Dr Muhammad Sajjad

Dr Muhammad Sajjad Welcome to Dr Muhammad Sajjad’s Medical Case Forum
Daily real-life medical cases, clinical insights, and practical management tips.

This page aims to educate, guide, and create awareness for patients, students, and healthcare professionals.

Testicular Sonographic Signs 1️⃣ Normal Te**is 🟢🔹 Size: 4–5 × 2–3 × 2–3 cm🔹 Volume: 15–25 mL (≥12 mL)🔹 Echotexture: Homo...
05/01/2026

Testicular Sonographic Signs

1️⃣ Normal Te**is 🟢
🔹 Size: 4–5 × 2–3 × 2–3 cm
🔹 Volume: 15–25 mL (≥12 mL)
🔹 Echotexture: Homogeneous, medium-level
🔹 Doppler: Symmetric vascularity
➡ Indicative of: Normal te**is ✅

2️⃣ Testicular Cyst 💧
🔹 Well-defined, round/oval anechoic lesion
🔹 Thin wall with posterior acoustic enhancement
🔹 No internal vascularity 🚫🩸
➡ Indicative of: Benign intratesticular cyst

3️⃣ Rete Te**is (Tubular Ectasia) 🧬
🔹 Multiple tiny anechoic tubular cysts
🔹 Located at mediastinum te**is
🔹 No Doppler flow 🚫
➡ Indicative of: Benign rete te**is ectasia

4️⃣ Epididymal Cyst 💧
🔹 Anechoic, well-defined cyst in epididymis
🔹 Posterior acoustic enhancement
➡ Indicative of: Benign epididymal cyst

5️⃣ Spermatocele 🧫
🔹 Cystic lesion with internal low-level echoes
🔹 Arises from epididymal head
➡ Indicative of: Spermatocele

6️⃣ Hydrocele 🌊
🔹 Anechoic fluid surrounding te**is
🔹 Te**is appears floating ⚓
➡ Indicative of: Hydrocele

7️⃣ Epididymo-Orchitis 🔥
🔹 Enlarged, hypoechoic te**is and epididymis
🔹 Marked hypervascularity on Color Doppler 🔴🔵
➡ Indicative of: Infection / inflammation

8️⃣ Funiculitis 🧵
🔹 Thickened, hyperechoic spermatic cord
🔹 Increased Doppler flow 📈
➡ Indicative of: Spermatic cord inflammation

9️⃣ Testicular Torsion 🚨
🔹 Enlarged, hypoechoic te**is
🔹 Absent / reduced intratesticular flow 🚫🩸
➡ Indicative of: Acute testicular torsion

🔟 Whirlpool Sign 🌪️
🔹 Twisted, spiral appearance of spermatic cord
➡ Indicative of: Spermatic cord torsion
⭐ Pathognomonic sign

1️⃣1️⃣ Varicocele 🪱
🔹 Dilated pampiniform veins >2–3 mm
🔹 Venous reflux on Valsalva 🔄
➡ Indicative of: Varicocele

1️⃣2️⃣ Testicular Tumor 🎯
🔹 Solid, hypoechoic intratesticular mass
🔹 Internal vascularity present 🩸
➡ Indicative of: Testicular malignancy

1️⃣3️⃣ Microlithiasis ✨
🔹 Multiple tiny echogenic foci
🔹 No acoustic shadow 🚫
➡ Indicative of: Testicular microlithiasis

1️⃣4️⃣ Hematoma 🩸
🔹 Heterogeneous hypoechoic lesion
🔹 No internal vascularity 🚫
➡ Indicative of: Testicular trauma

1️⃣5️⃣ Testicular Rupture 💥
🔹 Disrupted tunica albuginea
🔹 Irregular testicular contour
➡ Indicative of: Testicular rupture

Your understanding of why Normal Saline (NS) is typically used for vomiting and Ringer's Lactate (RL) for diarrhea is co...
03/01/2026

Your understanding of why Normal Saline (NS) is typically used for vomiting and Ringer's Lactate (RL) for diarrhea is correct. This choice is based on the different types of fluid, acid, and electrolyte loss each condition causes .

Here's the breakdown of the reasoning in English, along with key practical considerations.

🔬 Understanding the Logic Behind the Choice

The strategy aims to both replace lost fluids and correct the resulting chemical imbalance in the blood.

