrophic rhinitis - characterized by thickening of mucosa, submucosa, seromucinous glands, periosteum and bone. Changes are more marked on the turbinates
• Atrophic rhinitis (ozaena) - a form of chronic rhinitis in which the mucous membrane thins (atrophies) and hardens, causing the nasal passages to widen (dilate) and dry out
• Rhinitis sicca - It is also a crust-forming disease seen in patients who work in hot, dry and dusty surroundings
• Rhinitis medicamentosa - is a form of drug-induced non allergic rhinitis which is associated with nasal congestion brought on by the use of certain oral medications and topical decongestants
• Rhinitis caseosa - It is an uncommon condition, usually unilateral and mostly affecting males. Nose is filled with offensive purulent discharge and cheesy material

RHINITIS ALLERGIC

• It is an IgE-mediated immunologic response of nasal mucosa to airborne allergens and is characterized by watery nasal discharge, nasal obstruction, sneezing, and itching in the nose

RHINITIS VASOMOTOR

• A type of non allergic rhinitis caused by an increase in blood flow to the nasal mucosa
• Clinically simulating nasal allergy with symptoms of nasal obstruction, rhinorrhoea and sneezing. One or other of these symptoms may predominate
• All tests of nasal allergy will be negative and condition usually persist throughout the year

CHRONIC SINUSITIS

• Sinusitis refers to inflammation of the mucosa of one or more paranasal sinuses where the muco-ciliary clearance mechanism is affected leading to blockage of the sinus ostium
• It rarely occurs without concurrent inflammation of the nasal mucosa (rhinitis) and is therefore commonly referred to as rhinosinusitis
• Chronic sinusitis is an inflammatory process that involves the paranasal sinuses and persists for 12 weeks or longer. The primary symptoms are purulent rhinorrhoea and facial pain (particularly when leaning forward)
• Chronic sinusitis is almost always accompanied by concurrent nasal airway inflammation and is often preceded by rhinitis symptoms; thus, the term chronic rhino sinusitis (CRS) has evolved to more accurately describe this condition
• Current consensus classifies CRS into CRS with nasal polyps and CRS without nasal polyps

SUPPURATIVE OTITIS MEDIA-ACUTE

• An infection of the middle ear that typically follows an upper respiratory infection in children < 5years 
• Characterized by an acute onset of symptoms (Otalgia, fever, anorexia) with symptoms of middle ear inflammation ( Erythema, bulging tympanic membrane)
• It is an acute inflammation of the middle ear by pyogenic organisms

SUPPURATIVE OTITIS MEDIA-CHRONIC

• Chronic inflammation of the middle ear and mastoid cavity associated with conductive hearing loss and recurrent otorrhea through a defect in the tympanic membrane
• Patient presenting with a history of recurrent ear infection associated with painless discharge from the ear is usually indicative of CSOM

Types of CSOM

Clinically, it is divided into two types:

• Tubotympanic - also called the safe or benign type; it involves anteroinferior part of middle ear cleft, associated with a central perforation
• Atticoantral - also called unsafe or dangerous type; it involves posterosuperior part of the cleft associated with an attic or a marginal perforation

SEROUS OTITIS MEDIA

• Insidious condition characterized by accumulation of non purulent effusion in the middle ear cleft without signs of acute infection
• Occurs after an episode of acute otitis media or in the context of Eustachian tube dysfunction
• Young children presenting with hearing problems, often describe sound as muffled associated with aural fullness and with upper respiratory tract infections may be serous otitis media

TENSION TYPE HEADACHE

• Tension-type headaches (TTH) are recurrent episodes of headache lasting minutes to weeks. It is the most common type of headache overall
• The words “tension” and “type” underscore its uncertain pathogenesis and indicate that some kind of mental or muscular tension may play a causative role
• Tension-type headaches are characterized by a dull, non pulsating, band-like pain that is often bilateral. Autonomic symptoms like photophobia, phonophobia, or nausea are usually not present

Classification

• Episodic (ETH)- It can be infrequent or frequent
• Chronic (CTTH)

TINNITUS

• Tinnitus is ringing sound or noise in the ear in the absence of an external source. It can be unilateral or bilateral, acute or chronic, and intermittent or constant
• Tinnitus is not a specific disease but a symptom that can be connected to a wide variety of etiologies, most commonly conditions associated with hearing loss

TYPES OF TINNITUS

• Subjective, which can only be heard by the patient
• Objective, which can even be heard by the examiner with the use of a stethoscope

TRIGEMINAL NEURALGIA

• Trigeminal neuralgia or tic douloureux is characterized by a sudden usually unilateral severe brief stabbing recurrent episodes of pain in the distribution of one or more branches of the trigeminal nerve
• Trigeminal neuralgia affects women more often than men, and it's more likely to occur in people who are older than 50
• Attacks can occur without provocation but are sometimes triggered by innocuous stimuli like chewing
• Classical trigeminal neuralgia (CTN): caused by neurovascular compression, most often by an aberrant loop of a neighbouring artery (usually the superior cerebellar artery)
• Secondary trigeminal neuralgia (STN): caused by a major underlying neurological disease, most frequently multiple sclerosis, a tumour at the cerebellopontine angle, or arteriovenous malformation
• Idiopathic trigeminal neuralgia (ITN): no identifiable cause (unremarkable findings on MRI and electrophysiological tests)

TONSILLITIS-ACUTE

• An inflammation of the pharyngeal tonsils. The inflammation regularly lengthens to the adenoid and the lingual tonsils. It frequently arises in combination with inflammation of the pharynx; for this reason, the term tonsillitis and pharyngitis are often used interchangeably or in combination ( tonsilopharyngitis)
• It is most common in children and young adults and are primarily caused by group A streptococci
• Characterized by the sudden onset of fever, sore throat, and painful swallowing. Patients may also have tender, swollen cervical lymph nodes and tonsillar exudates
• Acute catarrhal or superficial tonsillitis - Tonsillitis is a part of generalized pharyngitis and is mostly seen in viral infections
• Acute follicular tonsillitis -The infection spreads into the crypts which become filled with purulent material, presenting at the openings of crypts as yellowish spots
• Acute parenchymatous tonsillitis - Tonsil substance is affected. Tonsil is uniformly enlarged and red
• Acute membranous tonsillitis - Exudation from the crypts coalesces to form a membrane on the surface of tonsil

TONSILLITIS-CHRONIC

• Subclinical infections of tonsils without an acute attack
• It may be a complication of acute tonsillitis
• Mostly affects children and young adults. Rarely occurs after 50 years

TYPES

• Chronic follicular tonsillitis - Tonsillar crypts are full of infected cheesy material which shows on the surface as yellowish spots
• Chronic parenchymatous tonsillitis - There is hyperplasia of lymphoid tissue. Tonsils are very much enlarged and may interfere with speech, deglutition and respiration
• Chronic fibroid tonsillitis - Tonsils are small but infected, with a history of repeated sore throats

ANKYLOSING SPONDYLITIS

• Ankylosing spondylitis, a type of seronegative spondyloarthropathy, is a chronic inflammatory disease of the axial skeleton that leads to partial or even complete fusion and rigidity of the spine.
• Males are disproportionately affected and the histocompatibility antigen type HLA B27 is positive in over 90% of patients and 53% of their first degree relatives
• The predominant clinical feature is inflammatory back ache followed by stiffness of spine. The pain typically improves with activity and is especially prominent at night
• Ankylosing spondylitis typically affects the structures of the spine and enthuses. Ascending progression of the disease leads to typical bamboo spine appearance
• Synonyms – Marie-Strumpell disease, Bamboo spine, Poker back

ATAXIA

• The word ataxia is derived from the greek word “a taxis” meaning without order. Persons with ataxia have problems with coordination of movements because parts of the nervous system that controls coordination, equilibrium and balance are affected

The three broad categories of ataxia are

• Cerebellar ataxia due to disorder of the cerebellum and its connections
• Sensory ataxia due to disorders of proprioception
• Vestibular ataxia due to peripheral vestibular disorders

BELL’s PALSY

• It is an acute, acquired, non traumatic , unilateral, infranuclear facial palsy
• It causes a temporary weakness or paralysis of the muscles in the face and occurs when the nerve that controls facial muscles becomes inflamed, swollen, or compressed
• The onset of Bell’s palsy is usually abrupt. Pain behind the ear may be present prior to the paralysis
• Although Bell’s palsy can occur at any age, the condition is more common among people between ages 16 and 60. Bell’s palsy is named after the Scottish anatomist Charles Bell, who was the first to describe the condition

BENIGN PROSTATIC HYPERPLASIA (BPH)

• Benign prostatic hyperplasia (BPH) is a non-neoplastic glandular and stromal hyperplasia of the transition zone of the prostate. It is a common disorder affecting 30 -40% of male population by the age of 50 years
• Sex hormones (androgens, estrogens, and androgen-estrogen imbalance) have been implicated as a key factor in the development of prostatic hyperplasia
• Patients present with symptoms of urinary frequency, urgency, urge incontinence, urinary hesitancy, straining to urinate, sensation of incomplete voiding, and/or haematuria

BRONCHIAL ASTHMA

• Asthma is defined as a heterogeneous disease usually characterized by chronic air way inflammation. It is defined by history of respiratory symptoms of wheezing, breathlessness, chest tightness and coughing, and by variable expiratory airflow limitation
• The cardinal symptoms of asthma are intermittent dyspnoea, coughing, and high-pitched expiratory wheezing. Allergic (extrinsic) asthma usually develops in childhood and is triggered by allergens such as pollen, dust mites, and certain foods. Non allergic (environmental or intrinsic) asthma usually develops in patients over the age of forty and can have various triggers, such as cold air, medication (e.g. aspirin), exercise, and viral infection

BRONCHIECTASIS

• Bronchiectasis (broncos – airways, ectasia – dilation ) is an irreversible and abnormal dilation in the bronchial tree that is generally caused by cycles of bronchial inflammation in addition to mucous plugging and progressive airway destruction
• The most important clinical finding is a chronic cough with copious mucopurulent sputum. Other symptoms may include dyspnoea, rhinosinusitis, and haemoptysis
• It affects all ages, although the prevalence increase with age. Bronchiectasis should be suspected in patients with a chronic cough that produces large amounts of sputum

BUERGER’S DISEASE

• It is an inflammatory occlusive vascular disorder involving small and medium sized arteries and veins in the distal and lower extremities. Also called Thromboangitis obliterans (TAO)
• TAO most commonly affects adult males with a significant history of cigarette smoking. In susceptible individuals, smoking causes inflammation of the tunica intima of small vessels by an unknown mechanism, which results in thrombotic occlusion of the vessel
• Patients initially present with a classic triad of intermittent claudication, Raynaud phenomenon, and migratory thrombo phlebitis.
• Eventually, critical limb ischemia develops and the patient presents with rest pain, absent pulse in the extremities, and/or digital gangrene. Cerebral, visceral and coronary vessels are rarely affected

DIABETIC NEUROPATHY

• A demonstrable neuropathic disorder either clinically evident or sub clinical that occurs in the setting of DM without other causes of peripheral neuropathy. It affects both somatic and autonomic components of the nervous system
• Diabetic neuropathy is the most common complication of diabetes affecting 50 % of type 2 DM patients. 50% of these have painful symptoms severely disturbing the quality of life while 50% have painless neuropathy
• Metabolic disruptions in the peripheral nervous system due to hypoglycaemia play a key role in the development of Diabetic neuropathy

DYSTONIA

• Dystonia is a movement disorder characterized by sustained or intermittent muscle contractions causing abnormal, often repetitive movements, postures or both
• It is characterized by muscle contractions which are patterned leading to abnormal postures or repetitive similar movements of the concerned body part. They are non jerky in nature. Other features associated with dystonia are dystonic tremor, overflow, mirror dystonia, and sensory trick
• The disorder may be idiopathic, hereditary, or acquired. Acquired dystonia is most commonly due to drugs (antipsychotics), metabolic disorders, cerebrovascular disease, or traumatic brain injury

