eMedici- surgery Flashcards
Nonpyogenic liver abscess Amebic liver abscess; Entamoeba histolytica
Hepatic echinococcosis (hydatid cyst of the liver) *
Pyogenic liver abscess- On CT- Atrial phase, double target sign- membranous portion and outer enhancement (odema)
16 year old male. Knee pain with activity, especially explosive jumping.No swelling of joint. No joint space tenderness. Pain on palpation of anterior tibia (below knee) , pain with resisted extension. Main DDx?
Main DDx? Traction apophocitis or Patella tendonitis. Both occur with repetitive, explosive exercises. Key difference: Traction apophocitis- below the knee, at quadriceps tibial tenderness. X-rays are diagnostic for traction apophysitis which would reveal anterior soft tissue swelling and fragmentations of the tubercle. Patella tendonitis- Normal x-ray. anterior knee pain at the inferior border of the patellar and pain with prolonged flexion
2.8 cm diameter solid lesion in the right kidney, incidental find. 84 yoa with co-morbs
This is almost certainly a renal cell carcinoma.Small (<3cm) incidental and asymptomatic lesions in patients over the age of 70 could be managed by active surveillance and left well alone if there is no observed change in size. This woman has some serious co-morbidities and therefore a plan of active surveillance would probably be the most appropriate strategy. Although there are no randomised clinical trials to support this approach, an analysis of the published literature supports this management strategy, showing that active surveillance is safe and feasible, particularly for the elderly and unwell patients. Furthermore, the possibility of developing metastasis from small renal masses is extremely low, supporting the role of active surveillance.A CT-guided biopsy is not indicated; it is unreliable and unable to differentiate between oncocytoma or chromophobe renal cell carcinoma.Partial and total nephrectomies are usually reserved for renal masses 4-7cm and >4cm respectively. Furthermore, they may be inappropriate given this patient’s age and comorbidities.Nivolumab is a programmed death-1 (PD-1) immune checkpoint inhibitor monoclonal antibody. It is a novel treatment for advanced and metastatic renal cell cancer; and would therefore not be appropriate for this case.Small (<3cm) incidental renal masses are best managed with active surveillance in elderly .
24 hour history of a swelling around his anus, associated with severe pain. This followed an episode of constipation and straining at stool. The lesion is shown (Image).
This patient has a prolapsed and thrombosed internal haemorrhoid. There is ulceration over one of the prolapsed haemorrhoids.Thrombosis is a serious complication of internal haemorrhoids. Patients with thrombosed or strangulated haemorrhoids present with severely painful and irreducible, incarcerated haemorrhoids, which may become necrotic. Acutely thrombosed internal haemorrhoids can be extremely painful and distressing. The most effective way of giving this patient rapid relief from his symptoms is to perform a semi-urgent haemorrhoidectomy. Unless the surrounding tissue is necrotic, mucosa and anoderm should be preserved to prevent post-operative anal stricture. If this was a perianal haematoma, then incision and evacuation of the haematoma would be appropriate.Learning PointsProlapsed and thrombosed haemorrhoids are best treated by prompt haemorrhoidectomy.
5th metatarsal- mid-shaft tenderness, not at base . What #?
Stress #- midshaft (diaphysis)Jones #- MetaphysisAvulsion # at base 5th
A 37-year-old man presents to his general practitioner with a three-month history of an intermittent and painless passage of blood per rectum. This occurs typically when he is constipated. He reports bouts of constipation alternating with normal bowel movements. He has noticed small amounts of blood streaked on the surface of the faeces. Sometimes mucus is present. He has never had these symptoms before. Digital rectal examination is unremarkable. Proctoscopy shows some fleshy haemorrhoids. His blood reports are shown below:Haemoglobin = 107 g/LMCV = 68 fLWBC = 9.1 x 109/LPlatelets = 220 x 109/L
Internal haemorrhoids. Blood streaking on the sides of faeces is typically seen in haemorrhoids. Internal haemorrhoids are usually painless while external haemorrhoids are usually painful. Although the haemorrhoids may well be the source of the bleeding - this should never be assumed until other - and potentially more serious - causes have been excluded. Patients with red flags need to undergo further investigations to exclude a potential colorectal carcinoma regardless of their age. Red flags that would indicate further investigation with colonoscopy or sigmoidoscopy in patients with rectal bleeding include:* Change in bowel habits (eg, change in calibre, frequency, and consistency of the stools)* Constitutional symptoms (eg, fever, weight loss, night sweats)* Iron deficiency anaemiaFamily history of colon cancerThis patient has change in bowel consistency and has low MCV (most likely due to iron deficiency anaemia), and could well have a carcinoma of the rectum and a thorough examination of the lower digestive tract must be undertaken - this means a colonoscopy or a flexible sigmoidoscopy. Such a diagnosis is very important to exclude - as colorectal malignancies are now being seen with increasing frequency in younger patients.High fibre diet, injection sclerotherapy, and rubber band ligation are all appropriate management options for haemorrhoids. However, this patient needs to undergo further investigations to rule out colorectal carcinoma.CT abdomen and pelvis may be appropriate for preoperative staging of colorectal cancer to determine the extent of the malignancy. Colonoscopy should be performed first, however, to confirm the diagnosis.Learning PointsColorectal malignancy is now being encountered in younger patients cohorts and this potential diagnosis must always be considered in a patient who presents with rectal bleeding.
A 66-year-old man presents to the Emergency Department with a four-hour history of sudden onset of severe pain in his right leg. His medical history includes atrial fibrillation, for which he takes apixaban. On examination his blood pressure is 142/84 mmHg and an irregular pulse 100/min. The right leg is pale, cool and no pulses can be felt below the femoral pulse. A CT angiogram show an obstruction at the femoro-popliteal junction. He is diagnosed with a Rutherford class IIa acute limb ischaemia. A heparin infusion is started.Which one of the following is the most appropriate next step in management- various interventions for ALI
ALI- need to decide if obstruction d/t embolus or thrombusThrombus- atherosclerosis etcTreated with - angioplasty endovascular ( short segment and aorto-illiac), endarectomy, bypassEmbolus- AF/recent MICatheter directed Thrombolysis with/ w/o embolectomy Bypass procedures might be preferred for thrombotic situations, but in this case with embolism, a catheter-directed line of approach should be considered first. Of course this will depend on the availability of an interventional radiologist. Input from haematology will be important, as the anticoagulation with apixaban will make the risk of intraprocedural bleeding high.Balloon angioplasty and endarterectomy are considered approaches for limb ischaemia caused by a thrombotic phenomenon.
ALI mx of each class
Acute limb ischaemia is often characterised by a sudden onset of these symptoms. A normal, pulsatile contralateral limb is a sensitive sign of an embolic occlusion.In the history, the causes of potential embolisation should be explored. These include chronic limb ischaemia, atrial fibrillation, recent MI (resulting in a mural thrombus), or a symptomatic AAA (ask about back/abdominal pain) and peripheral aneurysms.The later the patient presents to a hospital, the more likely that irreversible damage to the neuromuscular structures will have occurred (more common >6hrs post-symptom onset), which will ultimately result in a paralysed limb.CategoryPrognosisSensory LossMotor DeficitArterial DopplerVenous DopplerI – ViableNo Immediate threatNoneNoneAudibleAudibleIIA – Marginally ThreatenedSalvageable, if promptly treatedMinimal (toes) or noneNoneInaudibleAudibleIIB – Immediately ThreatenedSalvageable if immediately revascularisedMore than toes, rest painMild/ModerateInaudibleAudibleIII – IrreversibleMajor tissue loss, permanent nerve damage inevitableProfoundProfound, paralysisInaudibleInaudibleTable 1 – Clinical Categories of Acute Limb Ischemia, adapted from Rutherford et al., 2009
allergic rhinitis presents more with symptoms of
sneezing, rhinorrhoea, watery eyes, and if chronic patients may also complain of postnasal drip, chronic nasal congestion, and obstruction. It can be intermittent, with particular triggers or exposures.
