Necrotic pulp

A 40 year male having multiple joint involvement, PIP ,wrist , right shoulder, knee joint He has presentation of migratory arthritis. On physical examination he has subcutaneous nodules (painless & non tender) on both forearm since 3 years. *On asking he said his R.A FACTOR was Negative* What should be the next line of investigations. & DDx ? *Chief Complaints* He is suffering from pain & tenderness in joints. Assymetric joint involvement. From last 3 years *History* No family history of arthritis *Physical Examination* Subcutaneous nodules painless non tender on forearms

F.55yrs. Diagnosis please.

12 year old boy c/o these lesions from past 3 months (appeared in winter 1st time) As per parents, these are not active lesions, earlier they were more erythematous and dry, when child scratches bleeding+ *History* On Elbow he has LICHEN NITIDIS I was suspecting him to be ATOPIC , on taking history, his brother's father (chacha) has ASTHAMA & his Maternal side also has ASTHAMA.

F.71 years. Shortness of breath 6 days.

Pedunculated subserous fibroid torsion *Chief Complaints* Abdominal pain with vomiting *History* 45 year old Para 2 previous 2 normal vaginal deliveries presented with sudden onset abdominal pain with two episodes of vomiting. Pain gradually increased in intensity. Patient had history of heaviness in lower abdomen for 3 months. No history of loss of weight or appetite. *Vitals* Pulse 100/ min. BP 116/90 mmHg. *Physical Examination* Per abdomen mass palpable around 16 weeks size of gravid uterus mobile from side to side. Tenderness present . Per vaginal examination uterus irregularly enlarged to 16 weeks. Tenderness present. *Investigations* Ultrasound done revealed fibroid 9*8 cm in uterus in fundal area. Free fluid in pelvis present. *Diagnosis* Fibroid uterus with acute abdomen. *Management* Patient taken for emergency laparotomy and proceed. OT findings :Fundal subserous pedunculated fibroid with torsion of two and half turns with intra fibroid hemorrhage and necrosis. Rest uterus normal. Bilateral ovaries and fallopian tubes normal. Peritoneal fluid hemorrhagic. Myomectomy done and peritoneal lavage given.