ESSENTIAL TREMORS

• Hyperkinetic movement disorder characterized by the presence of a variety of different involuntary movements. It can affect any part of the body and occurs often in the hands , but the head, voice, tongue, legs and trunk may also be involved
• Most common involuntary movement disorder with bimodal distribution ;in teens and 6^th decade of life (commonly in elder patients )
• Essential tremor is also sometimes called benign essential tremor. It is the most common type of tremor

GASTRO ESOPHAGEAL REFLEX DISEASE (GEARD)

• Gastroesophageal reflux disease (GERD) is a chronic condition in which stomach contents flow back into the oesophagus, causing irritation to the mucosa. The reflux is primarily caused by an inappropriate, transient relaxation of the lower oesophageal sphincter
• The typical reflex syndrome is defined by the presence of troublesome heartburn or regurgitation and/or oesophageal injury/complications
• Typical symptoms are retro sternal burning pain (heartburn) and regurgitation, but the presentation is variable and may also include symptoms like chest pain and dysphagia

GOUT

• Gout is an inflammatory arthropathy characterized by painful and swollen joints. It is an inflammatory response to Monosodium urate crystals formed secondary to hyperuricemia.
• Decreased renal excretion and/or increased production of uric acid leads to hyperuricemia, which is commonly asymptomatic, but also predisposes to gout
• Acute gout attacks typically manifest with a severely painful big toe (podagra) and occur most often in men following triggers such as alcohol consumption. It is rare in children and premenopausal women. The peak age of onset in men is between 40 -60 years

IRRITABLE BOWEL SYNDROME (IBS)

• Irritable bowel syndrome (IBS) is a common chronic condition affecting the intestine presenting with recurrent, non specific changes in bowel movements and abdominal symptoms diffuse pain, bloating, diarrhoea, constipation and/or both
• The exact pathophysiology is unknown, but may involve changes in gastrointestinal motility, visceral hypersensitivity, and altered gastrointestinal permeability

JAUNDICE (ICTERUS)

• Jaundice, or icterus, is a yellowish discoloration of skin, sclera and mucous membranes caused by the accumulation of bilirubin deposits. Jaundice is one of the most common presenting symptoms of liver disease and this is due to elevation of bilirubin levels
• Jaundice can occur due to prehepatic, intrahepatic, or posthepatic causes
• Prehepatic jaundice is caused by the accumulation of unconjugated bilirubin due to increased haemoglobin breakdown or impaired hepatic uptake/conjugation of bilirubin. Intrahepatic and posthepatic jaundice may be due to decreased excretion/impaired reuptake of bilirubin by the liver or cholestasis, which can result from either reduced formation/secretion of bile (non obstructive cholestasis) or biliary obstruction (obstructive cholestasis)
• Jaundice is also characterized by pruritis, darkening of urine, and pale stools (in case of intra hepatic or post hepatic cholestasis). Skin discoloration becomes apparent at serum bilirubin levels > 4–5 mg/dl

MOTOR NEURON DISEASE (MND)

• Motor neuron diseases or disorders are a heterogeneous group of disorders of motor neurons referring to myriad of diseases manifesting with weakness, wasting and /or spasticity
• It is a progressive neurological disorder in which motor neurons or the cells that control voluntary muscle activity such as speaking, breathing, swallowing and walking are destroyed 

Spectrum of MND includes

• Amyotrophic lateral sclerosis(ALS)
• Progressive muscular atrophy
• Primary lateral sclerosis
• Progressive bulbar palsy
• Juvenile ALS
• Madras variant MND

The disorder has the following features:

• Upper motor Neuron involvement : Impaired dexterity of limbs, Generally mild weakness, Stiffness in limbs due to spasticity , Exaggerated deep tendon reflex, Extensor plantar response, Hoffmann sign ,loss of abdominal refelexes

• Lower motor Neuron involvement :Moderate to severe weakness, Wasting, Fasciculations, Muscle cramp, Reduced or absent deep tendon reflexes

Other motor neuron diseases like spinal muscular atrophy, bulbospinal atrophy have molecular pathology distinct from ALS and, while being motor neuron disorders, are not included as ALS or MND

MYASTHENIA GRAVIS

• Myasthenia gravis (MG) is an autoimmune disorder of the neuromuscular junction characterized by generalized muscle weakness. The pathophysiology involves auto antibodies directed against postsynaptic acetylcholine receptors, thereby impairing neuromuscular transmission
• Arrest of the neuromuscular transmission causes a fatigable skeletal muscle weakness with diurnal variation of symptoms. Most patients are young or in their sixth decade of life. Females are more commonly affected in younger age
• The most common initial symptoms are ptosis and/or diplopia due to ocular muscle weakness, with the disease usually progressing to generalized weakness within two years. At that point, patients have difficulties standing up, climbing stairs, and possibly even swallowing and/or chewing. Muscle weakness worsens throughout the day with increased activity and improves after rest

OSTEOPOROSIS

• Osteoporosis is an asymptomatic progressive metabolic skeletal disorder. It is characterized by the loss of bone mineral density that leads to decreased bone strength and an increased susceptibility to fractures
• WHO defines osteoporosis as a systemic skeletal disease characterised by low bone mass and micro architectural deterioration of bone tissue with a consequent increase in bone fragility and susceptibility to fractures involving the wrist, spine, hip, pelvis, ribs or humerus.
• The disease typically affects postmenopausal women and the elderly, as an abrupt decrease in oestrogen, and age-related processes play a key role in the development of osteoporosis

PARKINSON’S DISEASE

• Parkinson’s disease is the most common form of Parkinsonism and the second most common neurodegenerative disorder. It involves a progressive depletion of dopaminergic neurons in the basal ganglia, particularly the substantia nigra. Parkinson disease can be defined as parkinsonism for which no cause can be determined (idiopathic)
• PD usually manifests at approximately 60 years of age. The typical clinical picture seen in PD is called Parkinsonism and features the classical cardinal symptom of bradykinesia along with resting tremor and/or rigidity.
• Though PD is the main cause, parkinsonism may also result from other factors, e.g. medication (secondary parkinsonism), and as a feature of neurodegenerative diseases ( Atypical parkinsonism)

REACTIVE ARTHRITIS (ReA)

• Reactive arthritis, (formerly known as Reiter syndrome), is defined as a sterile joint inflammation within a month following a gastrointestinal or genitourinary infection
• It is categorized as a seronegative spondyloarthritis because of its association with HLA-B27. The usual age of onset is 20-40 years and both sexes are equally affected
• The characteristic triad consists of urethritis, arthritis, and conjunctivitis

RHEUMATOID ARTHRITIS

• Rheumatoid arthritis (RA) is a common chronic systemic inflammatory disease that clinically presents as symmetric polyarthritis affecting small and large diarthrodial joints of the extremities. It is an inflammatory autoimmune disorder characterized by joint pain, swelling, and synovial destruction
• The peak age of onset is in the fourth and fifth decade of life and women are more commonly affected. It is a heterogeneous disease with variable severity, and unpredictable course
• Most commonly the onset of symptoms of joint pains and swellings are insidious, evolving slowly in a fluctuating manner, over weeks to months

SJOGREN’S SYNDROME

• Sjogren’s syndrome is a chronic autoimmune exocrinopathy characterised by lymphocytic infiltration of lacrimal, salivary and other exocrine glands. Sjogren’s syndrome derives its name from Henrik Sjogren who introduced the term Kerato conjunctivitis sicca for dryness of eyes noted in patients
• It can occur in any age group but generally presents in fourth to sixth decade mainly in women. Sjogren’s syndrome may exist as primary or secondary when it occurs in association with other systemic auto immune diseases like RA, SLE, polymyositis etc.
• In sjogren’s the immune system mainly attacks lacrimal and salivary glands, patients typically present with xerophthalmia (dry eyes) and xerostomia (dry mouth), the combination of which is also known as sicca syndrome. The disease may also involve the skin, joints, internal organs, and nervous system

STROKE

• The term Stroke is applied to an acute focal (rarely global) neurological deficit that results from decreased perfusion of the brain due to occlusion or rupture of blood vessels supplying the Brain
• About 85% of strokes are ischemic in nature, due to in-situ thrombus superimposed on an atherosclerotic plaque or an embolism from a proximal source. Warning symptoms can sometimes present as a transient ischemic attack (TIA) which resolves within 24 hours but usually within minutes. The rest of strokes are haemorrhagic in nature due to rupture of a blood vessel. Hemorrhagic strokes are further classified as intracerebral or subarachnoid
• Clinically, strokes are characterized by the acute onset of focal neurologic deficits, including hemiparesis, paresthesias, and hemianopsia.

SYSTEMIC LUPUS ERYTHEMATOSIS

• Systemic lupus erythematosus (SLE) is a chronic multisystem autoimmune disease characterised by the presence of auto antibodies directed against various cells or their components
• It is characterised by periods of remissions or low disease activity and disease flares and predominantly affects women of childbearing age
• The presentation of the disease is variable and may range from mild localized symptoms to life-threatening systemic disease. Typical findings include fever and fatigue, a malar rash (facial butterfly rash), myalgia, and arthritis

ULCERATIVE COLITIS

• Ulcerative colitis (UC) is an inflammatory bowel disease characterised by chronic mucosal inflammation of the rectum, colon, and caecum
• Dominant symptom in UC is diarrhoea often associated with blood and mucous. In addition nocturnal defaecation, abdominal pain ( usually lower quadrant or rectal), fever, malaise, and weight loss may also be reported
• Most cases begin indolently and gradually worsen over several weeks, but some cases exhibit an initial attack of fulminant disease
• Individuals with UC are predisposed to colorectal cancer and should thus undergo regular surveillance colonoscopy

ACHILLES TENDINITIS

• It is an overuse injury of the Achilles tendon, the band tissue that connects calf muscles at the back of the lower leg to the heel bone. The loose connective tissue of the Achilles tendon becomes thickened and painful due to excessive use 
• It typically manifests with pain over the posterior aspect of the heel, proximal to the insertion of the Achilles tendon on to the Calcaneus
• Most commonly seen in men than females, in runners who have suddenly increased the intensity or duration of their runs, and in middle-aged people who play sports such as tennis or basketball only on weekends frequently complain of pain and stiffness in the back of the heel, which worsens with activity due to Irritation and inflammation of the Achilles tendon in the back of the ankle

BRACHIAL PLEXUS INJURY

• Injury to the upper and lower trunk of brachial plexus
• Patients complain of weakness or numbness, loss of sensation, loss of movements and pain along the upper limb often with a history of trauma to the shoulder
• The lesion in the brachial plexus may be either complete or partial
• Complete – It is rare and occurs only after severe injury. It damages all the roots of brachial plexus and is often fatal
• Incomplete - It may be due to stabs or cuts and may affect any of the roots. But the common injury is due to traction or pressure which affects either the upper or lower portion of the plexus
• Upper brachial lesion (Erb -duchenne palsy) - Injury affects the new born babies or adults. Nerve roots involved are C5 and sometimes C6
• Lower brachial lesion (Klumpke palsy) - Nerve root involved is T1

CALCANEUS SPUR

• Calcaneal spur is a bony projection forwards from the undersurface of the calcaneal tuberosity. It is nothing but the ossification of the plantar fascia at its calcaneal end
• Heal spurs are common and do not always cause pain, pain is caused by contact of the spur with the surrounding soft tissue
• Patients (usually middle-aged adults) frequently complain of pain behind or below the heels which increases in intensity after prolonged periods of rest

Classification:

• Inferior calcaneal spur – located in the inferior aspect of calcaneum, typically a response to plantar fasciitis over a period
• Posterior calcaneal spur – develops on the back of the heel at the insertion of achilles tendon