Amebiasis
Entamoeba histolytica, a protozoanTransmissionFecal-oral* Amebic cysts are excreted in stool and can contaminate drinking water or foodInfection typically occurs following travel to endemic regionsIncubation and Clinical Features Intestinal amebiasis: 1–4 weeksExtraintestinal amebiasis: a few weeks to several yearsClinical coursesIntestinal amebiasis (Amebic dysentery)Loose stools with mucus and bright red bloodPainful defecation, tenesmus, abdominal painFever in 10–30%* High risk of recurrenceAlways consider amebiasis when a patient presents with persistent diarrhea after traveling to a tropical or subtropical destination!Extraintestinal amebiasis* Mostly acute onset of symptoms; subacute courses are rareIn 95% of cases: amebic liver abscess, usually a solitary abscess in the right lobeFever in 85–90%RUQ pain or pressure sensationDiarrhea precedes only a third of all cases of amebic liver abscesses.Intestinal amebiasisStool analysisMicroscopic identification of cysts or trophozoites in fresh stoolThe following tests confirm the microscopic findings (important since E. histolytica and Entamoeba dispar are morphologically identical ):EIA or coproantigen ELISAPCRStool microscopy is not sensitive; at least three stool samples should be examined before reporting a negative resultExtraintestinal amebiasisSerological antibody detectionAspiration of abscesses: shows brown fluid/pus (exudate resembles anchovy paste)In amebic hepatic abscessALP, AST, ALT, bilirubin slightly elevatedImaging: shows a solitary lesion, typically in the right lobe of the liverTreatmentMedical therapyAsymptomatic intestinal amebiasisIn nonendemic areasLuminal agents such as paromomycin, diloxanide, or iodoquinolSymptomatic intestinal amebiasis and invasive extraintestinal amebiasisInitial treatment with a nitroimidazole derivative such as metronidazole or tinidazoleFollowed by a luminal agent (e.g., paromomycin, diloxanide, or iodoquinol) to eradicate intestinal cysts and prevent relapseInvasive proceduresAspiration: of complicated liver abscesses at risk for perforationSurgical drainage: should generally be avoided
An ultrasound confirms the presence of gallstones. She is counselled to undergo a laparoscopic cholecystectomy.What is most suggestive that an ERCP should be undertaken prior to the cholecystectomy?
In the assessment of any patient with symptomatic gallstones, consideration must always be given to the chances of finding stones in the common bile duct (CBD), which occurs in 10-20% of patients. If stones in the common bile duct are identified on US, then further imaging is not usually required and these patients should proceed to ERCP pre-operatively for stone extraction or laparoscopic cholecystectomy with bile duct exploration (if surgical expertise permits). Studies have found these approaches to be equally valid. ie Stones visable- ERCP (less sensitive MRCP) will suffice. Patients who have deranged liver function tests (LFTs) with normal calibre biliary system, or CBD dilation with normal LFTs should either have further imaging with MRCP, or proceed to laparoscopic cholecystectomy with intraoperative cholangiogram (IOC) for ductal imaging. IE MRCP is more sensitive. Some moderate elevation of all serum liver enzymes can occur after episodes of biliary colic or acute cholecystitis. The finding of a common bile duct greater than 7mm might increase the probability of a stone in the duct - but this diameter can still be a normal finding in many individuals.
anterior knee pain that worsens with physical activity, involving knee extensions (jumping or lunges). Proximal tibial swelling involved as well. X-ray- anterior soft tissue swelling and fragmentations of the tubercle. Disease name
Traction apophysitis, also known as Osgood-Schlatter disease, is a tibial osteochondritis at the tibial insertion of the quadriceps tendon. It is thought to be due to the overuse of quadriceps muscle during growing teenagers or children. It is more common in boys than in girls. The overuse of the quadriceps, especially during physical activities involving jumping or sprinting, during ossification periods in a child may cause repeated avulsion of the patellar ligament on the tibial tuberosity. This results in inflammation or irritation at the apophysis.Clinical features involve * anterior knee pain that worsens with physical activity,* physical activity commonly involving knee extensions such as jumping or lunges.* There may be proximal tibial swelling involved as well.X-rays are diagnostic for traction apophysitis which would reveal: * anterior soft tissue swelling and fragmentations of the tubercle.Treatment involves non-operative management such as resting, ice and NSAIDs for pain relief. Cast and immobilisation for 6 weeks or ossicle excision may be necessary if there are severe symptoms involved. This disease may be self-limiting but may not resolve until bone growth has halted.
Bariatric surgery: types of procedures with specific C/I
Some general contraindications to consider for any bariatric surgery include * severe heart failure,* unstable heart disease,* end-stage lung disease,* cancer or liver disease and* drug/alcohol addiction/dependence.Additionally, the surgery requires general anaesthetic and hence the patient must be suitable for this. A contraindication to sleeve gastrectomy is gastro-oesophageal reflux disease (GORD), as this type of bariatric procedure can worsen the reflux and increase the risk of Barrett’s oesophagus. Sleeve gastrectomy is a procedure to remove a large portion of the stomach (around the greater curvature) to reduce the size of the stomach. As can be imagined with a reduced stomach capacity reflux worsens in these individuals as there is both less room in the stomach for acidic contents to go as well as reduced cells able to produce bicarbonate and other anti-reflux products.Roux-en-Y gastric bypass surgery involves reducing the size of the stomach to a small pouch and connecting this directly onto the small intestine. This procedure has been determined to be the most effective bariatric surgery in terms of both weight loss and improvement of reflux symptoms. Hence, if he were to undergo a type of bariatric surgery this would be the ideal procedure for him. Compared to sleeve gastrectomy which has been shown to worsen already existing disease and even increase the incidence of disease in previously unaffected individuals. Active renal calculi would be a factor in delaying elective surgery such as bariatric, but his history of renal calculus disease two years prior does not influence his suitability for the surgery now. Undergoing the surgery can place the body under stress and cause dehydration, which can precipitate stone formation, so this may be taken into consideration by the anaesthetist.Learning PointsGORD is a contraindication for a sleeve gastrectomyIn a patient with GORD Roux-en-Y gastric bypass is the best option for bariatric surgeryThe indications for bariatric surgery include a BMI >40 or BMI >35 + co-morbid conditions
Benign breast lessions
Fibrocystic changesInflammatory breast conditions* Mastitis* Breast abscess* Fat necrosis of the breast* Mammary duct ectasiaBenign breast neoplasms* Fibroadenoma- young women- mousy* Phyllodes tumor- 40-50. Varied growth U/S similar to Fibroad. Tx is to excise (benign, but Ca equivalent difficult to distinguish)Intraductal papilloma- 40-50 y/o, Intraductal papilloma is the most common cause of bloody nipple discharge. U/S, mamog; Core biopsie if palpable. Tx excison of duct. Lobular carcinoma in situ (LCIS)- malignant trans to invasive less than DCIS. ore biospy and Immunohist diff DCIS/LCIS. * Follow up imaging for LCISExcision for non classic LCIS Mastalgia - Cyclical and non cyclical
carcanoid tumour in removed appendix (<10mm and clear margins)
Appendiceal carcinoid tumours that are less than 10mm in size and with clear margins do not require any further follow up or investigations. Carcinoid or neuroendocrine tumours can be found incidentally in up to 2% of appendicectomy specimens. Small (<10mm) carcinoid tumours with clear margins that are found incidentally at the time of appendicectomy do not need any further treatment or follow-up.Urinary 5-hydroxyindoleacetic acid (5HIAA) is a serotonin metabolite which may be raised in patients with carcinoid tumours. However, this test should only be used in patients who are symptomatic and is not required especially as the tumour has been surgically removed. Serum chromogranin is a carcinoid tumour marker and is usually normal in patients with a tumour size of <2cm. It is not required for the follow up of this patient. CT abdomen is not required for this patient due to the tumour size (<10mm) and clear margins. A right hemicolectomy may be required for patients with more advanced tumours or residual disease.
choice of chemo prophalaxis in non orthopeadic surgery
Low molecular weight heparin is the agent of choice for VTE prophylaxis based on direct data showing efficacy in nonorthopaedic surgical populations. Unfractionated heparin is an alternative in patients with renal insufficiency. Oral agents such as apixaban have limited evidence in nonorthopaedic populations, Aspirin is an anti-platelet and is not indicated.
Clinical features of meniscal tearsTests for meniscal
Knee pain: exacerbated by weight‑bearing or physical activityJoint line tenderness (medial or lateral)Restricted knee extensionIntermittent joint effusionsMcMurray test [1]The patient lies in a supine position.The examiner holds the patient’s knee in one hand and palpates the joint spaces while holding their ankle in the other.The examiner brings the patient’s knee to maximal flexion.For medial meniscus tear, the examiner performs external rotation of the tibia and applies valgus stress while extending the knee.For lateral meniscus tear, the examiner performs internal rotation of the tibia and applies varus stress while extending the knee.Pain on palpationPalpable or audible pop/click with maneuvers
Clinical features to distinguish lesser and greater trochanteric #
A greater trochanter fracture is suggested by local pain exacerbated by abductionA lesser trochanter fracture presents with groin pain, which radiates to the knee or posterior thigh, and worsens with hip flexion and rotation
Clinical findings of osteoarthritis
Common clinical findings: Pain during or after exertion (e.g., at the end of the day) that is relieved with restPain in both complete flexion and extensionCrepitus on joint movementJoint stiffness and restricted range of motionMorning joint stiffness usually lasting < 30 minutesJoint-specific findings Heberden nodes; pain and nodular thickening on the dorsal sides of the distal interphalangeal jointsBouchard nodes: pain and nodular thickening on the dorsal sides of the proximal interphalangeal jointsHeberden and Bouchard nodesIn contrast to rheumatoid arthritis, osteoarthritis can affect the distal interphalangeal joints.
complication of pancreatitis- necrotising pancreatitis (. CT non enhancement with peri-pancreatic stranding). Unwell- fever signs of sepsis (bloods), When is the risk of infection of necrotic pancreatitis greatest? What investigation is appropriate to initiate?