In Case of Vomiting:

· Main Losses: Stomach acid (hydrochloric acid, HCl), chloride (Cl⁻), and water .
· Imbalance Created: Metabolic Alkalosis. Losing stomach acid makes the body's pH more alkaline.
· Why Normal Saline (0.9% NaCl) is Preferred: It is rich in chloride ions (Cl⁻). Providing this chloride helps the kidneys excrete excess bicarbonate and correct the alkalosis. It effectively acts as a "chloride replacement solution" to treat the underlying acid-base disorder .

In Case of Diarrhea:

· Main Losses: Intestinal and pancreatic fluids rich in bicarbonate (HCO₃⁻), sodium (Na⁺), potassium (K⁺), and water .
· Imbalance Created: Metabolic Acidosis. Losing bicarbonate makes the body's pH more acidic.
· Why Ringer's Lactate is Preferred: Its composition more closely mimics the fluid lost from the gut. Importantly, it contains lactate. In the liver, lactate is metabolized into bicarbonate, which directly helps correct the acidosis .

To make it easy to compare, here are the key details:

For Vomiting

· Preferred Fluid: Normal Saline (0.9% NaCl)
· Primary Loss: HCl, Chloride (Cl⁻), Water
· Resulting Imbalance: Metabolic Alkalosis
· Mechanism: High chloride content helps kidneys correct alkalosis.

For Diarrhea

· Preferred Fluid: Ringer's Lactate (or similar balanced solution)
· Primary Loss: Bicarbonate (HCO₃⁻), Sodium, Potassium, Water
· Resulting Imbalance: Metabolic Acidosis
· Mechanism: Lactate is converted to bicarbonate, correcting acidosis.

⚠️ Important Practical Considerations

In real-world clinical practice, the choice is not always rigid and depends on several factors:

1. Severity and Route: For mild to moderate dehydration, Oral Rehydration Solution (ORS) is the first-line, safest, and most effective treatment for both vomiting and diarrhea, especially in children . Intravenous (IV) fluids like NS or RL are reserved for severe dehydration, shock, or when a patient cannot keep fluids down.
2. Clinical Context: The choice of IV fluid is adjusted based on the patient's overall condition. For example:
· Normal Saline is often used when blood products need to be administered, in cases of head injury, or with certain electrolyte imbalances like hyponatremia (low sodium) .
· Ringer's Lactate is commonly preferred for general fluid resuscitation (e.g., in sepsis, trauma, burns) because its composition is more "physiological" or balanced and is less likely to cause certain side effects than large volumes of Normal Saline .
3. Complications of Large Volumes: Giving very large amounts of any single IV fluid can have drawbacks. Excessive Normal Saline can cause hyperchloremic metabolic acidosis (too much chloride) and may affect kidney function . Ringer's Lactate contains potassium and calcium, so it may not be suitable for patients with kidney failure or certain metabolic conditions .

I hope this detailed explanation is helpful. If you would like to know more about how Oral Rehydration Therapy (ORT) works or the signs of dehydration, I can provide further information.

Approach to secondary HTNSecondary Hypertension:●Up to 35% of all hypertensive patients ●Up to 50% of resistant hyperten...
03/01/2026

Approach to secondary HTN
Secondary Hypertension:
●Up to 35% of all hypertensive patients
●Up to 50% of resistant hypertension
●Most common causes:
1. Primary Aldosteronism
( should be excluded in all adults with confirmed HTN ( class IIa)
2. Renovascular HTN
3. OSAS
obstructive sleep apnea syndrome

ESC guidelines

Here’s a clear, organized guide to first-line antihypertensive choices based on comorbidities. I’ll make it concise and ...
03/01/2026

Here’s a clear, organized guide to first-line antihypertensive choices based on comorbidities. I’ll make it concise and clinically practical:

1. Hypertension with Diabetes Mellitus
Drug of choice: ACE inhibitors (ACEi) or ARBs
Reason: Protect kidneys (reduce diabetic nephropathy progression)
Alternatives: CCBs or thiazide diuretics if ACEi/ARB not tolerated

2. Hypertension with Heart Failure (HFrEF, LVEF

Here is a clear, exam-oriented step-wise management of Hypertension, suitable for OPD practice, ward work, and viva.STEP...
03/01/2026

Here is a clear, exam-oriented step-wise management of Hypertension, suitable for OPD practice, ward work, and viva.
STEP 1: Confirm Diagnosis
BP ≥140/90 mmHg on ≥2 occasions (office)
OR HBPM ≥135/85, ABPM ≥130/80
Exclude white-coat hypertension
STEP 2: Initial Assessment (Baseline Workup)
History
Duration, symptoms, drugs (NSAIDs, OCPs), family history
Secondary causes (renal disease, endocrine)
Examination
BMI, waist circumference
Fundoscopy
CVS, renal bruits
Baseline Investigations
Urine R/E ± ACR
Serum creatinine, electrolytes
Fasting glucose / HbA1c
Lipid profile
ECG (LVH)
± Echo, renal USG if indicated
STEP 3: Lifestyle Modifications (For ALL patients)
🕒 Trial for 3 months if BP

02/01/2026

You might encounter this in MRCP Part 1 and Part 2.