CARPAL TUNNEL SYNDROME

• Carpal tunnel syndrome(CTS) is a peripheral neuropathy caused by compression of the median nerve by the transverse carpal ligament
• Most common compressive neuropathy Characterised by both sensory disturbances ( pain, tingling and numbness) and motor symptoms ( weakness and clumsiness of the thumb) in the area innervated by the median nerve distal to the carpal tunnel
• More common in middle aged woman

COLLES FRACTURE

• A collie’s fracture is a break in distal end of radius 2.5 cm away from the articular surface
• Complete fracture of the distal radius (typically the last two centimetres) usually accompanied by damage to the ulnar collateral ligament or the ulnar styloid process
• It is the commonest fracture in people above forty years of age, and is particularly common in women because of post-menopausal osteoporosis

DE QUERVAIN’S DISEASE

• Non inflammatory thickening of the tendons of the abductor pollicis longus and extensor pollicis brevis due to myxoid degeneration
• Characterised by pain and swelling over the radial styloid process
• Patients often complaints of pain near the base of thumb with an associated swelling
• It is common in women of age 30-50 years & those with occupation involving repetitive movements of the wrist

DEEP VEIN THROMBOSIS (PHLEBOTHROMBOSIS)

• Deep vein thrombosis is the formation of a blood clot within the deep veins, most commonly those of the lower extremities
• Mostly an asymptomatic disease, only one fourth of the cases of DVT present with minor complaints
• Symptoms include oedema, warmth, and dull pain of the affected extremity. Patients also presents with features of pulmonary embolism, a severe complication of DVT
• Proximal DVT : DVT of the lower extremity affecting the femoral vein, and/or the popliteal vein
• Distal DVT : DVT of the lower extremity that is confined to the veins beyond the calf vein trifurcation (below knee joint)
• Venous thromboembolism : An umbrella term that encompasses DVT and pulmonary embolism

ELBOW DISLOCATION

• Elbow dislocations are the most common major joint dislocation second to the shoulder and most commonly dislocated joint in children
• Posterior dislocation is the commonest type of elbow dislocation. Other dislocations are postero-medial, postero-lateral, and divergent
• It may be associated with fracture of the medial epicondyle, fracture of the head of the radius, or fracture of the coronoid process of ulna
• Complex elbow dislocations have an associated fracture, while simple elbow dislocations do not 

FISSURE-IN-ANO

• An anal fissure is a longitudinal tear of the perianal skin distal to the dentate line, often due to an increased anal sphincter tone
• Patients (usually women ,between 30 to 50 years of age, sometimes in children too) frequently complain of sharp agonizing pain during defecation which lasts for one hour or more even after defecation , with streaks of blood on stool with a history of chronic constipation
• It is an elongated ulcer in the long axis of the anal canal

Sites:

• Occurs most commonly in the midline posteriorly and the least protected part of the anal canal
• Males - Fissures usually occur in the midline posteriorly (90%) and much less commonly than anterior (10%)
• Females - fissures on the midline posteriorly are slightly common than anterior

FROZEN SHOULDER (PERIARTHRITIS SHOULDER)

• Inflammation and fibrosis of the joint capsule leading to contracture of the shoulder joint
• Characterized by functional loss of passive and active shoulder motion with no clear underlying cause 
•  The glenohumeral joint becomes painful and stiff because of the loss of resilience of the joint capsule, possibly with adhesions between its folds
• Often, there is a history of preceding trauma 
• More common among women, aged 40-60 years and in diabetic patients

HAEMORRHOIDS

• Haemorrhoids (Piles) are dilated plexus of superior haemorrhoidal veins, in relation to anal canal
• Patient frequently complaints of bleeding per rectum (bright red coloured) along with defecation, feeling of mass per anus, slimy mucous discharge and feeling of fullness of the bowels with a history of chronic constipation

Classification:

Depending on Location

• Internal - above the dentate line ,is within the canal and internal to anal orifice
• External – below the dentate line, is situated outside the anal orifice and is covered by the skin
• Interno-external haemorrhoids – above and below the dentate line, the two varieties coexist

Depending on etiology

• Primary
• Secondary

HYDROCELE

• A hydrocele is an abnormal collection of serous fluid in the tunica vaginalis of the testis or within some part of the processus vaginalis
• Painless swelling of one or both testicles with mild discomfort from the heaviness of swollen scrotum
• Middle aged men are mostly affected

Classification:

PRIMARY HYDROCELE

The cause of which is unknown; there is no associated disease in the testis or the epididymis

• Vaginal hydrocele- Commonest variety of hydrocele, There is abnormal accumulation of serous fluid within the tunica vaginalis
• Encysted hydrocele of the cord - When the central portion of the processus vaginalis remains patent, but its upper and lower parts are obliterated, such a condition is developed. Fluid accumulates in the patent portion of the processus vaginalis and presents a swelling in relation to the spermatic cord, hence called it as encysted hydrocele of the cord
• Infantile hydrocele - This condition is just opposite to the funicular hydrocele. The tunica vaginalis is continuous with the processus vaginalis which is shut off from the peritoneal cavity at the deep inguinal ring
• Congenital hydrocele -In this condition, the processus vaginalis remains patent so there is direct communication of the tunica vaginalis with the peritoneal cavity
• Funicular hydrocele- In this condition, the processus vaginalis remains patent up to the top of the testis where it is shut off from the tunica vaginalis

3 rare varieties

• Hydrocele of the canal of nuck - This condition is female counterpart of the previous condition. Seen in relation to round ligament
• Hydrocele of the hernial sac - Sometimes hydrocele may associate with the hernia sac, the reason is that some fluid gets stagnated within the hernia sac when a tag of omentum blocks the opening of the sac at the deep inguinal ring
• Bilocular hydrocele- In this condition, the hydrocele has two communicating sacs- one above and one below the necks of scrotum. The upper sac has no connection with the processus vaginalis and it is in fact the herniated tunica vaginalis

SECONDARY HYDROCELE

• Abnormal collection of fluid into the tunica vaginalis which accompanies disease of the testis and/ or the epididymis

INGUINAL HERNIA

• An inguinal hernia is an abnormal protrusion of intra abdominal contents through the inguinal canal
• This inguinal region is a weak part of the abdominal wall by the presence of the inguinal wall, the deep inguinal ring and the superficial inguinal ring
• Patients complain of a swelling in the groin which becomes more obvious on coughing or straining associated with dragging pain

Classification:

Indirect hernia– Contents of the abdomen enter the deep inguinal ring and transverse the whole length of the inguinal canal to come out through the superficial inguinal ring. This is more common than direct hernia

According to the extent of the hernia, it is divided into

• Bubonocele – hernia is limited in the inguinal canal and the processus vaginalis is closed at the superficial inguinal ring. This presents as inguinal swelling. Usually seen in young adults
• Funicular hernia –The processus vaginalis is closed at its lower end just above the epididymis. So the contents of the hernia can be felt separately from the testis and the testis lies below the hernia. occurs in adults
• Complete or vaginal or scrotal hernia - Processus vaginalis is patent throughout. Hernia descends down to the bottom of the scrotum lying in front and at the sides of the testis. It is congenital and common in children yet may not appear until adolescent or adult life

Direct hernia– a direct inguinal hernia protrudes through the posterior wall of the inguinal canal medial to the inferior epigastric vessels

According to the contents of the sac, hernia can be classified into:

• Enterocele - sac contains intestine
• Omentocele – sac contains omentum
• Entero-omentocele – sac contains both intestine and omentum
• Cystocele – sac contains a part of urinary bladder

INTERVERTEBRAL DISC PROLAPSE(IVDP)

• A form of degenerative disc disease in which pressure on a vertebra causes the nucleus pulposus to press against the annulus fibrosus which results in spinal nerve compression and pain
• The intervertebral disc consists of three distinct components — the cartilage end-plates, nucleus pulposus and annulus fibrosus
• The term 'prolapsed disc' means the protrusion or extrusion of the nucleus pulposus through a defect in the annulus fibrosus
• The site of exit of the nucleus is usually postero-lateral on one or the other side. Occasionally, it can be central
• The commonest level of disc prolapse is between L4 -L5 in the lumbar spine and C5 -C6 in the cervical spine

Stages of disc prolapse

Nucleus degeneration- Degenerative changes occur in the disc before displacement of the nuclear material

Nucleus displacement

• Stage of disc protrusion: When the annulus becomes weak, the nucleus tends to bulge through the defect
• Stage of disc extrusion: When the nucleus comes out of the annulus and lies under the posterior longitudinal ligament; though it has not lost contact with the parent disc
• Stage of sequestration: The extruded disc may loose its contact with the parent disc

Stage of fibrosis- The residual nucleus pulposus becomes fibrosed. The extruded nucleus pulposus becomes flattened, fibrosed and finally undergoes calcification

KNEE LIGAMENT INJURIES

• Knee ligaments are injured most often from indirect, twisting or bending forces on the knee, or often the result of rotational movement of the knee joint
• Four ligaments in the knee that are prone to injury are- Anterior cruciate ligament (ACL) , Posterior cruciate ligament (PCL), Lateral collateral ligament (LCL), Medial collateral ligament (MCL)
• With increasing sporting activities, injuries to the knee ligaments are on the rise
• The type of injury depends upon the direction of force and its severity
• Most common is MCL injury (40 %)

OSTEOARTHRITIS (OSTEOARTHROSIS)

• Osteoarthritis is a degenerative condition of the articular cartilage and the underlying bone as a result of wear and tear
• Usually occurs in the elderly but can be accelerated in patients with an underlying joint pathology and increased or abnormal biochemical forces on the joint, including elevated BMI
• Patient complaints of Pain which increases on activity and relieves on rest
• Swelling, stiffness of the joints along with difficulty in movements and cracking sounds during movements is seen
• It mainly affects the weight bearing and high use joints such as the hip, knee, hands, and vertebrae

Classification:

• Primary OA – it occurs in old age, mainly in the weight bearing joints (knee and hip).It is commoner than the secondary OA
• Secondary OA –There is an underlying primary disease of the joint which leads to degeneration of the joint, often many years later. it may occur at any age after adolescence and occurs commonly at the hip

ANAL ABSCESS

• Anal abscesses are the acute manifestation of a purulent infection in the perirectal area. It is a pus filled cavity that most commonly develops from an infected anal crypt gland following obstruction and bacterial overgrowth
• An anorectal abscess may heal spontaneously following drainage into the anal canal. In 40-50% cases, it progress into fistula
• Patients complain of painful swelling around the anus associated with discharge of pus occasionally and the pain increase on continuous sitting or during defecation

PERTHES’ DISEASE

• Perthes disease is an idiopathic, avascular necrosis of the femoral head. It is an osteochondritis of the epiphysis of the femoral head.
• Children (usually the age between 5 to 1o years) frequently complain of pain which radiates to knee occasionally associated with limping and hip stiffness
• Also known as Coxaplana, Pseudo-coxalgia

PILONIDAL SINUS

• Pilonidal sinus means nest of hairs in Greek. Also called Jeep bottom because it is very common in jeep drivers
• It is an acquired condition, commonly found in hairy males. It is found in the natal cleft overlying the coccyx, consisting of one or more, usually non-infected, midline openings, which communicate with a fibrous track lined by granulation tissue and containing hair lying loosely within the lumen
• Patients usually complain of painful swelling associated with or without blood stained foul discharge at the bottom of the spine

Sites of pilonidal sinus:

• Midline over the coccyx
• Interdigital cleft of barbers
• Axilla
• Umbilicus
• Interdigital web of the foot of a worker in hair mattress factory
• Face

Contents of tract

• Hairs – usually dead and are found lying loose in the sinus, embedded in the granulation tissue or buried deep in the mature scar tissue at the depth
• Granulation tissue
• Epithelial scales and debris