Per-cutaneous aspiration, via FNA then culture and microscopy.This patient has developed a complication of acute pancreatitis - namely, pancreatic necrosis. This local complication puts this man in the category of moderately-severe acute pancreatitis. One-third of patients with necrotising pancreatitis will develop infection within the necrotic tissues. Typically such infection occurs 7-10 days after the onset of pancreatitis and this will manifest by the patient becoming unwell with fever and showing evidence of sepsis. If infection is present the patient will require antibiotic therapy, however percutaneous or endoscopic drainage risks introduction of infection into a sterile field. Therefore, needle aspiration is more prudent, with aspirate being sent for laboratory analysis and culture. If required, drain insertion can be US or CT guided. If the aspiration proves to be aseptic, then antibiotics are not required as use of antibiotics to prevent infection is not supported.If the culture is positive or his condition deteriorates then antibiotics may be initiated. Initial percutaneous drainage prevents the greater risk of complications associated with surgical debridement (necrosectomy), while maintaining the ability to step-up treatment if there is inadequate response. DDX Walled-off necrosisDefinitionAn encapsulated collection of sterile necrotic material, usually occurring > 4 weeks after the onset of necrotizing pancreatitis [5]Previously known as pancreatic abscessDiagnostics: CT abdomen with IV contrast showing an encapsulated heterogeneous collection containing fluid and debris [8]Treatment (of symptomatic walled-off necrosis): percutaneous drainage or transmural endoscopic necrosectomyNB pancreatic psuedocyst is a feature of acute and chronic pancreatitisNecrotizing pancreatitis [14]Definition: necrosis of pancreatic and peripancreatic tissueClinical features: fever, persistent tachycardia, or insufficient symptomatic improvement over several daysDiagnostics: nonenhancing areas of pancreatic parenchyma on CECT abdomen [8]Treatment [14]Sterile necrotizing pancreatitis can usually be managed conservatively. [6]Encourage enteral nutrition if feasible.* Provide supplemental nutritional support as needed. Infected necrotizing pancreatitis [14]Definition: bacterial superinfection of necrotic pancreatic parenchymaClinical features: similar to those of necrotizing pancreatitisDiagnosticsLaboratory studies: persistent or worsening leukocytosis, bacteremia, increasing inflammatory markers [14]CECT abdomen: gas within the pancreas and/or peripancreatic tissue or fluid collections [5]Fine-needle aspiration of necrotic areas: not routinely recommended [6][10]Treatment [14]Supportive care: fluid therapy, analgesics, nutritional supportBroad-spectrum empiric antibiotics with good tissue penetration (e.g., carbapenems ) for 4 weeks [14]Drainage of infected material if there is clinical deterioration or persistence of symptoms despite antibiotic therapyOperative pancreatic debridement (necrosectomy) should ideally be performed at least 2–4 weeks after initial presentation. [14]Minimally invasive procedures (e.g., image-guided percutaneous drainage) can be performed in the first 2 weeks in seriously ill patients.Prognosis: high mortality rate (30%) [14]
Contrast features of cyclical and non-cyclical Mastalgia. What is imaging and tx for each
Cyclical mastalgiaOften bilateral, diffuse breast painTypically, most severe in the upper outer quadrant of the breastsMay radiate to the medial aspect of the upper armUsually worsens the week prior to the onset of menstruationNoncyclical mastalgiaUnilateral or bilateral breast pain, usually located over the costal cartilages* Sharp or burning pain and/or sorenessDiagnostics* Medical history (e.g., hormone therapy, trauma, surgical history, risk factors for breast cancer)* Physical examination: focused breast examination* Look for signs of infection (e.g., erythema, swelling, pain)* Rule out signs suggestive of breast malignancy (e.g., skin changes, mass, nipple discharge)Imaging* Breast ultrasound and/or mammographyIndications: depend on the patient’s age and the presence of findings suggestive of malignancyWomen with cyclical breast pain usually do not require imaging.Women with noncyclical or focal breast pain that is not extramammary should undergo breast imaging.< 30 years of age: ultrasound* 30–39 years of age: ultrasound and/or mammography* ≥ 40 years of age: ultrasound and/mammographyTreatmentFirst-line treatment: conservativeProvide reassuranceRecommend well-fitting sports braUse of warm or cold compresses* Analgesia (e.g., acetaminophen, NSAIDs)Second-line treatment: for patients with persistent (> 6 months of conservative treatment) or severe symptoms* Tamoxifen* Postmenopausal hormone therapy should be decreased or discontinued if it is the cause of breast pain.
CT findings would be the strongest reason for admission to hospital?A 5 mm stone in the lower ureterA stone at the pelvi-ureteric junctionStranding around the right kidneyA pelvic kidneyMild hydronephrosis
Peri-renal stranding seen on CT suggests pyelonephritis.The finding of stranding around the kidney, in addition to a clinical picture of fever and renal angle tenderness, would support a diagnosis of pyelonephritis and the need for antibiotics and inpatient urological consultation for consideration of lithotripsy or stenting (the latter if the kidney appeared to be obstructed). Whilst a solitary kidney might well be an indication for inpatient treatment of nephrolithiasis, one situated in the pelvis should not influence management. Mild hydronephrosis alone is not necessarily an indication for inpatient treatment, but should be considered with other factors such as stone size, location, and other co-morbidities when deciding on a management plan.An uncomplicated 5mm stone is not an indication for inpatient treatment. If the stone does not pass spontaneously, the patient may be referred for an outpatient urological opinion. A stone at the pelviureteric junction (PUJ) is not an indication for inpatient treatment, unless it was causing obstruction. Depending on stone size and composition, many of these stones at this site (PUJ) may pass spontaneously and those that do not, may be treated on an outpatient basis.
ddx for new nuerology post anuerysmal SAH
differentials include complications of the haemorrhage, such as vasospasm (subsequently causing delayed cerebral ischaemia), hydrocephalus, re-bleeding, and seizure, as well as intercurrent problems such as hyponatraemia, sepsis, metabolic encephalopathy, and de novo ischaemic stroke. The non-localising features seen (confusion, reduced conscious level, headache) are common across these differentials, but the superimposed localising features (left-sided faciobrachial weakness) increase suspicion of a territorial vascular event. risk 3-14 days post anuerysmal SAH In this case, the most likely cause is delayed cerebral ischaemia.Re-bleeding is a catastrophic complication of untreated ruptured aneurysms that typically occurs early: a third within 3 hours, half within 6 hours. Overall, 15-20% re-bleed within 2 weeks. Hydrocephalus is detected on initial imaging in ~15-20% of SAH patients, caused by extravasated blood products interfering with CSF circulation. Only 3% of patients without hydrocephalus on initial imaging go on to develop it within the first week. Up to a quarter of SAH patients have seizures at onset, and a third have delayed seizures; non-convulsive status epilepticus occurs in 3-18%. De novo thromboembolic stroke would be quite coincidental and is unlikely (n.b. the next step of workup for this patient - a CT brain with angiography and perfusion maps - is the same scan used to investigate a potential stroke and would identify this anyway).
DDX for shoulder injuries
AC joint disruption would be more likely to present with obvious deformity of the acromioclavicular joint of the shoulder, usually following some form of traumatic event (e.g. direct trauma to the shoulder)Cervical radiculopathy often presents in older patients, who are at greater risk of osteoarthritic degenerative changes, which may subsequently cause foraminal stenosis and nerve root impingement. Furthermore, this condition often presents with paraesthesia or anaesthesia in C5-T1 dermatomal distributions, alongside weakness in accompanying myotomal movements.Bicepital tendonitis is more likely to present with tenderness over the long head of biceps brachii, alongside some potential swelling over the same area.Subacromial bursitis is perhaps the most reasonable differential for rotator cuff tear, however this would present with * a painful abduction arc, * and positive Neer’s (flexion to >90 degrees causing pain) and* Hawkin’s-Kennedy (internal rotation and flexion to 90 degrees causing pain) tests’.
ddx of groin mass
* Rectus sheath haematoma* Indirect inguinal hernia* Femoral hernia* Direct inguinal hernia* Saphena varixpatient on warfarin, a rectus sheath haematoma is a reasonable differential for an abdominal mass with pain. Other findings may include a history of trauma, haemodynamic instability and abdominal bruising. These haematomas are typically deep to the rectus abdominis muscle and do not extend into the groin.A saphena varix occurs due to dilation of of the saphenous vein at the saphenofemoral junction. This is may result in a palpable groin mass and will typically be associated with varicose veins elsewhere in the limb. These swellings are soft.Learning PointsIndirect inguinal hernias pass through the inguinal ring
84 year old with co-morbidities2.8 cm lesion on the right kidney was incidentally found. Her renal function is normal and there is no evidence of metastatic disease on further CT scanning
There is a 2.8 cm diameter solid lesion in the right kidney. This is almost certainly a renal cell carcinoma.Small (<3cm) incidental and asymptomatic lesions in patients over the age of 70 could be managed by active surveillance and left well alone if there is no observed change in size. This woman has some serious co-morbidities and therefore a plan of active surveillance would probably be the most appropriate strategy. Although there are no randomised clinical trials to support this approach, an analysis of the published literature supports this management strategy, showing that active surveillance is safe and feasible, particularly for the elderly and unwell patients. Furthermore, the possibility of developing metastasis from small renal masses is extremely low, supporting the role of active surveillance.Partial and total nephrectomies are usually reserved for renal masses 4-7cm and >4cm respectively. Furthermore, they may be inappropriate given this patient’s age and comorbidities.