Type 1 DM: Low insulin + low C-peptide
Type 2 DM (early): High/normal insulin + high/normal C-peptide
Type 2 DM (late): Declining C-peptide
Insulinoma: High insulin + high C-peptide
Exogenous insulin: High insulin + low C-peptide

Management of Ni**le Discharge (Clinical Approach – OPD & Exam-oriented)1️⃣ First step: Assess the dischargeAsk and exam...
02/01/2026

Management of Ni**le Discharge (Clinical Approach – OPD & Exam-oriented)

1️⃣ First step: Assess the discharge
Ask and examine for “red flag” features
History
Unilateral or bilateral
Single duct or multiple ducts
Color: milky, serous, green, purulent, bloody
Spontaneous or expressed
Associated lump, pain, fever
Drugs (antipsychotics, OCPs)
Pregnancy / lactation history
Examination
Breast & axilla
Identify duct of origin
Check for mass or skin changes

2️⃣ Categorize → then manage
A. Physiological discharge
Features
Bilateral
Multiple ducts
Milky / clear
Non-spontaneous
Management
Reassurance
Avoid ni**le squeezing
Review drugs
Pregnancy test if needed

B. Galactorrhea (milky, non-lactational)

Causes
Hyperprolactinemia
Hypothyroidism
Drugs (antipsychotics, metoclopramide)

Investigations
Serum prolactin
TSH
MRI pituitary (if prolactin ↑)

Treatment
Treat cause
Dopamine agonists:
Cabergoline / Bromocriptine

C. Infective discharge (mastitis / abscess)
Features
Purulent discharge
Pain, fever, redness

Management
Antibiotics (e.g. Flucloxacillin / Amoxiclav)
Analgesics
Drain abscess if present
Breastfeeding can continue (if lactational)

D. Duct ectasia
Features
Green / brown / sticky discharge
Perimenopausal women
Multiple ducts
Management
Reassurance
NSAIDs
Warm compresses
Surgery (microdochectomy) if persistent

E. Pathological discharge 🚩
Features
Unilateral
Single duct
Spontaneous
Bloody or serous
Likely causes
Intraductal papilloma
Breast carcinoma
Investigations
Breast ultrasound (40 yrs)
Duct excision biopsy
Management
Surgical referral
Excision of affected duct
Oncology referral if malignancy

3️⃣ Quick mnemonic (Viva)
“BLOOD is BAD”
Bloody
Localized (unilateral)
One duct
Ongoing spontaneous
Danger (malignancy)

4️⃣ When to refer urgently
Bloody discharge
Associated lump
Skin retraction
Axillary nodes
Male patient with ni**le discharge

Embryology
31/12/2025

Embryology

Histology
31/12/2025

Histology

ELECTRICAL INJURY IN CHILDREN :Injury caused by passage of electric current through the body, leading to thermal, cardia...
28/12/2025

ELECTRICAL INJURY IN CHILDREN :
Injury caused by passage of electric current through the body, leading to thermal, cardiac, neurological, and muscular damage.

COMMON SOURCES (Age-related)
• Infants/toddlers:
• Household sockets, exposed wires
• Electrical cords (oral burns)
• Older children/adolescents:
• High-voltage lines
• Lightning
• Industrial/railway accidents

⸻

TYPES OF ELECTRIC CURRENT

Type Features
Low voltage (1000 V) Power lines, industrial injuries
AC (Alternating current) Causes tetany → prolonged contact (more dangerous)
DC (Direct current) Single strong muscle contraction → throws victim away

⸻

PATHOPHYSIOLOGY (Key Effects)