PLANTAR FASCIITIS

• Commonest cause of pain in the heel. It occurs from the inflammation of plantar Apo neurosis at its attachment on the tuberosity of the calcaneum
• Also called Policeman’s heel
• Patients frequently complain of pain beneath the heel with increased intensity in the early morning which gradually improves with activity

RETROCALCANEAL BURSITIS

• Retrocalcaneal bursitis is the inflammation of bursa located between the calcaneus and the anterior surface of achilles tendon
• Also called as achilles tendon bursitis
• Patients, especially sporting athlete and individuals who are accustomed to wearing high heeled shoes on a long-term basis frequently complain of pain and swelling behind the heel which increases on activities

SHOULDER DISLOCATION

• A dislocated shoulder occurs when the head of humerus is out of the glenoid cavity. Because the head of humerus is substantially larger than the glenoid fossa, shoulder dislocation is the most common type of joint dislocation
• It occurs more commonly in adults, and is rare in children
• A fall on an out-stretched hand with the shoulder abducted and externally rotated is the common mechanism of injury

Classification:

Anterior dislocation — the head of the humerus comes out of the glenoid cavity and lies anteriorly. It may be further classified in to 3 subtypes

• Preglenoid: The head lies in front of the glenoid
• Sub coracoid: The head lies below the coracoid process
• Sub clavicular: The head lies below the clavicle

Posterior dislocation — In this injury, the head of the humerus comes to lie posteriorly, behind the glenoid

Inferior dislocation– This is a rare type, where the head comes to lie in the sub glenoid position

TENNIS ELBOW (LATERAL EPICONDYLITIS)

• Overuse injury of the hand, especially finger extensor tendons which originate in the lateral humeral epicondyle
• It is caused by activities that involve repetitive wrist extension and /or repetitive forearm supination – pronation with the elbow in near complete extension(e.g. racket sports)
• Characterised by pain and tenderness at the lateral epicondyle of humerus due to non-specific inflammation at the origin of the extensor muscles of the forearm
• Although, it is sometimes seen in tennis players, other activities such as squeezing clothes, carrying suitcase etc. are frequently responsible
• Commonly seen in age group - 40 to 50 years

TRIGGER FINGER

• An inflammation of the flexor tendon sheath leading to a stenosing tenosynovitis
• Patients experience locking or catching sensation during active flexion extension activity and often have a palpable nodule along the axis of the flexor tendon
• It results from the constriction of the fibrous digital sheath, so that free gliding of the contained flexor tendon does not occur
• Inflammation and hypertrophy of the retinacular sheath progressively restricts the motion of the flexor tendon 

UMBILICAL HERNIA

• An umbilical hernia is an outward bulging (protrusion) of the lining of the abdomen or part of the abdominal organs through the area around the umbilicus
• Patients (usually females) complain of abdominal swelling near to naval gradually increasing in size, becomes prominent on coughing or straining such as on strenuous exercise associated with intermittent dull ache

Types:

Umbilical Hernia of Newborn (Exomphalos)

• It is a developmental anomaly due to failure of whole or part of the mid-gut to return into the abdominal cavity during early foetal life. Abdominal organs remain protruded and being covered by a membrane – which consists of an outer layer of amniotic membrane, a middle layer of Wharton’s jelly and an inner layer of peritoneum
• Exomphalos minor - Where the sac is relatively small and its summit is attached the umbilical cord
• Exomphalos major - Umbilical cord is attached to the inferior aspect of a large swelling containing small and large intestine and a portion of the liver

Umbilical hernia in infants & children

• Hernia through a weak umbilical scar which occurs as a complication of umbilical sepsis
• It is a true umbilical hernia containing either omentum / intestines

Umbilical hernia of Adults (Para umbilical hernia)

• It is not a true umbilical hernia but it is a para umbilical protrusion through the linea alba just above the umbilicus (supra umbilical) or occasionally below the umbilicus (infra-umbilical)
• Contents are Greater omentum, Small intestine or Transverse colon

VARICOSE VEINS

• Dilated, tortuous and elongated superficial veins of the limbs are called varicose veins
• Most commonly affected is superficial venous system of lower limb affecting either the long saphenous or the short saphenous vein or both

VENOUS ULCER

• An ulceration of the skin caused by chronic venous insufficiency. Classically develops superior to the medial ankle. Often associated with skin changes ( hyperpigmentation) and unilateral oedema
• Commonest ulcer of the leg
• Basic cause is the abnormal venous hypertension in the lower third of the leg, ankle and dorsum of the feet
• Also known as varicose ulcer, post-thrombotic ulcer, gravitational ulcer etc.

ABNORMAL VAGINAL DISCHARGE

• A common symptom in the Gynaecologic clinic
• Commonly associated with itching, foul smell, burning sensation, etc.
• It may be non-infective (Leucorrhoea), infective, neoplastic, or due to a foreign body
• Pelvic examination - to find whether there is an infection, foreign body, or any premalignant or malignant lesions
• Leucorrhoea is excessive normal vaginal discharge (non-purulent, non-offensive, and non-irritant)
• Common infections occurring in vulva and vagina are Bacterial vaginosis, Candidiasis, Trichomonas vaginitis, STI such as Gonorrhea, Chlamydia, etc.

ABNORMAL UTERINE BLEEDING (AUB)

• Any uterine bleeding beyond normal volume, duration, regularity, or frequency is considered AUB
• Patterns of AUB:
• Menorrhagia
• Metrorrhagia
• Polymenorrhea / Epimenorrhea
• Menometrorrhagia

• Menorrhagia – Cyclic bleeding with normal intervals, but bleeding is either excessive in amount (> 80 ml) or duration (> 7 days) or both
• Metrorrhagia – Irregular acyclic bleeding (of any amount) from the uterus (bleeding occurs between normal ovulatory cycles)
• Polymenorrhea –Cyclic bleeding where the cycle is reduced to an interval of less than 21 days and remains constant at that frequency. If it is associated with excessive and/or prolonged bleeding, it is called Polymenorrhagia / Epimenorrhagia
• Menometrorrhagia –Bleeding is so irregular & excessive that periods cannot be identified at all

ADENOMYOSIS

• Benign invasion of the endometrium into the myometrium due to hyperplasia of the endometrial basal layer producing a diffusely enlarged uterus (Endometriosis internal)
• Both glandular and stromal components of the endometrium are involved
• Associated with myometrial hypertrophy and may be either diffuse or focal
• Peak incidence at 35-50 years

AMENORRHOEA, OLIGOMENORRHOEA & HYPOMENORRHOEA

• Amenorrhoea - absence of menstruation for more than 6 months
• Oligomenorrhoea - menstrual bleeding occurs more than 35 days apart and remains constant at that frequency
• Hypomenorrhoea - menstrual bleeding is unduly scanty and lasts for less than 2 days
• Physiological Amenorrhoea – Primary (before puberty) & Secondary (during pregnancy, during lactation, following menopause
• Pathological Amenorrhoea – Concealed (Cryptomenorrhoea) & True (Primary & Secondary)

CHANCROIDS (SOFT SORE)

• Chancroid ( also known as soft chancre) is a highly contagious sexually transmitted infection caused by Haemophilus ducreyi
• Characterized by the formation of small, painful ulcers on the genitalia 
• Swollen, painful lymph glands or inguinal buboes in the groin area are often associated with chancroid
• If left untreated, chancroid may facilitate the transmission of HIV

CHLAMYDIAL INFECTIONS

• Chlamydia is a common sexually transmitted disease (STD) caused by infection with Chlamydia trachomatis
• Most prevalent STD. Known as a ‘silent’ disease because, although it often has no outward symptoms, it can cause major internal damage
• Can cause cervicitis in women and urethritis and proctitis in both men and women
• Chlamydial infections in women can lead to serious consequences including pelvic inflammatory disease (PID), tubal factor infertility, ectopic pregnancy, and chronic pelvic pain

DYSFUNCTIONAL UTERINE BLEEDING (DUB)

• A state of abdominal uterine bleeding without any clinically detectable organic, systemic and iatrogenic cause
• Primary DUB - Abnormal bleeding from the uterus where there is no disease of the genital tract, no IUCD, and no history of sex hormone administration
• Secondary DUB- Abnormal bleeding from the uterus secondary to IUCD, administration of sex hormones, Organic disease outside the genital tract- e.g. hypothyroidism, bleeding disorders

DYSMENORRHOEA

• Dysmennorhoea is a term describing painful menstruation that typically involves cramps caused by uterine contractions
• Painful menstruation in such a magnitude that limits daily activities
• Also known as painful periods or menstrual cramps
• Primary dysmenorrhoea- recurrent lower abdominal pain shortly before or during menstruation (in the absence of pathologic findings)
• Secondary dysmenorrhoea- recurrent lower abdominal pain shortly before or during menstruation that is due to an underlying condition

ENDOMETRIOSIS

• The presence of functional epithelium in sites other than the uterine mucosa is termed endometriosis
• An oestrogen-dependent disease frequently resulting in substantial morbidity, severe pelvic pain, multiple surgeries, and impaired fertility
• Characterized by microscopic internal bleeding, development of painful endometriomas, inflammation, fibrotic scarring, and formation of adhesions; distortion of pelvic anatomy may also be present
• Leading cause of gynecologic hospitalization and hysterectomy

Common sites :

• Ovaries
• Pelvic peritoneum
• Pouch of Douglas
• Uterosacral ligaments
• Rectovaginal septum
• Sigmoid colon

Remote sites

• Umbilicus
• Abdominal scars
• Episiotomy scars
• Lungs

FIBROADENOMA

• Benign oestrogen dependant breast tumour composed of fibrous and glandular tissue that is usually found in premenopausal women
• Fibroadenoma is the most common benign tumour of the breast 
• It forms from the proliferation of epithelial and mesenchymal elements and stroma
• Peak incidence is between 15 and 35 yrs of age
• It is symptomless, being accidentally discovered by self-palpation 

FIBROID UTERUS

• Fibroids are benign hormone-sensitive uterine neoplasms and the most common cause of hysterectomy 
• Peak incidence during the reproductive age; between 35 – 45 years
• It is predominantly an oestrogen dependent tumor and does not occur before menarche and the fibroid regress after menopause
• Increased growth of fibroid can be seen in pregnancy and can cause several complications

Types of fibroids

• Intramural / Interstitial - lie within the myometrial wall of the uterus. Subsequently, they grow outwards or inwards
• Subserous - localized in the outer uterine wall and grows outward towards the peritoneal cavity and is covered by peritoneum
• Submucous - localized directly below the endometrial layer ( uterine mucosa)
• Cervical fibroids
• Broad ligament fibroids

ANOGENITAL WARTS

• Epidermal manifestation attributed to the epidermotropic human papillomavirus(HPV)
• Genital warts are fleshy growths that develop around the genitals or anus
• Also known as Condyloma acuminate or venereal warts

GONORRHEA

• A sexually transmitted disease caused by the bacterium Neisseria gonorrhoea that leads to urogenital, anorectal, conjunctival, and pharyngeal infections
• Second most frequently reported bacterial STD after Chlamydia
• Acute infectious STD and can become chronic if neglected
• If untreated it may cause infertility

HERPES GENITALIS

• A sexually transmitted infection caused by Herpes simplex virus (HSV)
• Characterized by the formation of fluid-filled blisters on the genital organs
• After the initial infection, the virus lies dormant in the body and can reactivate several times a year
• If infected, it can be contagious even if there are no visible sores

INTRA UTERINE GROWTH RETARDATION (IUGR)

• IUGR is defined as lower than normal foetal growth characterized by an estimated foetal weight below the 10th percentile for a given gestational age
• Asymmetrical IUGR is caused by extrinsic influences (most commonly placental insufficiency) that affect the foetus in the later stages of gestation. It manifests with normal foetal head size with a disproportionately small body and limbs
• Symmetrical IUGR is caused by intrinsic influences (e.g., early intrauterine infections, aneuploidy) that affect the foetus in the early stages of gestation. It typically manifests with a global growth restriction of the head and body and can lead to an increased risk of neurologic sequelae