Dermatomes of cerval spine- ie loss of sensation
difference between pancreatic psuedocyst vs walled off necrosis
Pancreatic pseudocysts Encapsulated collection of pancreatic fluid that develops 4 weeks after an acute attack of pancreatitis (can occur in both acute and chronic pancreatitis) [11]PathophysiologyPancreatic secretions leak from damaged ducts → inflammatory reaction of surrounding tissue → encapsulation of secretions by granulation tissueClinical features [26]* Often asymptomatic* Painless abdominal massPressure effectsGastric outlet obstruction (early satiety, nonbilious vomiting, abdominal pain)Obstruction of the distal duodenum (bilious vomiting) may result in steatorrhea.Bile duct obstruction with jaundiceDiagnostics [27]First line: CT abdomen with contrastFindings: Extrapancreatic fluid collection within well-defined wall or capsule with contrast enhancementOther imaging modalitiesTransabdominal ultrasound* Fast and readily availableHigh sensitivity, but low negative predictive valueERCP (gold-standard test): more invasive, but allows treatment to be performedMRI/MRCP: highly sensitive and specific test, but associated with high costWalled-off necrosisDefinitionAn encapsulated collection of sterile necrotic material, usually occurring > 4 weeks after the onset of necrotizing pancreatitis [5]Previously known as pancreatic abscessDiagnostics: CT abdomen with IV contrast showing an encapsulated heterogeneous collection containing fluid and debris [8]Treatment (of symptomatic walled-off necrosis): percutaneous drainage or transmural endoscopic necrosectomy
do displaced or non- displaced intracapsular NOF # need arthroplast (ie head of femor replacement)
Neck of femur (NOF) fractures can occur anywhere from the subcapital region of the femoral head to 5cm distal to the lesser trochanter (Fig. 1).By TeachMeSeries Ltd (2020)Figure 1 – The bony landmarks of the anterior proximal femurThe neck of femur can be considered to have two distinct areas, which are described relative to the joint capsule:Intra-capsular – from the subcapital region of the femoral head to basocervical region of the femoral neck, immediately proximal to the trochantersExtra-capsular – outside the capsule, subdivided into:Inter-trochanteric, which are between the greater trochanter and the lesser trochanterSub-tronchanteric, which are from the lesser trochanter to 5cm distal to this pointThe blood supply to the neck of the femur is retrograde*, passing from distal to proximal along the femoral neck to the femoral head. This is predominantly through the medial circumflex femoral artery, which lies directly on the intra-capsular femoral neck.Consequently, displaced intra-capsular fractures disrupt the blood supply to the femoral head and, therefore, the femoral head will undergo avascular necrosis (even if the hip is fixed). Patients with a displaced intra-capsular fracture therefore require joint replacement (arthroplasty), rather than fixation.Intracapsular fractures can also be further classified by the Garden Classification (Table 1)Garden ClassificationSimplified ClassificationDescriptionINon-displacedIncompleteIIComplete fracture but nondisplacedIIIDisplacedComplete fracture, partial displacementIVComplete fracture fully displaced
DOC for recently treated billary colic .
Tramadol 50mg immediate release oral tablet is the most appropriate choice for analgesia in these circumstances. Codeine has a spasmodic effect on the sphincter of Oddi, and so should be avoided in biliary colic. It was even associated with acute pancreatitis in patients with history of cholecystectomy (odds ratio 2.64) in a large case controlled study.Slow release opioids and patches are inappropriate for the treatment of acute pain. A 2018 position statement from the Australian and New Zealand College of Anaesthetists: ‘the inappropriate use of slow-release opioids for the treatment of acute pain has been associated with a significant risk of respiratory depression, resulting in severe adverse events and deaths.’Learning PointsTramadol (IMMEDIATE RELEASE) provides effective pain relief for recently treated biliary colic.
ecently noticed some discomfort in his lower limbs, particularly towards the end of the day. On examination, his BMI is 34 and his blood pressure is 146/86. All other vital signs are normal. Systemic examination is largely unremarkable, although the following changes are observed on inspection of the right lower limb (Image). The legs are non-tender, with a normal temperature gradient.
A term used to describe the edema, characteristic skin changes (hyperpigmentation, stasis dermatitis), and ulcers secondary to chronic venous hypertension. Varicose veins may or may not be present. This patient presents with lower limb discomfort in the setting of an elevated BMI. This information, along with the photograph, which demonstrates haemosiderin staining, suggests chronic venous insufficiency to be the correct answer. The mechanism behind the haemosiderin staining in venous skin changes is due to venous hypertension (due to vein incompetence or occlusion) resulting in increased capillary permeability with resultant tissue oedema, leakage of red cells (breaking down to haemosiderin) and extravasation of activated white cells, leading to an inflammatory cascade.Necrobiosis lipoidica is a rare granulomatous lesion that is most often observed on the shins of diabetic patients. Initially, this condition begins as a dull red papule or plaque on the shin which slowly enlarges into one or more yellowish-brown patches with a red rim. Whilst this patient does have diabetes, the appearance of the leg as seen in the photograph is not consistent with necrobiosis lipoidica. As such, this is not the correct answer. Features of venous hypertensionGeneralized or localized pain, lower extremity discomfort/cramping, and limb swelling* Worsened by heat* Worse while standing, relieved by walking and raising of legsPruritus, tingling, and numbnessEdema (may be unilateral) that starts in the ankle and may involve the calf later in the disease course (in about half of affected individuals)TelangiectasiasYellow-brown or red-brown skin pigmentation of the medial ankle; later of the foot and possibly lower legRBC breakdown leads to hemosiderin release → accumulation in the dermis → skin pigmentationMay lead to stasis dermatitis; a scaly, pruritic rashParaplantar varicose veinsLipodermatosclerosis: Localized chronic inflammation and fibrosis of skin and subcutaneous tissues of lower leg [7]Painful, indurated, and hardened skinAtrophie blanche: white, coin- to palm-sized atrophic plaques due to absent capillaries in the fibrotic tissue
elderly patient with streptococcus bovis infection. What occult malignancy should be suspected. Which organisms are associated with cholecystitis?
Strep Bovis is associated (strongly) with colorectal cancer. Colonoscopy should be arranged ASAP. Treatment- Cephazolin. S.Bovis can cause- Infect Endo and CholecystitisS. Bovis is not a usual organism associated with Cholecystitis. Normal orgs (gram - KEEPS)Klebsiella pneumoniae, Escherichia coli, Enterobacter cloacae, Proteus vulgaris and Streptococcus faecalis. Empirical antibiotic therapy is aimed at this with metronidazole and ceftriaxone; another antibiotic that may be added is gentamicin.
epitaxis in an elderly patient with AF and anti coagulated, ongoing for a while
ABCDE_ Airway protection, assesment and large bore IV first!!!!The majority of episodes cease with simple nasal compression, however, the clinician must be aware of the potential for catastrophic bleeding. Appropriate assessment is needed in this patient as she is on anticoagulation and is elderly. As such a Primary Survey approach is most suitable, starting with airway assessment as blood clots can occlude the airway. Insertion of a wide-bore cannula is a standard practice in resuscitation; in this case, although the patient is currently haemodynamically stable, she may quickly decompensate and require aggressive volume expansion. Compression of the nose can be useful but the bleeding has been going for an hour and there is more pressing management. Silver nitrate cauterisation may be beneficial if there is a clear identify anterior bleeding vessel but AFTER an primary survey assessment. ENT are the experts in managing these scenarios and should be called after initial management is commenced. Radiological embolisation is a management option after considering the above.Learning PointsEpistaxis can be an emergency and requires A-E assessment
Features of tension headche
This is because a tension headache typically is located in a ‘band’ around the head, holocranial, or bifrontal, and is not usually located in the occiput. It can also be associated with a maximum of one of the following symptoms – nausea, phonophobia, or photophobia.
first line and scond line Rx for cyclical mastalgia
First-line therapy for cyclical mastalgia pain includes conservative measures including reassurance, physical aids (clothing, etc), and simple analgesia.Second-line therapies for cyclical mastalgia may be required in patients who continue to have severe breast pain for six months despite first-line therapy.Medications used to treat mastalgia have a significant side effects and their use needs to be strictly monitored by a GP or in consultation with a specialist. A trial of pharmacologic therapy may be considered when patients have severe pain or when conservative measures fail.First-line therapy for cyclical breast pain involves conservative measures including reassurance, breast support (ie., a well-fitting bra), and simple analgesia like nonsteroidal anti-inflammatories (i.e., Panadol or additional NSAIDs). Topical NSAIDs can also be used (i.e., diclofenac gel).Second-line therapy for cyclical mastalgia is indicated with consistent pain for 6-months despite adequate first-line therapy. Options include Tamoxifen and Danazol.Tamoxifen use is restricted due to adverse effects include thromboembolism and endometrial cancer. Further, to this, as an aromatase inhibitor, it can also induce vaso-motor symptoms, menstrual irregularity, vaginal discharge, hair thinning, and weight gain. The patient is 35-years-old, and premenopausal, good practice should also include advice about the risk of reducing her bone density, and the implementation of strategies to maintain bone health. Danazol is an androgen that can cause weight gain, oily skin, hot flashes, menstrual irregularities, and virilization. It is contraindicated in pregnancy and has been identified as a risk factor for arterial thrombosis. Given these many undesirable effects, both tamoxifen and danazol should be used under the guidance of a GP, OBGYN, or appropriate specialty.