1. Skin
• Entry & exit burns (may look small but deep damage)
• Charred or crater-like wounds

2. Cardiac ⚠️
• Arrhythmias (VT, VF, asystole)
• Myocardial injury
👉 Can occur even without severe burns

3. Neurological
• Seizures
• Loss of consciousness
• Peripheral neuropathy
• Delayed neuro deficits

4. Musculoskeletal
• Tetanic muscle contraction
• Fractures/dislocations
• Rhabdomyolysis → myoglobinuria

5. Respiratory
• Respiratory muscle paralysis
• Apnea (especially in infants)

6. Renal
• Acute kidney injury (secondary to myoglobin)

⸻

SPECIAL PEDIATRIC INJURY

⚠️ Oral Electrical Burns
• Common in toddlers chewing cords
• Leads to delayed labial artery bleeding (5–14 days later)
• Causes lip deformity if untreated

⸻

CLINICAL FEATURES
• Burns (entry/exit points)
• Loss of consciousness
• Arrhythmia
• Muscle pain, dark urine
• Seizures
• Respiratory distress

⸻

INVESTIGATIONS
• ECG (mandatory for all electrical injuries)
• Cardiac monitoring (24 hrs if high risk)
• CK levels (rhabdomyolysis)
• Urine for myoglobin
• Renal function tests
• Imaging if trauma suspected

⸻

MANAGEMENT (ABC APPROACH)

1️⃣ Immediate First Aid
• Ensure power source OFF
• Do NOT touch child directly if current active
• Call emergency services

⸻

2️⃣ Emergency Department Management

A – Airway
• Secure airway if unconscious
• Watch for airway edema (oral burns)

B – Breathing
• Oxygen
• Ventilatory support if apnea

C – Circulation
• IV access
• Treat shock
• Continuous cardiac monitoring

⸻

3️⃣ Burn Care
• Cool burns (not ice)
• Cover with sterile dressing
• Tetanus prophylaxis
• Surgical referral if deep burns

⸻

4️⃣ Cardiac Care
• ECG for all
• Admit if:
• Loss of consciousness
• Arrhythmia
• High-voltage exposure
• Chest pain

⸻

5️⃣ Prevent Renal Failure
• Aggressive IV fluids
• Maintain urine output
• Monitor CK & urine color

⸻

6️⃣ Specific Care
• Oral burns → plastic surgery + dental review
• Seizures → anticonvulsants
• Fractures → orthopedic care

⸻

INDICATIONS FOR ADMISSION
• High-voltage injury
• ECG abnormalities
• Loss of consciousness
• Significant burns
• Rhabdomyolysis
• Oral electrical burns

⸻

COMPLICATIONS
• Delayed arrhythmias
• Renal failure
• Neurological deficits
• Contractures
• Cosmetic deformities

⸻

PREVENTION (VERY IMPORTANT)
• Socket covers at home
• Avoid exposed wiring
• Supervision of toddlers
• Public education

⸻

EXAM PEARL ⭐

Small skin burns do NOT reflect severity — internal injury may be extensive.
Always do ECG in electrical injuries, even if child looks well.




Ultrasound Severity Grading of Pleural EffusionMeasurement PointThe maximum distance between the visceral pleura (lung s...
26/12/2025

Ultrasound Severity Grading of Pleural Effusion
Measurement Point

The maximum distance between the visceral pleura (lung surface) and the diaphragm/parietal pleura is typically measured in the posterior axillary or posterior basal scan.

Grading by Interpleural Distance

Mild / Small Effusion

< 2.0 cm separation
Estimated volume ≈ < 500 mL

Characteristics:
• Anechoic or thin stripe
• Seen only in dependent region
• Lung still closely apposed
• No compressive atelectasis

Think: “just a puddle, not a pond.”

🟡 Moderate Effusion

2.0 – 4.0 cm separation
Estimated volume ≈ 500 – 1000 mL

Common findings:
• Larger anechoic pocket
• Partial lung compression
• Sinusoid sign present
• Extends toward mid-axillary line

Clinically — this is the “hmm… probably needs tapping soon” zone.

🔴 Severe / Large Effusion

> 4.0 cm separation
Estimated volume ≈ > 1 L

Often shows:
• Significant lung collapse
• Floating / “jellyfish lung”
• Possible diaphragm inversion
• Reduced diaphragmatic excursion

Translation: big boy effusion, crowding the lung out.

Quick Volume Estimation Rule

(Posterior axillary view — supine/sitting)

Distance (cm) × 200 ≈ mL of effusion

Examples:
• 1.5 cm → ~300 mL (mild)
• 3.0 cm → ~600 mL (moderate)
• 5.0 cm → ~1000 mL (severe)

It’s not gospel — but clinically clutch. Ultrasonography for insights & DeepView

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Sheikh Umer
Kot Addu

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