LYMPHOGRANULOMA VENEREUM (LGV)

• Lymphogranuloma venereum (LGV) is a sexually transmitted disease caused by L1-3 serotypes of Chlamydia trachomatis
• It is an uncommon STD characterized by inguinal lymphadenopathy
• Patients initially develop a small, painless papule in the genital region that may ulcerate but will heal and disappear within one week
• 2-4 weeks after the initial lesion, patients present with painful, suppurative, bilateral inguinal lymphadenopathy and systemic symptom such as fever, malaise, chills, and/or myalgia

MENOPAUSAL SYNDROME

• Menopause is the permanent cessation of menstruation at the end of reproductive life due to the loss of ovarian follicular activity
• Menopausal syndrome includes symptoms associated with the physiological changes that take place in a women’s body as the period of fertility ends
• The age of menopause ranges between 45-55 yrs, the average being 50 yrs

OVARIAN CYSTS

• Ovarian cysts are fluid-filled sacs within the ovary
• The most common types are functional follicular cysts, corpus luteum cysts, and theca lutein cysts, all of which develop as part of the menstrual cycle and are usually harmless and resolve on their own
• Nonfunctional cysts include chocolate cysts, which are related to endometriosis, dermoid cysts, cystadenomas, and malignant cysts (a type of ovarian cancer)

PELVIC INFLAMMATORY DISEASES

• Infection and inflammation of the upper genital tract involving the uterus, fallopian tube, and adjacent pelvic structures
• Usually, an ascending infection and may include endometritis, salpingitis, tubo-ovarian abscess, and pelvic peritonitis
• Symptoms may vary considerably, while some women are asymptomatic, others may complain of mild pressure pain and discharge or present with signs of systemic inflammation, such as fever and severe abdominal pain

PELVIC ORGAN PROLAPSE (POP)

• Pelvic organ prolapse is the descent of the genital organs beyond their normal anatomical confines
• It is caused by herniation through deficient pelvic fascia or due to weakness or deficiency of the ligaments or muscles or deficient blood or nerve supply to the organs
• Commonly seen in women of advanced age
• Partial/subtotal prolapse: pelvic organs are only partially outside the vaginal opening
• Total prolapse: pelvic organs are everted and located outside of the vaginal opening

POLYCYSTIC OVARY SYNDROME (PCOS)

• Most common endocrine disorder of women in the reproductive age group
• The disorder is manifested clinically as ovulatory disturbances, hyperandrogenism, and polycystic ovarian morphology on ultrasound
• A multifactorial and polygenic condition
• Up to 50% of PCOS patients have metabolic syndrome which is associated with obesity, insulin resistance, hypercholesterolemia
• PCOS primarily manifests with hirsutism, acne, and virilization
• The most common cause of infertility in women

PREMENSTRUAL SYNDROME (PMS)

• Premenstrual syndrome (PMS) is a psychoneuroendocrine disorder of unknown aetiology, often noticed just before menstruation
• The cyclic appearance of a large number of symptoms during the last 7-10 days of the menstrual cycle
• When these symptoms disrupt daily functioning they are grouped under the name premenstrual dysphoric disorder (PMDD)
• PMS is more common in women aged 30-45

SYPHILIS

• Syphilis is a sexually transmitted bacterial infection with the spirochete Treponema pallidum
• The disease presents with four distinct, successive clinical stages if left untreated. Primary syphilis manifests with a painless chancre (primary lesion), typically on the genitals
• Secondary syphilis is characterized by a polymorphic, maculopapular rash that appears on the palms and soles also
• The first two stages are followed by an asymptomatic phase (latent syphilis), in which the disease may resolve entirely or progress to tertiary syphilis
• In the tertiary stage, characteristic granulomas (gumma) may appear, which can cause irreversible organ damage, particularly in the cardiovascular system (syphilitic aortic aneurysm) and the CNS (neurosyphilis)

URINARY TRACT INFECTIONS

• Urinary tract infections (UTIs) are infections of the urinary tract system (bladder, urethra, kidneys) that are generally caused by bacteria, especially E. coli. UTIs are the most common bacterial infections
• UTI can vary from asymptomatic colonization, through self-limiting, unpleasant lower tract infection to life-threatening sepsis. Women are at high risk of contracting UTIs due to a shorter urethra and the proximity of the anal and genital regions
• Clinical findings depend on which part of the urinary tract is affected. Lower UTIs manifest with dysuria, suprapubic pain, urinary urgency, and increased urinary frequency, whereas upper UTIs additionally manifest with fever and flank pain

1FEMALE INFERTILITY- IN GENERAL

• Infertility is a condition in which successful pregnancy has not occurred, despite normal intercourse over 12 months. The cause of female infertility is multifactorial 
• Infertility in women who have never been pregnant is primary infertility and infertility in women who have previously conceived is termed secondary infertility
• In nearly 30 % of the cases, the cause of infertility may be attributed to the female partner

HYPERPROLACTINEMIA

• Hyperprolactinemia is a condition of elevated serum prolactin. Prolactin is a 198-amino acid protein produced in the lactotroph cells of the anterior pituitary gland
• The primary function of prolactin is to enhance breast development during pregnancy and to induce lactation

POLYCYSTIC OVARY SYNDROME (PCOS)

• Most common endocrine disorder of women in the reproductive age group
• The disorder is manifested clinically as ovulatory disturbances, hyperandrogenism, and polycystic ovarian morphology on ultrasound
• A multifactorial and polygenic condition
• Up to 50% of PCOS patients have metabolic syndrome which is associated with obesity, insulin resistance, hypercholesterolemia
• PCOS primarily manifests with hirsutism, acne, and virilization
• The most common cause of infertility in women

LUTEAL PHASE DEFECT

• Luteal phase is the second phase of the ovarian cycle which corresponds with days 14-28 of the menstrual cycle. It is characterized by the transformation of granulosa and theca cells into luteal cells under the influence of progesterone 
• A luteal phase defect is a condition that affects a woman’s ovulation cycle and makes it difficult to experience a healthy pregnancy. LPD, characterized by low progesterone levels and limited uterine lining growth, undermines egg implantation and foetal development

LUTEINIZED UNRUPTURED FOLLICLE

• In a small percentage of normal women, the dominant follicle will occasionally undergo the luteinization process without rupture following the mid-cycle surge
• As a result of the increased progesterone secretion, the uterine lining develops its normal characteristic changes following ovulation, but no oocyte is released and conception cannot occur. This phenomenon is called the luteinized unruptured follicle (LUF)

PREMATURE OVARIAN FAILURE

• Ovarian insufficiency despite adequate gonadotrophin stimulation is termed as Primary ovarian insufficiency or premature ovarian follicle 
• When ovarian failure occurs before the age of 40, it is termed Premature Ovarian Failure. Women who experience ovarian failure prior to the age of 30 should have a genetic evaluation to ensure a normal karyotype
• These women should also have an autoimmune workup because of possible autoimmune causes of ovarian failure

ABNORMAL VAGINAL DISCHARGE

• A common symptom in the Gynaecologic clinic
• Commonly associated with itching, foul smell, burning sensation, etc.
• It may be non-infective (Leucorrhoea), infective, neoplastic, or due to a foreign body
• Pelvic examination - to find whether there is an infection, foreign body, or any premalignant or malignant lesions
• Leucorrhoea is excessive normal vaginal discharge (non-purulent, non-offensive, and non-irritant)
• Common infections occurring in vulva and vagina are Bacterial vaginosis, Candidiasis, Trichomonas vaginitis, STI such as Gonorrhea, Chlamydia, etc.

ENDOMETRIOSIS

• The presence of functional epithelium in sites other than the uterine mucosa is termed endometriosis
• An oestrogen-dependent disease frequently resulting in substantial morbidity, severe pelvic pain, multiple surgeries, and impaired fertility
• Characterized by microscopic internal bleeding, development of painful endometriomas, inflammation, fibrotic scarring, and formation of adhesions; distortion of pelvic anatomy may also be present
• Leading cause of gynecologic hospitalization and hysterectomy

Common sites :

• Ovaries
• Pelvic peritoneum
• Pouch of Douglas
• Uterosacral ligaments
• Rectovaginal septum
• Sigmoid colon

Remote sites

• Umbilicus
• Abdominal scars
• Episiotomy scars
• Lungs

FIBROID UTERUS

• The most common benign tumor of uterus
• The most common cause of hysterectomy now days.
• Peak incidence during the reproductive age; between 35 – 45 years
• Predominantly an oestrogen dependent tumor.
• They do not occur before menarche.
• After menopause, the fibroid regress
• Increases growth of fibroid can be seen in pregnancy & causes several complications.

Types of fibroids

• Intramural / Interstitial
• Subserous
• Submucous
• Cervical fibroids
• Broad ligament fibroids
• Intramural fibroids lie within the myometrial wall of the uterus. Subsequently, they grow outwards or inwards.
• Subserous fibroid – the intramural fibroid grows outward towards the peritoneal cavity and is covered by peritoneum.
• Submucous fibroid – the intramural fibroid grows into the uterine cavity and is covered by the endometrium. They produce maximum menstrual problems

PELVIC INFLAMMATORY DISEASES

• Infection and inflammation of the upper genital tract involving the uterus, fallopian tube, and adjacent pelvic structures
• Usually, an ascending infection and may include endometritis, salpingitis, tubo-ovarian abscess, and pelvic peritonitis
• Symptoms may vary considerably, while some women are asymptomatic, others may complain of mild pressure pain and discharge or present with signs of systemic inflammation, such as fever and severe abdominal pain

TUBAL BLOCK

• In tubal block, the passage for sperm to reach the eggs, as well as the path back to the uterus for the fertilized egg is blocked
• The common reason for blocked fallopian tube includes scar tissue, infection and pelvic adhesions

UNEXPLAINED INFERTILITY

• Infertility is idiopathic in the sense that its cause remains unknown even after an infertility work-up, usually including semen analysis in men and assessment of ovulation and fallopian tubes in the woman
• Unexplained infertility is estimated to occur in about 15% of patients

ANTENATAL CARE – FIRST TRIMESTER

• Antenatal care refers to the healthcare that women receive throughout pregnancy 

Aims and Objectives

• To detect high-risk pregnancies
• To monitor the course of pregnancy and Foetal development
• To ensure continued medical surveillance and prophylaxis
• To motivate the couple about the need for family planning
• To advise the mother about breastfeeding, post-natal care, and immunization

Schedule for Antenatal Visits 

• up to 28th week – Monthly 
• From 28th week – 36th week – Every two weeks
• From 36th week until birth – Every week

ANTENATAL CARE – SECOND TRIMESTER

• Second trimester – 13 to 28 weeks

Schedule for Antenatal Visits 

• up to 28th week – Monthly 
• From 28th week – 36th week – Every two weeks
• From 36th week until birth – Every week

ANTENATAL CARE – THIRD TRIMESTER

• Third trimester – 29 to 40 weeks

Schedule for Antenatal Visits 

• up to 28th week – Monthly 
• From 28th week – 36th week – Every two weeks
• From 36th week until birth – Every week

FISTULA-IN-ANO

• Fistula-in- ano is an inflammatory track which has an external opening in the perianal skin and an internal opening in the anal canal or rectum. The track is lined by unhealthy granulation tissue and fibrous tissue
• Patients complain of pain, swelling, discharge of blood or pus from the anus with irritation of the surrounding skin
• Even though multiple openings are seen in the perianal skin , the internal opening is always single

Classification

Low fistula (below anorectal ring)

• Subcutaneous
• Submucous
• Intersphincteric
• Transphincteric
• Suprasphincteric

High fistula (above anorectal ring)