First line investigation of suspected prostate Ca
Multi-parametric MRI is now becoming the standard of practice in the initial assessment of a patient with suspected carcinoma of the prostate.
First step of MX of osteoarthritis.
Learning PointsMuscle strengthening exercises should be the first step in the management of osteoarthritis.Over the counter pain relief such as paracetamol may provide some benefit to patients. Prolonged courses of non-steroidal anti-inflammatories should be avoided however, especially in patients with renal impairment.Mainstays of treatment include weight loss if BMI is elevated, and physical therapy to improve joint stability through muscle strengthening exercises. Intra-articular injections have also been shown to confer benefit in OA patients, however in a randomised controlled trial of both treatment modalities, patients who underwent physical therapy had less pain and functional disability at 12 months without the adverse effects associated with pharmacological interventions.Curcumin is advocated as an anti-inflammatory herbal preparation, but is of unproven value.
For a unilateral joint pain and swelling, reasonable differentials would include septic arthritis, crystal arthropathy, haemarthrosis, fracture, and soft tissue injury.
Gardner classification for femur neck #
Garden classification of femoral neck fracturesThe degree of femoral neck displacement is determined by the course of the trabeculations in the femoral neck and head (depicted here as blue lines; grey area = impaction; red area = line of fracture).Garden I: nondisplaced, incomplete, impaction fracture with valgus configuration (lateral distortion of the trabeculations)Garden II: complete, but nondisplaced fracture (disruption of the trabeculations without distortion)Garden III: complete and partially displaced fracture with medial contact of the fracture elements and varus displacement (medial distortion of the trabeculations)Garden IV: complete, fully displaced fracture
GIST vs Gastric Cancer
gastrointestinal stromal tumour (GIST). Large mass in stomachOn CT This is because of the well-circumscribed, homogenous mass in the stomach surrounded by contrast. These tumours usually occur after 40 years of age, and most commonly occur in the stomach. They are most likely to be asymptomatic, and are hence commonly discovered incidentally upon CT scan or endoscopy. Depending on their location in the digestive tract, GISTs are unlikely to cause symptoms until they are very large. If large, they can ulcerate and sometimes cause gastrointestinal haemorrhage. They also obstruct or may present with non-specific gastrointestinal symptoms. Gastric carcinoma may have no specific symptoms when they are superficial and potentially curable, although some patients have nonspecific gastrointestinal complaints such as dyspepsia. As it progresses they may present with anorexia, weight loss, as well as vague abdominal pain. If this lesion was a gastric cancer, it would almost certainly have produced symptoms by now.
Hip fractures are divided into:
IntracapsularFemoral headFemoral neck (sub capital) ExtracapsularTrochantericIntertrochantericSubtrochantericTypical fracture sites of the proximal femur
How is a suspected CSF leak tested for?
The presence of CSF can be confirmed by testing the fluid for beta-2-transferrin.
Hydatid cyst
Hydatid cysts are parasitic infections typically located within the liver, occurring due to ingesting food contaminated with E. granulosus eggs. The domestic dog is the main host of E. granulosus. They present on CT as well-defined encapsulated cystic or multicystic masses. Pathogens: Echinococcus tapewormsEchinococcus granulosus causes CEEchinococcus multilocularis causes AETransmissionHand-to-mouth* petting a dog or catContaminated dirt (e.g., dog feces)* Fecal-contaminated food or waterDiagnosticsLaboratory tests: mild eosinophiliaSerology: positive ELISAImagingUltrasonographyCystic echinococcosis: unilocular, anechoic, smooth, well-defined hepatic cyst with or without daughter cystsEggshell calcifications within the wall of a hydatid cystCT scan: indicated for further evaluation of cystsAlveolar echinococcosis usually not well-defined, but shows infiltration of the liver and surrounding tissueTreatmentCystic echinococcosisMedical therapy: may be considered as the sole treatment for cysts < 5 cmDrug of choice: albendazoleUltrasonography/CT-guided percutaneous drainagedone in combination with medical therapy (albendazole)Surgery* Indications: > 10 cm, complicated cystsAny invasive procedure (drainage or surgery) of hydatid cysts should be performed with the utmost care to prevent spillage of cyst contents, which could cause life-threatening anaphylactic shock and/or secondary seeding of infection!
Incidental throid papilary microcarcinoma (o.5cm), after subtotal thyroidectomy for treatment of graves- what to do? * CT neckRepeat ultrasound in six monthsRight hemithyroidectomyTotal thyroidectomyRadioiodine ablation
Papillary carcinoma is the most Prevalent type of thyroid cancer, it features Palpable lymph nodes, and it has the best Prognosis compared to all other types of thyroid cancer. incidental thyroid carcinoma’ as it was detected unexpectedly in tissue resected for a benign pathology. Observational studies suggest that patients with these tumours do not need resection and can be kept under surveillance with repeat ultrasonography. In this case, the tumour has been resected as part of another procedure and certainly no further intervention is needed.With the increased use of various imaging tools, the incidence of “thyroid cancer” has increased dramatically over the last decade. Despite this increase in incidence, the mortality of the disease remains unchanged. This suggests that most of these newly diagnosed tumours are of little, if any, clinical significance.Learning PointsSmall, incidental thyroid tumours can be managed by surveillance.
increasing calf cramping on exertion, a history of smoking and hypertension, pale lower extremities, and absent pedal pulses, the combination of which suggests peripheral arterial disease (PAD).what is next treatment
Treatment of PAD Overview Intermittent claudicationFirst-line therapy [23][24]* Structured exercise therapyCardiovascular risk factor modificationCLI: Consider revascularization in addition to structured exercise therapy and cardiovascular risk factor modification.Risk modification [3][25]patients with PAD are at an increased risk of atherosclerotic cardiovascular disease (ASCVD) events such as MI or strokeSmoking cessationTreatment of dyslipidemiastatin therapy in all patients with PADGlycemic controlAntihypertensive treatmentSingle-agent antiplatelet therapy ; : aspirin OR clopidogrel (ticagrelor may also be considered) [3][7][28]Recommended in all patients with symptomatic PAD (reduces morbidity and mortality from cardiovascular events)Structured exercise therapy [3][22]Recommended first-line therapy for claudicationVasodilators [3][7][28]Preferred agent: cilostazol; a phosphodiesterase III (PDE3) inhibitorRevascularization [7][10][23]IndicationsLifestyle-limiting claudication despite optimal medical therapy and exerciseMAXIMIZE TABLETABLE QUIZRevascularization procedures for peripheral arterial disease Percutaneous transluminal angioplastyMay be combined with stent placement and/or atherectomyPeripheral artery bypass surgery: Open surgical bypass of the vascular stenosis with an autologous vein or prosthetic materialEndarterectomy (may be combined with endovascular treatment)Indications [10][33][34]Endovascular revascularizationConsider in the following situations:Short segment disease: stenosis < 10 cm or occlusion < 5 cmAortoiliac diseaseHigh-risk patients [10][33][34]Surgical revascularizationConsider in low- and average-risk patients with any of the following: [10][33][34]* Extensive and complex disease: long segment lesions (> 10 cm); multifocal lesionsLesions of the common femoral artery* Purely infrapopliteal disease* Chronic total occlusionUnsuccessful endovascular revascularization [10][33][3
Indications for bariatric surgery
Indications for bariatric surgery are based on a person’s BMI (body mass index), which needs to be 40 or greater to be considered or greater than 35 with a co-morbid conditions such as type 2 diabetes, hypertension, hyperlipidaemia, obstructive sleep apnea, non-alcoholic fatty liver disease, among others* must have failed non-operative weight loss attempts, * been cleared by a psychologist/psychiatrist and be able to give their informed consent.
Indirect vs Direct hernia difference
Indirect moves through the deep inguinal ring - Indirect in Inguinal ring. Direct moves through weakness of wall. - medial to inguinal ringFemoral- lateral and inferior to inguinal indirect inguinal hernia, where abdominal contents (typically bowel) pass through the inguinal ring and into the inguinal canal. The patient is experiencing abdominal pain and the hernia is irreducible, which is concerning for strangulation (although the swelling is not tender at this stage) and requires immediate surgical input.Femoral hernias are more common in women and of high risk of strangulation. However, these travel through the femoral ring. Direct inguinal hernias occur medial to the deep ring, where the aponeurosis of the abdominal wall is most weak.