• Extrasphincteric
• Transphincteric
• Pelvi-rectal fistula

ALCOHOL USE DISORDER

• A chronic disease characterized by uncontrolled drinking and clinically significant psychosocial and behavioural problems associated with alcohol use
• Alcoholism is the inability to control drinking due to both physical and emotional dependence on alcohol. Alcohol dependence syndrome is a cluster of physiological, behavioural, and cognitive phenomena in which the use of a substance or a class of substance takes on a much higher priority for a given individual than other behaviours that once had greater value
• AUD is a chronic condition in which an uncontrolled pattern of alcohol use leads to significant physical, psychological, and social impairment or distress. Symptoms of withdrawal emerge when drinking is discontinued
• It accounts for > 3 million deaths per year worldwide and the Peak incidence of onset is in the late 2nd or early 3rd decade

ATTENTION DEFICIT DISORDER

• A relatively common neuro developmental disorder that presents in childhood with symptoms such as impulsivity, hyperactivity, and inattention . A core feature of this disorder is that symptoms must impair social, occupational, or academic performance. The onset occurs before the age of 7 years and a large majority of patients exhibit symptoms by the 4^th year of age. Attention deficit disorder is of four clinical types, with hyper activity, without hyperactivity, residual type and with conduct disorder
• Attention deficit disorder with hyperactivity (Hyperkinetic disorder/ ADHD) is the most commonest type
• Attention deficit disorder without hyperactivity is a rare disorder with similar features of ADHD without hyperactivity
• Residual type – Usually diagnosed in adulthood, with presence of few residual features in adult life
• It occurs in about 3% of school age children and males are 6-8 times more often affected

BIPOLAR AFFECTIVE DISORDER (BPAD)

• Bipolar disorder is a psychiatric illness characterized by repeated (i.e. at least two) episodes in which the patient's mood and activity levels are significantly disturbed. This disturbance can occur on two occasions; one with an elevation of mood and increased energy and activity ( mania or hypomania) and the second with lowering of mood and decreased energy and activity. The recovery is usually complete between the episodes.
• Manic episodes usually begin abruptly and last for between 2 weeks and 4-5 months. Depressive episode tend to last longer about 6 months
• Women have an increased risk of manic and depressive episodes and are more inclined to the rapid cycling subtype. The average age of onset is 20 years and prevalence in the general population is 1-3 %. A first degree relative with bipolar has 20 % chances of having the disease

MAJOR NEUROCOGNITIVE DISORDER (DEMENTIA)

• Major neurocognitive disorder (previously called dementia) is an acquired disorder of cognitive function usually of chronic or progressive nature, in which there is impairment of multiple higher cortical functions, including memory, thinking, orientation, comprehension, calculation, learning capacity, language, and judgment
• Impairments of cognitive function are commonly accompanied or occasionally preceded by deterioration in emotional control, social behaviour, or motivation. Overall Prevalence is 5-10 % after 60 or 65 years old

DEPRESSION

• Depression is a common mental disorder that presents with depressed mood, loss of interest and enjoyment and reduced energy leading to increased fatiguability and diminished activity. The most important feature is the sadness of mood or loss of interest and or pleasure in almost all activities present throughout the day. Based on the severity Depression can be Major, Moderate and Mild
• Major depressive disorder (MDD) is an episodic mood disorder primarily characterized by depressed mood and anhedonia lasting for at least 2 weeks. 5-6 diagnostic Clinical Features for depressive disorder should be present

There are various subtypes of MDD characterized by additional symptoms or occurrence in specific conditions, such as

• Atypical depression (additionally characterized by, e.g. weight gain and increased appetite)
• Psychotic depression (with additional psychotic features such as hallucinations and delusions) and
• Peripartum depression (which occurs during or shortly after pregnancy).
• In elderly patients, MDD can also manifest with memory loss and other symptoms seen in dementia, referred to as Pseudo Dementia.

Moderate depressive disorder

• Symptoms are present for 2 weeks for < 2 years.
• 4-5 diagnostic Clinical Features for depressive disorder (must include depressed mood or loss of interest)

Minor depressive disorder

• Symptoms are present for 2 weeks for < 2 years.
• 2–4 diagnostic Clinical Features for depressive disorder (must include depressed mood or loss of interest)

SEIZURE DISORDER

• Seizure disorder is a neurological disorder caused due to abnormal brain activity. It is characterized by recurrent seizures, which are brief episodes of involuntary movement that may involve a part of the body (partial) or the entire body (generalized) and is sometimes accompanied by loss of consciousness and control of bowel or bladder function
• A seizure is an irregular electrical activity in the brain caused by the hyperexcitability of neurons, especially in cortical areas
• Individuals who experience a single seizure do not necessarily have epilepsy

Epilepsy: a chronic neurologic disorder characterized by any of the following:

• Two or more unprovoked seizures occurring more than 24 hours apart
• One unprovoked seizure and a probability of further seizures similar to the general recurrence risk after two unprovoked seizures, occurring over the next 10 years.
• Diagnosis of an epilepsy syndrome

Risk of experiencing at least one seizure up to the age of 75 (in the general population) is 3%

GENERALIZED ANXIETY DISORDER

• Anxiety can be conceptualized as a normal and adaptive response to a threat that prepares the organism for flight or fight
• It is normal to feel anxious from time to time. Ongoing anxiety and worry that are difficult to control and interfere with day to day activities may be a sign of GAD
• GAD is a mental disorder characterized by a feeling of worry, anxiety or fear that are strong enough to interfere with daily activities and can occur without any trigger. Worry is a pervasive human experience, often unrealistic and the individual may feel more than what it seems.
• The ratio of women to men is about 2: 1 and lifetime prevalence is 5- 10 per cent. Among anxiety disorder about 25% of the patients have GAD and it is the most common anxiety disorder among the elderly population

INSOMNIA

• Insomnia is also known as the Disorder of Initiation and/or maintenance of sleep
• Individuals with insomnia find it difficult to fall asleep or stay asleep. As a result, the person may get too little sleep or have poor-quality sleep, and may not feel refreshed on waking up
• Insomnia is a common symptom of other mental disorders such as affective, neurotic, organic, schizophrenia etc.
• Prolonged sleeplessness is often associated with substantial distress, impairment in day time functioning or both
• Reduction in perceived health and quality of life, increase in workplace injuries and absenteeism and even fatal injuries are all associated with chronic insomnia
• It is very common, with nearly 15-30% of the population complaining of a period of insomnia per year requiring treatment

INTELLECTUAL DISABILITY/ MENTAL RETARDATION

• It is defined as significantly subaverage general intellectual functioning associated with significant deficit or impairment in adaptive functioning, which manifests during the developmental period (below 18 years of age). A deficit in both general intellectual functioning and adaptive behaviour is seen in Mental Retardation Usually IQ below 70 is considered as MR.

Classification:

• Mild – IQ 50-70
• Moderate – IQ 35-50
• Severe – IQ 20-35
• Profound – IQ <20

MANIA

• Mania is a mood disorder characterised by abnormally elevated, expansive, or irritable mood and increased goal-directed behaviour not attributable to an organic psychic disorder or psychotropic substances
• The features should last at least 1 week, most of the day for at least 4 consecutive days and disrupt occupational and social activities
• This disorder tends to occur in episodes lasting usually 3-4 months followed by complete clinical recovery. A lesser degree of mania in which abnormalities of mood and behaviour are too persistent is called hypomania. Symptoms of mania are much more intense than those of hypomania, If psychotic symptoms are present, the episode is, by definition, manic and not hypomanic
• The lifetime risk of a manic episode is 0.8-1% and women have an increased risk of manic episodes

MILD COGNITIVE IMPAIRMENT

• Mild Cognitive Impairment (MCI) is defined as cognitive impairments beyond that expected for age and education of individuals, but which are not significant enough to interfere with their daily activities. MCI is often found to be a transitional stage between normal ageing and dementia
• The diagnostic criteria ICD says it as “a disorder characterized by impairment of memory, learning difficulties, and reduced ability to concentrate on a task for more than brief periods. There is often a marked feeling of mental fatigue when mental tasks are attempted, and new learning is found to be subjectively difficult even when objectively successful. None of these symptoms is so severe that a diagnosis of dementia can be made

OBSESSIVE COMPULSIVE DISORDER (OCD)

An obsession is defined as;

• An idea, impulse, or image which intrudes into the conscious awareness repeatedly.
• Patient tries to resist against it but is unable to
• Failure to resist leads to marked distress

An obsession is usually associated with compulsion. Compulsion is defined as

• A form of behaviour which usually follows obsessions.
• It is aimed at either preventing or neutralizing the distress or fear arising out of obsession.

OCD is characterized by persistent and recurring thoughts, urges or images that lead to repetitive behaviours or mental acts.

Lifetime prevalence is 2-3 % and the average age of onset is 20 years of age

SCHIZOPHRENIA

• The word schizophrenia means splitting of the mind. Schizophrenia is characterized by disturbances in thought and verbal behaviour, perception, affect, motor behaviour and relationship to the external world. Clear consciousness and intellectual capacity are usually maintained, although certain cognitive deficit may evolve.
• The disturbance involves the most basic functions that give the normal person a feeling of individuality, uniqueness, and self-direction. Schizophrenia is a severe psychiatric disorder characterized by chronic or recurrent psychosis.
• Majority of individuals initially experience symptoms in their 20s. Males and Females are equally affected

SCHOLASTIC BACKWARDNESS

• Scholastic backwardness is being increasingly identified as a major issue in children now a day. The child fails to perform in comparison to the average performance of the class

SUBSTANCE USE DISORDER

• Substance use disorder (SUD) also known as drug use disorder, is a condition in which the use of one or more psychoactive substances leads to clinically significant impairment or distress. Cannabis, nicotine (cigarette smoking), opium, hallucinogens like LSD, stimulants like amphetamine, anxiolytic drugs, inhalants (whitener, cough syrup, spray paint etc containing volatile solvents like toluene) are commonly abused substances other than alcohol.
• It is characterized by a craving for, the development of tolerance to, and difficulties in controlling the use of a particular substance or a set of substances, as well as withdrawal syndromes upon abrupt cessation of substance use.
• They act on the brain's reward system and affect emotion, mood, and perception thereby producing what is colloquially referred to as a “high.”
• Alcohol and nicotine use is the most common substance used

ANTE NATAL - VOMITTING IN PREGNANCY

• Vomiting in pregnancy can manifest as an outcome of pregnancy or as an outcome of an underlying medical or surgical disorders. Nausea and vomiting in pregnancy, commonly known as morning sickness affects approximately 75-85 % of pregnant women. It is generally mild, self-limited condition, commonly encountered between 4^th and 7^th week of pregnancy, diminishing greatly in intensity by 14-16 weeks of pregnancy. Hyperemesis gravidarum is a syndrome defined as severe nausea and vomiting in early pregnancy associated with weight loss of more than 5% during early pregnancy.

ANTE NATAL - THREATENED ABORTION

• The process of abortion has started, but has not progressed towards completion is termed as threatened abortion. Here choriodecidual hemorrhage has commenced but has not progressed to the stage of irreversibility.

ANTE NATAL - INEVITABLE ABORTION

• The process of abortion has progressed to the stage or extent of irreversibility, hence so called.

ANTE NATAL - ANAEMIA IN PREGNANCY

• WHO defines anaemia as presence of haemoglobin of less than 11 gm/dL and haemocrit of less than 0.33gm/dL
• Centre of disease control (CDC) have defined anaemia as Hb levels below 11 gm/dL in the pregnant women in first and third trimester and less than 10.5 gm/dL in second trimester

ANTE NATAL - OEDEMA IN PREGNANCY

• Fluid present in the subcutaneous tissue is called oedema
• In pregnancy physiological pedal edema is very common around 24 weeks
• It resolves on its own without any treatment soon after delivery

ANTE NATAL - UTI IN PREGNANCY

• Bacteria is the most common cause
• Hormonal changes in pregnancy can alter the flora of urinary tract, and make women more likely to get infections

ANTE NATAL - VAGINAL DISCHARGE IN PREGNANCY

• Excessive vaginal discharge is common in pregnancy. Most pregnant women secrete sticky, white or pale-yellow mucous early in the first trimester and throughout their pregnancy
• Non pruritic, non-foul-smelling clear discharge is normal in pregnancy as said in first trimester
• Copious discharge with itching is infective and especially candidiasis

ANTE NATAL - HAEMORRHOIDS IN PREGNANCY

• Swollen veins in the anus and rectum are common during pregnancy, especially in the third trimester when the enlarged uterus exerts pressure on the veins
• Haemorrhoids can be painful and may also itch, or bleed, especially during or after bowel evacuation

ANTE NATAL - MINOR AILMENTS IN PREGNANCY

• Due to the physiological changes occurring in the body and due to the pressure effect of gravid uterus some symptoms are common in pregnancy. They include Back ache, Constipation, acidity, heart burn and leg cramps.

ERECTILE DYSFUNCTION

• Erectile dysfunction or impotentia coeundi is the inability to achieve or sustain an erection sufficient in rigidity or duration for sexual intercourse which is present for a minimum of 6 months 
• Affects 40 % of men older than 50 years exerting substantial effects on quality of life

PREMATURE EJACULATION

• Also referred to as rapid ejaculation
• Frequent sexual function disorder of men of all ages (prevalence of up to 30%) 
• May occur with erectile dysfunction

1MALE INFERTILITY - IN GENERAL

• Infertility is the inability of a sexually active, non- contracepting couple to achieve spontaneous pregnancy in one year
• An estimated 15% of couples meet this criterion and are considered infertile, with approximately 35% due to female factors alone, 30% due to male factors alone, 20% due to a combination of female and malefactors, and 15% unexplained

SEMINAL ABNORMALITIES

• The commonest cause of impaired male fertility is the defective or absent spermatogenesis
• The impairment may be in any one of the parameters like density, motility, or morphology of the spermatozoa

Reference range for semen characteristics:

• Semen volume 1.5- 5 ml
• Colour white, Opalescent
• Liquefaction in 30 minutes
• Total sperm count >39 million per ejaculate
• Sperm concentration >15 million per ml
• Total motility >40 %
• Progressive motility >32 %
• Vitality >58 %
• Morphology (normal forms) 4 %
• pH 7.2 – 8.0
• Leucocytes >1 million per ml
• Seminal zinc >2.4 µmol per ejaculate
• Seminal Fructose >13 µmol per ejaculate

VARICOCELE

• Varicocele is an abnormal enlargement and tortuosity of the pampiniform plexus in the scrotum due to proximal obstruction of the spermatic vein
• Usually left-sided since the left testicular vein is longer and drains into the left renal vein at a right angle without an anti-reflux valve at the junction, leading to a poor outflow of blood and an increased reflux
• Varicoceles are a common cause of low sperm production and decreased sperm quality, which can cause infertility. However, not all varicoceles affect sperm production. Varicoceles can also cause failure of testicles to develop normally or shrink

HYPOTHALAMIC AMENORRHOEA

• Amenorrhoea due to hypothalamic dysfunction. Women under constant stress performing strenuous exercise develop amenorrhoea due to a decrease in GnRH pulse frequency with elevation in endogenous opioids and corticotrophin release hormone (CRH)
• Menstruation become irregular when BMI is < 19 kg/mm2

ACNE VULGARIS

• Acne vulgaris is a self-limited disease seen frequently in adolescents and primarily involves the sebaceous follicles. The hallmark of acne is comedones, which can develop further into inflammatory papules, pustules or even abscesses and nodules. As a sequelae to active lesions –pitted or hypertrophic scars will be formed
• Symptoms typically begin in early puberty and cease spontaneously during the third decade of life

ALOPECIA

• Alopecia is the loss of hair from any hair-bearing area of the body, but most often the scalp. It may be diffuse or patch, scarring or non scarring.
• Androgenetic alopecia, a type of diffuse, nonscarring, acquired alopecia, is the most common, affecting > 70% of the general population by 70 years of age. Alopecia areata, an acquired, circumscribed, nonscarring alopecia, is the next most common type

ASTEATOTIC ECZEMA

• It is also called as Eczema craquele, winter eczema, Dermatitis Sicca . It is often found in elderly people, though it is not uncommon for people in their 20s. Seasonality is prominent and most people develop symptoms in winter months
• Many people who develop asteatotic eczema in old age will have a dry skin and a tendency to chap

ATOPIC DERMATITIS

• Atopic Dermatitis is a common chronic or relapsing dermatitis characterized by severe pruritis, occurring primarily in infants and children. The age of onset is between 2 and 6 months in majority of the cases, but it may start at any age, even before the age of 2 months in some cases.
• Although it often improved during adolescence, it may also become a chronic condition that extends into adulthood. Atopic dermatitis is often associated with atopic diseases such as asthma or allergic rhinitis

CANDIDIASIS

• Candidia albicans is the most common causative agent. This yeast like fungus is normally found on the mucous membrane, skin, in the gastro intestinal tract and in the vagina. Under certain circumstances, it changes from a commensal organism to a pathogen. More widespread and systemic infections may occur in immune compromised individuals with the oesophagus most commonly affected

CELLULITIS

• It is the infection of skin and subcutaneous tissue characterized by pain, swelling, and redness. The borders are usually ill defined

CONTACT DERMATITIS

• Contact Dermatitis is an inflammatory skin reaction involving the epidermis and dermis that is caused by exposure to allergenic or irritating substances in the environment. The acute form is characterized by erythema, oedema, vesiculation, and pruritus, while the chronic form may exhibit xerosis, lichenification, and hyperkeratosis
• It is sometimes referred to as "Occupational Dermatitis," as it is very common in occupations where individuals come into frequent contact with irritants and allergens.

DERMATOPHYTE INFECTIONS (TINEA, RING WORM)

• Dermatophyte infections also known as Tinea are the most common fungal infections of the Skin, hair and Nails. Dermatophyte refers to Fungus that infects Keratinized tissue. Tineas are classified based on their location.
• Children and immune compromised individuals are more likely to contract tinea infections. However people of any age may suffer. The clinical Features of dermatophyte infection includes pruritis, scaling and erythema.

HERPES ZOSTER (SHINGLES)

• Shingles refers to the segmental arrangement of the eruption. Shingles (herpes zoster) is a dermatomal rash with painful blistering that is caused by the reactivation of the varicella-zoster virus
• The initial infection usually occurs early in life, presenting as chickenpox (varicella), after which the virus remains dormant in the dorsal root ganglia. It gets reactivated after many years and the virus replicates in the dorsal root ganglia and travels through peripheral sensory nerves to the skin and causes shingles

ICHTHYOSIS

• Icthyosis (from greek- meaning fish) denotes a group of hereditary and acquired disorders of keratinisation characterized by the development of dry rectangular scales
• They are associated with various diseases, but may also be idiopathic. Ichthyosis vulgaris is the most common type, followed by X-linked ichthyosis

IMPETIGO

• Impetigo is an infectious disease caused by the bacteria Staphylococcus aureus or, less commonly, Streptococcus pyogenes
• It causes honey-coloured, crusted lesions with surrounding erythema and typically affects the face, but may also manifest on the extremities
• Impetigo is the most common bacterial skin infection among children

INSECT BITES

• Possibility of Insect bite should be considered in all cases of pruritic dermatoses. Presence of wheals or papules, linear or irregular grouping, asymmetrical distribution, localisation to areas accessible to insects is characteristic.
• Chronic recurrent eruption of irritable urticated papules, occurring in patients with an acquired sensitivity to insect bites is called papular urticaria(Lichen urticatus). Lesions tend to have a characteristic distribution and configuration. Mosquitoes, bed bugs and fleas are the important causes of popular urticaria. A number of dipterous flies and mites also produce it.

LICHEN PLANUS

• Lichen planus is a sub-acute or chronic dermatosis that involve skin, mucous membranes, hair follicles and nails. At least two third of cases occur between the ages of 30 and 60 years
• The four P’s – Purple, Polygonal, Pruritic , Papule is the abbreviation used to recall the constellation of symptoms and skin findings that characterize lichen planus. The disease has a predilection for the flexor surfaces of the forearm, legs, trunk and the genitalia including the glans penis

LICHEN SIMPLEX CHRONICUS (NEURODERMATITIS)

• Lichen simplex chronicus is characterized by lichenified plaque lesion or lesions due to repeated rubbing or scratching as a habit or due to Stress
• It may occur without a predisposing dermatosis, or may follow any pruriginous dermatosis. The term Lichen Simplex is used when there is no predisposing dermatosis
• It is common in Indian subcontinent amongst adults (30 -50 years)

MOLLUSCUM CONTAGIOSUM

• Molluscum contagiosum is a common localized skin infection caused by the molluscum contagiosum virus(MCV 1 to 4 and their variants) that often occurs on the trunk, face and genitalia
• It mainly affects children, sexually active adults and persons with impaired cellular immunity
• Individual lesions are smooth surfaced , firm, dome shaped pearly papules. A central umbilication is characteristic

NUMMULAR ECZEMA ( DISCOID ECZEMA)

• The word nummular means (latin – nummulus) coin like. It is a chronic inflammatory skin condition characterized by well demarcated round lesions.

PITYRIASIS ALBA

• Pityriasis alba is a common disorder in children that is characterized by an asymptomatic, hypo pigmented, slightly elevated, fine, scaling plaque with indistinct borders
• It usually disappears by adulthood
• The condition commonly affects the face
• It is more common in children with atopic dermatitis

PITYRIASIS ROSEA

• Pityriais rosea is a self limiting eruption seen predominantly in adolescents and young adults. Majority of patients present with a solitary, coin sized herald patch, followed by multiple, oval, scaly papules distributed in a classic Christmas tree pattern on the trunk

TINEA VERSICOLOR (PITYRIASIS VERSICOLOR)

• The term versicolor refers to the presence of both hyper and hypo pigmented lesions. It is a superficial skin infection that occurs most often in young adults during hot and humid weather caused by Malassezia globosa and malassezia furfur
• The infection is characterized by finely scaling hypo pigmented or hyper pigmented macules on the trunk and /or chest. Tinea versicolor despite its name , is not caused by Dermatophytes

PRURITIS

• It is defined as that unpleasant sensation which produces the desire to scratch. Pruritis may be generalized or localized, acute or chronic. Certain areas of the skin particularly susceptible to pruritis are ear canals, perianal and genital areas, eyelids etc.