Indirect vs Direct hernia difference
Indirect moves through the deep inguinal ring - Indirect in Inguinal ring. Direct moves through weakness of wall. - medial to inguinal ringFemoral- lateral and inferior to inguinal indirect inguinal hernia, where abdominal contents (typically bowel) pass through the inguinal ring and into the inguinal canal. The patient is experiencing abdominal pain and the hernia is irreducible, which is concerning for strangulation (although the swelling is not tender at this stage) and requires immediate surgical input. In this particular case it could be argued that the CT scan was unnecessary as the diagnosis of small bowel obstruction secondary to an incarcerated inguinal hernia should have been very clinically evident.Femoral hernias are more common in women and of high risk of strangulation. However, these travel through the femoral ring. Direct inguinal hernias occur medial to the deep ring, where the aponeurosis of the abdominal wall is most weak.
Intermittent soiling and perianal pain in an otherwise well individual.
Most likely an Anal fistula is an abnormal connection between the anus and the skin. This leads to a pathological opening from where leakage of stools can occur. The large majority of anal fistulae arise from anal crypts which have become infected (eg, perianal abscess). DDX for fistula , Whilst there are other conditions hat may be associated with anal fistula formation, most are a result of local sepsis. * Crohn’s disease, * Intestinal Schictosomiasis* actinomycosis, and * Chlamydia (eg, lymphogranuloma venereum) * anal fistula are radiation proctitis and malignancy. Crohn’s disease he might have concomitant malabsorption symptoms (eg, steatorrhoea, fat-soluble vitamin deficiency) and chlamydia may have associated painful inguinal lymphadenopathy and watery discharge from the urethra. Actinomycosis associated with anal fistula is an extremely rare finding.Intestinal schistosomiasis is associated with abdominal pain, bloody stools, diarrhoea, and strictures. Intestinal schistosomiasis is also a less likely cause of anal fistulae as compared to anal crypt infection.
Investigation of choice in SAH
This patient is presenting with classical features of subarachnoid haemorrhage (SAH), which include the hallmark ‘thunderclap headache’, nausea/vomiting, signs of meningeal irritation (photophobia and neck stiffness), focal neurological deficits, and loss of consciousness. The previous episode described likely represents a ‘sentinel bleed’ or ‘warning leak’, a minor haemorrhage that precedes 10-40% of major SAH. Hypertension and smoking are both risk factors.Urgent CT brain is the investigation of choice for suspected SAH, including a non-contrast scan to detect subarachnoid blood (which will appear hyperdense) and a CT angiogram to identify any potential culprit aneurysms. CT scanning is fast, widely available, and approaches 100% sensitivity in the first 3 days following SAH. In cases of high clinical suspicion but negative CT findings, lumbar puncture for xanthochromia and MRI can be used to further investigate. Formal cerebral angiography is used to either identify aneurysms when none are appreciated on non-invasive imaging, or to characterise detected aneurysms regarding their suitability for endovascular (coiling/stenting) versus open surgical (clipping) treatment.
Investigation/mx of choice of a groin mass?No cough impulse at mass, but signs of intestinal obstruction. What does this mean?
Irreducible/reducible only seen– cough refelxobstructed/stangulated –both signs obstruction, strangulated will show signs of local tenderness and systemically unwell (fever) A tender swelling in the groin of a patient with signs of intestinal obstruction supports the diagnosis of a strangulated hernia.—urgent surgical exploration with herniography This patient with a groin lump and clinical features of bowel obstruction (eg, nausea, vomiting, abdominal pain and distension, with tinkling bowl sounds: When the bowel is obstructed they become high pitched or tinkling as fluid drips from one distended and tympanic loop of bowel into another. ) most likely has an obstructed femoral hernia (older aage and female). Abdominal wall that is soft and distended- means no peritonism.Both obstructed and strangulated hernias tend to present with signs of bowel obstruction. A strangulated hernia may present with localised symptoms and signs (Richter hernia). In general, strangulated hernias are associated with toxic appearance and systemic symptoms (eg, fever). While most femoral hernias may show a positive cough reflex, this is only seen in reducible or irreducible femoral hernias. Obstructed and strangulated hernias do not generally show a positive cough reflex. Based on clinical suspicion of obstructed femoral hernia, this patient needs to undergo urgent surgical exploration of the groin with herniorrhaphy, no matter what the X-ray shows. Delaying the definitive surgical repair increases the risk of strangulation and necrosis of herniated bowel.
irregular superficial ulcer around his right medial malleolus. This has been present for about three weeks. There is moderate pain in the ulcer, which is relieved with elevation of the leg. On examination the area around the lower leg and ulcer is a dark purple rusty colour. His femoral pulses are of good volume and equal, and pedal pulses are strongly palpable. The ankle-brachial index in both legs is 1.0.
Compression bandages with moist wound dressingThe stem suggests a venous ulcer due to its location in the medial gaiter region, surrounding haemosiderin staining, and moderate pain that alleviates with elevation. The good arterial vascularity as evidenced by strong pedal pulses and normal ankle-brachial index reduces the likelihood of arterial malperfusion as the cause.Appropriate treatment at this stage would be compression bandages to reduce venous engorgement and moist wound dressing to control exudate and encourage epithelial regrowth. The presence of peripheral arterial disease would be a contraindication to direct compression - but that is not the case here.Skin grafting might be appropriate if the wound does not respond to simple measures. There is no need for any urgent vascular surgical opinion and nor is any other form of intervention (such as debridement) required as there are no apparent signs of infection or necrosis.Learning PointsA chronic ulcer around the ankle is most likely to be venous in origin.
IS VTE indicated?laproscopic Surg, female on OCP, no co morbidities.
Caprini thrombosis risk model which takes into account age, surgery type, medical history, and history of VTE as well as clinical evidence of peripheral venous disease. Interpretation of the Caprini model is as follows:Very low risk (<0.5%): 0 points- ambulation* Low risk (1.5%): 1-2 points- mechanical * Moderate risk (3%): 3-4 points- LMWH/mechanical High risk (>6%): >5 points - strong recommend VTE If risk were very low, then early ambulation would be recommended with no additional measures. If risk were low, then mechanical methods of prophylaxis would be indicated including intermittent pneumatic compression or graduated compression stockings. risk is moderate, a low molecular weight heparin such as enoxaparin given once per day until discharge would be appropriate. An alternative option may be graded compression stockings to be worn until discharge.If her risk were high, then pharmacological prophylaxis is strongly indicated.VTE prophylaxis is usually continued until the patient is fully ambulatory or until discharge. Although high-risk patients or those with prolonged immobility on discharge may be prescribed a longer duration (10-14 days).Following VTE risk, an assessment of bleeding risk should occur. EGVTE RISK: This patient is at moderate risk for a venous thromboembolic complication, in that she has two risk factors:Abdominal surgery (2 points)Oral contraceptive pill (1 point)BLEEDING RISK In this patient, undergoing laparoscopic surgery with no medical history, her bleeding risk is low. Therefore prophylactic anticoagulation is indicated.
Knee arthroscopy- when used
Knee arthroscopy is a common surgical procedure that is more frequently performed for meniscal tears, removal of loose bodies, focal cartilage lesions, or ligament reconstructions. It has a limited role in the management of an arthritic knee.
Left iliac fossa pain. Temp 37.4C, blood pressure 135/90 mmHg and pulse 100/min. PE: There is some tenderness in the left iliac fossa and the rest of the physical examination is normal. A CT confirms the clinical diagnosis of acute diverticulitis. There is a 5 cm length of the sigmoid colon affected, with some pericolic fat stranding and thickening of the bowel wall. No other abnormalities are detected.…two-day history of constant lower abdominal pain associated with loose stools. Her medical history includes hypertension, gout, type 2 diabetes, and a similar episode of abdominal pain two years previously. She looks well, with a blood pressure of 130/90 mmHg, pulse 90/min, and temperature 37.4C. abdomen is soft, with some tenderness in the left iliac fossa. Her haematological and biochemical values are all within normal limits. HbA1c at her last medical checkup one month ago was 68.3 mmol/mol. A CT scan is ordered and shows thickening of the sigmoid colon and no other abnormalities.
Mx of acute diverticulitis: Complicated vs uncomplicated (simple) Simple diverticulitis- no local complications ( perforation, abscess, fistula)Some 75% of cases of diverticulitis are uncomplicated. Uncomplicated can be managed as an outpatient with review, Analgesia.Antibiotics would be appropriate for high-risk patients who could be defined as:* immunocompromised* high C-reactive protein assays (>140 mg/L)* high white blood cell count (>15)* CT evidence of long segment involvement (>6.5 cm)* local complication (fluid collection, abscess, perforation)Complicated Diverticulitis- long segement 6.5 cm or more of gut In patient -Significant co-morbidities (including immunosuppression, chronic steroid use, uncontrolled diabetes mellitus)Evidence of infectious parameters (fever >39C, white cell count >15 x 106/L)Inability to tolerate oral intakeLimited home supportCT evidence of pneumoperitoneum, abscess formationPatients over the age of 65 are more likely to be managed in a hospital, but this is not an absolute indication. Eg 2: in this case, the patient has diabetes and this co-morbidity is a stronger reason than any of the other options to consider the need for in-patient management of her acute diverticulitis.Learning PointsUncomplicated diverticulitis can be managed in an out-patient setting - except where various co-morbidities, such as diabetes, indicate the need for hospitalisation. colonoscopy this should be left until the acute inflammatory episode has resolved.
Mx of head of femur fracture , classification and mx of each class
Pipkin Classification Pipkin I Luxational fracture of the femoral head: The fracture line lies below the fovea capitis and not in the weight-bearing portion (horizontal fracture).Surgical: open reduction internal fixation, e.g., with a traction boltConservative: immobilizationPipkin II Luxational fracture of the femoral head: The fracture line lies above the fovea capitis. The fragment is attached to the femoral head ligament and thus in the weight-bearing portion (vertical fracture).Surgical: open reduction internal fixation, e.g., with a traction boltPipkin III Pipkin I or II fracture in combination with a medial fracture of the femoral neckSurgicalYoung patients: open reduction internal fixation with maintenance of the femoral headElderly patients or those with predispositions: total hip replacementPipkin IV Pipkin I or II fracture in combination with an acetabular fractureSurgicalYoung patients: open reduction internal fixation with maintenance of the femoral headElderly patients or those with predispositions or instabilities: total hip replacement
mx of subcapital (femor neck fracture), what classification is used, and what surgery does each state require.
The main forms of intracapsular fracture management include -internal fixation (either multiple cancerous sores or single sliding hip screw), -or arthroplasty (either hemi or total replacement). The choice depends on the degree of displacement (Garden stage) and comorbidities of the patient. -Garden state I/II are managed with internal fixation regardless of age. -Generally, with patients under 65 it is best to aim for internal fixation as the arthroplasty may not last the patient’s life expectancy and there is greater risk of re-intervention. -Garden III/IV and older than 65 are usually managed with either hemi or total hip arthroplasty. -The decision between hemiarthroplasty and total is controversial and can be very patient dependant. Some factors that may push the clinician towards using a total hip replacement include good pre-fracture mobility, and no cognitive impairment. This patient is 75 and has suffered a valgus impacted subcapital fracture. ( see image) This is best managed with cannulated hip screws or dynamic hip screws. Her pre-existing cognitive impairment as well as mobility issues make her less of a candidate for arthroplasty but the principal deciding factor is the type of fracture.The dynamic hip screw or sliding hip screw fixation is designed for fixation of certain types of proximal femur or hip fractures. The screw is a large cancellous lag screw that can glide freely in a metal sleeve. The sleeve is attached to a plate which is fixed to the lateral femoral cortex with screws.
Name key myotome deficits in cervical radiculopathy (C5-T1)
C5 -elbow flexionC6- wrist extensionC7- wrist flexion, fingers extensionC8 - finger flexionT1- finger abduction
navicular and base of 5th meta tarsal
mid foot Ottawa rules- point tenderness in two points and inability to WB ( 4 steps) Note- the base of the 5th metatarsal rests against the cuboid- then the tuberosity therafter. up until age 12-14- apophysis (growth plate on tuberosity)
Ottawa anke rules- Midfoot and ankle
There are two components, assessing for ankle and midfoot fractures. A patient with traumatic ankle pain qualifies for ankle radiographs if they have any of the following:point tenderness at posterior edge (of distal 6 cm) or tip lateral malleoluspoint tenderness at posterior edge (of distal 6 cm) or tip medial malleolusinability to weight bear (four steps) immediately after the injury and in emergency departmentA patient with traumatic midfoot pain qualifies for foot radiographs if they have any of the following :point tenderness at the base of the fifth metatarsalpoint tenderness at the navicularinability to weight bear (four steps) immediately after the injury and in emergency department
Intermittent Claudication (PAD) - name the ABI categories and the Inx for each
PAD- use ABI to measure- measure of arterial flow. SBP of dorsalis peadis/ SBP of brachial ABI:* > 1.4 Medial calcific sclerosis (ass with DM and CKD) with noncompressible vascular wall* 1.3-09- normal * less than 0.9 is slight restriction of flow – * mild-moderate 0.5-0.9 – investigate with duplex ultrasound to find stenosis* severe- less than 0.4– will need imaging (angiography/ MRI) as a prelude to some form of surgical intervention. Choice of investigation- Imaging [7][18][19]Angiography: preferred modality for assessment for revascularizationModalities [18]First-line: MR angiography (MRA) without and with IV contrast Contraindications for MRI (e.g., prior stent placement): CT angiography with IV contrast (CTA)Digital subtraction angiography: considered the gold standard for PAD; uncommonly used [19]* Findings: demonstration of site(s) and extent of arterial occlusion or stenosis and collateral blood flowMRA has a lower risk of nephrotoxcicity than CTA, and also better visualises strongly calcified vessels , making it more suitable in renal impairment and diabetesDSA- was gold standard, but invasive and high contrast load.
Painful arc at specific points: 60-120, 120-180
Painful arc testProcedure: The examiner instructs the patient to abduct and raise the extended arm.Findings and significance: * Negative test (physiological): The patient’s arm can be repeatedly raised and lowered between 0–180°.Positive test: painful arc* Pain between 60–120° indicates subacromial impingement * Pain from abduction/elevation at 120–170° indicates a pathology of the AC joint * Pain during the entire movement (0°–180°) nonspecific indication of a glenohumeral pathology (e.g., osteoarthritis or frozen shoulder)https://youtu.be/zMnjj7YV-40Impingement syndrome can make an assessment of the actual range of motion in the shoulder difficult due to pain. To nullify the effects of, e.g., subacromial impingement, abduction in external rotation can be performed. As a result of this, the space between the acromion and the supraspinatus tendon is enlarged, leading to reduced pain.
patient with med Hx of Mysthenia gravis. Now with acute cholecystitisTreatment?
Acute cholecystitis is empirically treated with amoxicillin/gentimicin/metronidazole - gram + (enterococcus: in GUT) and grm - (enterobacteria: BT) coverage BUT gentamycin is CONTRAINDICATED IN MG- causes prolonged muscle relaxation Acute cholecystitis is usually caused by Enterobacteriaceae (Gram-negative - KEEPS) and Enterococcus faecalis(Gram positive: Enterococcus faecalis is the most common human pathogen, but Enterococcus faecium has become increasingly prevalent in hospital-acquired infections). Amoxicillin and gentamicin cover both these Gram-negative and Gram-positive bacteria. Metronidazole has activity against anaerobic bacterial infections which constitutes the majority of intestinal flora.However, in this case, Piperacillin/Tazobactam is the correct answer as the patient has a history of myasthenia gravis which is a contraindication to using gentamicin due to the risk of prolonged neuromuscular blockade. Hence, an alternative antibiotic regimen will be required.
Pes Ansures Bursitis?
Radiological signs of osteoarthritis
SCiSSor* Subchonsral cystsIrregular joint space narRowingSubchondral sclerosisOsteophytesosteoarthritis, plain X-rays are the most appropriate initial investigation; they are easily accessible and provide enough information to make the diagnosis. Information to be sought on the X-ray to support the diagnosis of osteoarthritis would include:Loss joint spaceOsteophyte formationSubarticular sclerosisSubchondral cystsThis can be remembered with the mnemonic ‘LOSS’.
Tests for a knee effusion
Tests for joint effusionPatellar tap testProcedureThe examinee lies supine with the knee extended.The examiner pushes the fluid from the suprapatellar pouch to the knee joint with one hand and uses the other hand to gently tap the area over the patella.Interpretation: floating of patella indicates joint effusionKnee bulge testDescription: The examiner applies pressure above the patella to milk fluid from the suprapatellar pouch and then applies pressure behind the lateral margin of the patella.Interpretation: The appearance of a bulge on the medial aspect of the knee indicates the presence of knee joint effusion.
Types of benign and malignant parotoid tumours.
Salivary glands- benign * pleomorphic adenoma* warthins tumour malignant * adenocystic carcinoma * mucoeitheliod carcinoma * note proportion of malignant tumours increases as the gland gets smaller.
unable to move the wrist or fingers from the position seen in the image. The GP additionally notes marked atrophy of the forearm on the affected side.He is otherwise well with no significant medical history, and the GP finds no other deformities on examination.