PSORIASIS

• Psoriasis is a common chronic disfiguring, inflammatory and proliferative epidermal skin disorder mediated by T cells and affecting individuals with underlying genetic predisposition. The time required for psoriatic epidermal cell to travel from the basal cell layer to the surface and be cast off is 3 to 4 days, in marked contrast to the normal of 26 to 28 days
• The typical lesions are sharply demarcated, erythematous, scaly, pruritic plaques which occur most often on the extensor surface of knees and elbows but may also affect the scalp and back

SCABIES

• Scabies is a parasitic skin infestation caused by the Sarcoptes scabiei var. hominis (S. scabiei) mite, which is primarily transmitted via close personal contact, but may be transmitted through clothing or towels
• The female scabies mite burrows into the stratum corneum, causing severe pruritus, particularly at night. Primary lesions commonly include erythematous papules, vesicles, or burrows

SCORPION STING

• Nearly 1000 species of scorpions are known worldwide, which belong to six families. Around 86 species are found in India. Scorpion belonging to Buthidae family is toxic to humans.
• Mesobuthus tamulus Indian red & Black scorpions is the most lethal among all the poisonous species of scorpions
• Scorpion venom: multiple toxins may be present in the venom of a single species of scorpion which is capable of producing potent synergistic effects. Neurotoxin of some scorpion is estimated to be 10 folds more potent than cyanide

SNAKE BITE

• Snake bites injure, or disable hundreds of thousands of people and kill close to 46000 Indians each year. The three major families of venomous snakes are the Elapidae, the viperidae and the hydrophidae
• The big four highly venomous snakes in India are common or spectacled cobra, Russell’s viper, Saw scaled viper and common krait. Other medically important poisonous snakes are banded krait, hump nosed viper, king cobra and sea snake
• Snake venom is a cock tail of enzymes, polypeptides, glycoproteins and compounds of low molecular weight. More than 90% snake venom is protein. Snake venoms are predominantly neurotoxic ( Cobras and kraits) or haemotoxic (Vipers)

SPIDER BITE

• Nearly 35000 species of spiders have been identified worldwide. Several species of spiders bite man accidentally. A few are poisonous and aggressive. The venom is generally neurotoxic, sometimes also haemolytic
• The bite is followed by intense local pain and the part becomes tender ad spastic. Generalised muscular rigidity especially marked over the abdomen, papillary constriction, salivation, excessive sweating and cardiovascular collapse may follow. Spiders of the genus loxoscelles seen in the tropical regions of several countries cause necrotic ulcers at the site of bite. Black widow spider and the brown recluse spider are the most poisonous

STASIS DERMATITIS

• Stasis dermatitis occurs as a result of venous stasis on the lower portions of the legs. It is more common in people who are 50 or older and is also called as venous eczema. People with stasis dermatitis usually experience swollen legs and feet, open sores, or itchy and reddish skin

URTICARIA

• Urticaria is a dermal vascular reaction of the skin characterized by the appearance of itchy wheals, which are elevated pale or erythematous transient evanescent plaque lesions. The lesions usually do not last beyond 24 hours. Wheals itch, and the intensity of itch varies. A similar process may occur at mucosal surface of the upper respiratory tract or gastro intestinal tract
• Angioedema is closely related to urticaria and is characterized by deeper oedema of both dermis and subcutaneous fat

VITILIGO

• Vitiligo is defined as a common dermatological disorder characterized by well circumscribed, milky white cutaneous macules devoid of identifiable melanocytes. The clinical course is highly variable, with unilateral or bilateral distribution which may progress during the course of the disease. The term vitiligo is derived from the latin word “vitium” (Blemish). It may occur at any age but the peak age at onset is 30 to 50 years

HUMAN PAPILLOMA VIRUS INFECTION (WARTS)

• Warts or Verrucae are benign proliferations of the skin and mucosa that result from infection with papilloma virus. These viruses do not produce acute signs or symptoms but induce slow growing lesions that can remain subclinical for long periods of time
• Warts is a hyperkeratosis and hyperplasia of epidermis commonly caused by human papillomavirus (HPV)

CHOLELITHIASIS

• Cholelithiasis refers to the presence of abnormal concretions (gallstones) in the gallbladder. Gallstones are essentially of three types: Cholesterol stones (80%), Pigment stones (20%) and rare stones (1%)
• Patient with cholelithiasis become symptomatic due to inflammation or obstruction caused by the stones. Cholelithiasis can manifest with biliary colic (postprandial right upper quadrant pain) but is most commonly an incidental finding in asymptomatic individuals

CHRONIC OBSTRUCTIVE PULMONARY DISEASE

• Chronic obstructive pulmonary disease (COPD) is a lung disease characterized by persistent respiratory symptoms and airflow limitation that is due to airway and/ or alveolar abnormalities usually caused by significant exposure to noxious particles or gases
• COPD begins with chronic airway inflammation that usually progresses to emphysema, a condition that is characterized by irreversible bronchial narrowing and alveolar hyperinflation. These changes cause a loss of diffusion area, which can lead to inadequate oxygen absorption and CO₂ release, resulting in hypoxia and hypercapnia
• Most affected individuals present with a combination of dyspnoea and chronic cough with expectoration. In later stages, COPD may manifest with more severe symptoms such as tachypnea, tachycardia, and cyanosis

CROHN’S DISEASE

• Crohn’s disease (CD) is an inflammatory bowel disease (IBD), in which inflammation is transmural and may involve any or all segments of the gastrointestinal tract
• CD mostly affects young adults and adolescents between the ages of 15 and 35. It typically affects the terminal ileum, but can discontinuously affect the entire gastrointestinal tract and commonly leads to complications such as fistulas, abscesses, and stenosis

FIBROMYALGIA

• Fibromyalgia (FM) is a clinical syndrome characterised by persistent, diffuse pain in the body. This is typically described by the patient as “pain all over the body” including joints, muscles and spine. However there is no clinical discernible evidence of inflammation at any of these sites and therefore, this condition is classified as a soft tissue rheumatism
• More commonly seen in young or middle aged women and the pain is accompanied by a number of other symptoms including fatigue, depressed mood, sleep disturbance, headache and social isolation

NEPHROLITHIASIS

• Nephrolithiasis generally refers to stones within the renal tubules or colleting system. Stones can however be seen in various sites of the urinary tract like renal parenchyma, ureters, bladder and urethra
• Urine stones are most commonly composed of calcium oxalates. Less common stones are made up of uric acid, struvite (due to infection with urease-producing bacteria), calcium phosphate, or cystine
• While nephrolithiasis can be asymptomatic, they occasionally present with excruciating pain and can even be cause of renal failure. Nephrolithiasis manifests as sudden onset colicky flank pain that may radiate to the groin, testes, or labia (renal/ureteric colic) and is usually associated with haematuria

URINARY TRACT INFECTIONS

• Urinary tract infections (UTIs) are infections of the urinary tract system (bladder, urethra, kidneys) that are generally caused by bacteria, especially E. coli. UTIs are the most common bacterial infections
• UTI can vary from asymptomatic colonisation, through self limiting, unpleasant lower tract infection to life threatening sepsis. Women are at high risk of contracting UTIs due to a shorter urethra and the proximity of the anal and genital regions
• Clinical findings depend on which part of the urinary tract is affected. Lower UTIs manifest with dysuria, supra pubic pain, urinary urgency, and increased urinary frequency, whereas upper UTIs additionally manifest with fever and flank pain.

CATARACT

• A condition in which the normally clear lens of the eyes become opaque, which results in decreased or blurry vision
• The word ‘cataract' has been derived from the Greek word 'katarraktes’ which means waterfall’
• Patients( usually between 50- 70 years) frequently complain of Web-like appearance, blurry vision, sensitivity to light and glare, Increasing difficulty with vision at night, Double vision, and haloes from lights should be suspected as cataract cases

CLASSIFICATION

Etiological classification

• Congenital and developmental cataract
  • Acquired cataract
  • Senile cataract
  • Traumatic cataract 
  • Complicated cataract
  • Metabolic cataract
  • Electric cataract
  • Radiational cataract
  • Toxic cataract
  • Cataract associated with skin diseases (Dermatogenic cataract)
  • Cataract associated with osseous diseases
  • Cataract with miscellaneous syndromes

Morphological classification 

• Capsular cataract. It involves the capsule and maybe
  • Anterior capsular cataract
  • Posterior capsular cataract
• Subcapsular cataract. It involves the superficial part of the cortex (just below the capsule)and includes
  • Anterior subcapsular cataract
  • Posterior subcapsular cataract
• Cortical cataract. - involves the major part of the cortex
• Supranuclear cataract. - involves only the deeper parts of the cortex (just outside the nucleus)
• Nuclear cataract. - involves the nucleus of the crystalline lens
• Polar cataract. - involves the capsule and superficial part of the cortex in the polar region only and may be:
  • Anterior polar cataract
  • Posterior polar cataract

Congenital and developmental cataracts

• Congenital and developmental cataracts occur due to some disturbance in the normal growth of the lens. When the disturbance occurs before birth, the child is born with a congenital cataract. Therefore, in congenital cataract, the opacity is limited to either embryonic or foetal nucleus
• A developmental cataract may occur from infancy to adolescence. Therefore, such opacities may involve infantile or adult nucleus, deeper parts of cortex or capsule.

Acquired cataract

• In acquired cataract, opacification occurs due to degeneration of the already formed normal fibres

Age-related cataract

• Is the commonest type affecting either sex usually above the age of 50 years
• Usually bilateral, but almost always one eye is affected earlier than the other

Morphologically, the senile cataract occurs in two Forms

• Cortical (soft cataract) 
• Nuclear (hard cataract)

The cortical senile cataract may start as 

• Cuneiform (more commonly)
• Cupuliform—Posterior Sub Capsular (PSC) cataract

Stages of Maturation

Maturation of the cortical type of senile cataract

• Stage of lamellar separation- The earliest senile change is the demarcation of cortical fibres owing to their separation by fluid. This can be demonstrated by slit-lamp examination only. These changes are reversible
• Stage of incipient cataract - In this stage, early detectable opacities with clear areas between them are seen. Two distinct types
• Cuneiform senile cortical cataract - wedge-shaped opacities with clear areas in between
• Cupuliform senile cortical cataract - saucer-shaped opacity develops just below the capsule
• Immature senile cataract (ISC) - Opacification progresses further. The lens appears greyish white but clear cortex is still present and so iris shadow is visible. In some patients, at this stage, the lens may become swollen due to continued hydration. This condition is called ‘intumescent cataract’
• Mature senile cataract (MSC) - Opacification becomes complete, i.e. the whole of the cortex is involved. The lens becomes pearly white in colour 
• Hyper mature senile cataract (HMSC)-  May occur in any of the two forms
• Morgagnian hypermature cataract
• Sclerotic type hyper mature cataract

MALE ACCESSORY GLAND INFECTION (MAGI)

• Male accessory gland infection (MAGI) also known as Male accessory gland inflammation has been identified among those diagnostic categories which have a negative impact on the reproductive function and fertility in males
• MAGI is a hypernym that groups the following different clinical categories viz. prostatitis, prostate‐vesiculitis, and prostate‐vesiculo‐epididymitis
• It is a condition with signs of inflammation involving one or more site in the male genital tract

Classification

• Uncomplicated form - including prostatitis
• Complicated forms, which encounter the inflammatory involvement of both prostate and seminal vesicles (prostate‐vesiculitis)
• The involvement of all three glands (PVE)

ANAL ABSCESS

• Anal abscesses are the acute manifestation of a purulent infection in the perirectal area. It is a pus filled cavity that most commonly develops from an infected anal crypt gland following obstruction and bacterial overgrowth
• An anorectal abscess may heal spontaneously following drainage into the anal canal. In 40-50% cases, it progress into fistula
• Patients complain of painful swelling around the anus associated with discharge of pus occasionally and the pain increase on continuous sitting or during defecation

CERVICAL SPONDYLOSIS

• Cervical spondylosis is a general term for age-related wear and tear in the cervical spine that can lead to neck pain, neck stiffness and radicular symptoms
• It occurs most commonly in the lowest three cervical intervertebral joints (commonest is at C5-C6)
• This degenerative condition of the cervical spine is usually found in persons over 50 years of age
• Intervertebral disc loses hydration and elasticity with age leading to cracks and fissures. This causes increased mechanical stress at cartilaginous end plates at the vertebral body lip. Sub periosteal bone formation occurs and this causes spinal canal diameter reduction resulting in radiculopathy

SEBORRHEIC DERMATITIS

• Seborrheic dermatitis(SD) is a chronic inflammatory skin condition that affects areas with high sebaceous activity. The condition is characterized by intermittent flares with intervening asymptomatic periods. The patient may exhibit either an erythematous, patchy scaling or greasy yellow crusts, both of which could be associated with burning or itching
• Seborrheic dermatitis has two age peaks, one in infancy within the first three months of life and the second around the second to the third decade of life. Men are affected more often than women in all age groups