Key Clues Wrist- unable to move –forearm musclesFingers- unable to extend (1st 3 dugits)Forearm atrophyInjuries to the median nerve and brachial artery, which both cross the elbow, are common complications of supracondylar fractures.The Median nn and brachial aa travel together over the medial lateral distal shaft over the lateral chondyl of the humerus. Supracondular fractures are the most common # in childhood. Complications of SC#:Volkmann’s ischaemic contracture. This is the result of an acute ischaemic insult to the flexor muscles of the forearm causing permanent fibrosis and shortening. The most common cause is a fracture of the distal humerus - specifically a displaced supracondylar fracture causing either disruption of the brachial artery, or compartment syndrome of the forearm. This is a rare condition which can be treated with physical therapy and surgery. Radial nn more likely to be injured in humeral shaft #.Radial nn wraps around lateral epichondyl then moves posteriorly.Ulna nn- posterior aspect medial epichondyl.
How to decide - bcc , hydatid cyst , liver abscess
Hydatid disease used to be common disease in sheep-rearing areas in Australia, where man became an inadvertent secondary host, after becoming infected from the primary hosts - dogs. Deworming of pets and working dogs has lowered the incidence of the disease in Australia, although hydatid remains relatively common in some parts of the world, such as Turkey. In endemic regions the prevalence of hydatid varies between 1% - 10% of the population. Most cases of hydatid cyst are incidental findings and have a characteristic calcified rim. In addition, the contents of a hydatid cyst tend to be homogenous - apart from the daughter cysts and ‘hydatid sand.’ This patient has a typical hydatid cyst with visible daughter cysts. Patients with liver abscess commonly present with infective symptoms including fever and malaise. On imaging, liver abscess present as a solid, single or multilocular cavity with possible gas collection. Acute cholecystitis is a less likely diagnosis due to the duration of the symptoms. Patients with acute cholecystitis usually present with acute severe right upper quadrant abdominal pain. It is also unlikely to diagnose acute cholecystitis with this film as the slice does not feature the gallbladder/gallbladder fossa. Liver lesions due to metastatic liver disease present as multiple lobulated solid lesions with possible central necrosis. Hepatocellular carcinoma clinically presents with jaundice, ascites, and constitutional symptoms of anorexia and weight loss. On CT imaging, hepatocellular carcinoma lesions is characteristically more hypervascular and solid than cystic. Learning Points Contents of a hydatid cyst tend to be homogenous - apart from the daughter cysts and ‘hydatid sand
Imaging and obstruction
78-year-old woman presents
four week history of increasing constipation associated with crampy abdominal pain and distension.
HX appendicectomy and an hysterectomy.
On examination her blood pressure is 134/84 mmHg, pulse 90/min and temperature 37.2C. Her abdomen is uniformly distended and there is mild widespread tenderness. The bowel sounds are increased and high-pitched. Her rectum is empty and nothing abnormal can be felt on digital examination. An abdominal X-ray showing large bowl dilation, with a clear transitional point at the sigmoid colon with no air in the rectum
An unexplained change in bowel habit in an older patient should always raise the possibility of malignancy.
Adhesional obstruction and volvulus tend to be acute events, with symptoms usually only appearing a day or two at most before the increase in their severity leads the patient to seek medical help.
Pseudo-obstruction usually has a clearly defined precipitating cause such as recent surgery or retroperitoneal trauma.
This particular patient has a recent change in bowel habit, suggesting something causing progressive luminal occlusion.
In her age group, colonic malignancy must be excluded and is the most likely explanation for her symptoms.
The diagnosis is given away by the radiological pattern of gas distribution - distended colon with a cut-off in the region of the sigmoid colon and no gas in the rectum. Whilst non-malignant sigmoid lesions or strictures such as in severe diverticulitis could present in such a way, this patient most likely has a carcinoma of the sigmoid colon.
appendicitis
five-day history of lower abdominal pain. The pain was initially intermittent and has now become constant. He has no other symptoms apart from some intermittent nausea.
On examination, the patient’s blood pressure is 115/90 mmHg, pulse 100/min and temperature 37.8ºC. Abdominal examination shows tenderness in the right iliac fossa and no other abnormalities.
reviously well 39-year-old man presents to the Emergency Department with a two-day history of colicky abdominal pain, worse on the right side. The pain started intermittently but has become more severe and constant in the last few hours. He also reports a fever and some nausea. The patient has never been hospitalised and has no surgical history.
On examination, his temperature is 38.4ºC, blood pressure 124/90 mmHg and pulse 90/min. His BMI is 35. Abdominal examination shows an area of tenderness in the right lower quadrant.
- Broad-spectrum antibiotics should be first line management for patients presenting with an appendix mass.
first instance he should be treated with antibiotics. The history and examination are also typical of appendiceal pathology. Acute appendicitis typically presents with abdominal pain that increases in severity, frequency and localises to the right lower quadrant over days.
In most instances, the administration of broad-spectrum antibiotics will resolve the situation and an elective appendicectomy would be considered.
Q2
he clinical description fits well for a diagnosis of acute appendicitis and is supported by a lack of previous surgeries indicating no past history of appendicitis with appendicectomy. Increasing severity and localisation to the right lower quadrant is typical of this diagnosis. Furthermore, the patient’s obesity might explain the paucity of signs on physical examination. The abdominal X-ray shows a calcified faecolith in the right lower quadrant which may have caused this episode of appendicitis.
A score ≤ 2 indicates a very low likelihood of acute appendicitis.
A score ≥ 9 indicates a very high likelihood of acute appendicitis.
Shoulder dislocation
The right shoulder is abducted and externally rotated. His right elbow remains flexed and forearm internally rotated, supported by the other hand. There is no loss of skin integrity on his right shoulder, but the acromion appears prominent as compared to the left shoulder. His vital signs are stable, and he has a normal radial pulse on both arms.
What is the most likely area of sensory loss in his right upper limb as a result of this injury?
Choose the single best answer.
- Medial aspect of his right upper arm
- Lateral aspect of his right upper arm
- Medial aspect of his right forearm
- Lateral aspect of his right forearm
- Dorsal aspect of his right hand
- Medial aspect of his right upper arm-
- Lateral aspect of his right upper arm- axillary nerve
- Medial aspect of his right forearm- medial cutaneous
- Lateral aspect of his right forearm-
- Dorsal aspect of his right hand- radial nerve
This patient presents with shoulder pain and a shoulder that is abducted and externally rotated with a prominent acromion. This is consistent with an anterior dislocation of the shoulder, commonly due to an anteriorly directed force on the arm as the shoulder is abducted and externally rotated.
Damage to the axillary nerve is a complication that may result from a shoulder dislocation as the nerve courses medially to the surgical neck of the humerus. This may affect the sensory innervation of the lateral aspect of the upper arm, as the posterior terminal branch of the axillary nerve innervates the upper lateral cutaneous nerve of the arm.
The sensory innervation of the medial aspect of the upper arm comes from the intercostobrachial and medial cutaneous nerve.
The sensory innervation of the lateral aspect of the forearm comes from the musculocutaneous nerve,
and the medial aspect of the forearm is from the medial antebrachial cutaneous nerve.
The radial nerve predominantly innervates the dorsal aspect of the hand. The ulnar nerve also innervates the dorsal aspect of the little finger and ½ of the ring finger.
PE
35-year-old woman presents to the Emergency Department with a 12-hour history of nonproductive cough and right-sided chest pain. The pain came on gradually and is worse when she coughs. She had a laparoscopic cholecystectomy one week earlier and was back at work three days later. On examination, she looks well, with a blood pressure of 125/80 mmHg, pulse 90/min and temperature 37.6 C. Pulmonary auscultation findings and the rest of the physical examination is unremarkable. Routine bloods are normal. A D-dimer is 0.4 mg/L.
Which one of the following would be the most appropriate plan of management?
Choose the single best answer.
Reassurance
Chest X-ray
V-Q scan
CT pulmonary angiogram
Doppler ultrasonography
Positive for D-dimer>500ng/dl or 0/5mg/L PE likely
This patient with nonproductive cough, normal vitals, low-grade fever, and chest pain most likely has an acute chest infection (eg, acute bronchitis). Although chest pain with a recent history of surgery should alert the physician for the possibility of pulmonary embolism, this patient has a low pretest probability of pulmonary embolism according to Well’s score. Patients with a Well’s score of ≤4 have a low probability of pulmonary embolism, whereas the patients with a Well’s core of >4 have a high probability of pulmonary embolism. Patients with a low pretest probability of pulmonary embolism should be followed up with a D-dimer assay. A D-dimer level of ≤0.5 mg/L excludes the diagnosis of pulmonary embolism. This patient’s Well’s score of 1.5 (due to recent history of surgery) and a D-dimer level of 0.4 mg/L excludes pulmonary diagnosis and should be reassured and managed supportively.
Acute bronchitis is primarily a clinical diagnosis. Chest X-ray would be indicated if this patient had features of pneumonia (eg, high-grade fever, crackles, productive cough with yellow sputum).
V-Q scan and CT pulmonary angiogram are indicated in patients with a high pretest probability of pulmonary embolism. CT pulmonary angiogram is preferred but V-Q scan may be used if the patient has contraindications to CT pulmonary angiogram (eg, renal failure) or if CT pulmonary angiogram is unavailable.
Doppler ultrasonography of the affected limb may be performed if the patient has clinical features suggesting deep venous thrombosis (DVT). This patient does not have any feature suggesting a DVT.
