general surgical/urology +opthalmology+ENT emergencies Flashcards
4 principles of management of Anal fissures ?
RCEM Learning SAQ
- Prescribe stool softeners &bulking agents
- Prescribe analgesia +/- topical local anaesthetic
- Prescribe topical gtn/diltiazem
- Safety net/ arrange GP follow up
What are the anatomical landmarks of the 3 zones of the neck?
RCEM Learning SAQ
ZONE 1: thoracic inlet inferiorly to cricoid cartilage
ZONE 2: cricoid cartlilage inferiorly up to the angle of
the mandible
ZONE 3: Angle of the mandible up to the base of the skull
What are the anatomical structures that lie in the 3 neck zones?
RCEM Learning SAQ
ZONE 1: TOLungs, thyroid and thoracic duct
( trachea, oesophagus,Lungs,Thyroid, Thoracic duct )
ZONE 2: TOLarynx/ JV/CA/VA
( Trachea, oesophagus,Larynx, Jugular veins,Carotid
arteries,Vertebral arteries )
ZONE 3: TOG( glands-salivary&parotid ) / CN/JV/CA/VA
( Trachea,oesophagus, salivary glands, Parotid glands,cranial nerves )
Differentiate the xray features of large bowel and small bowel obstruction
RCEM Learning SAQ
Large = peripheral , >5cm, presence of haustra, few loops
Small = central loops, <5cm , presence of valvulae coniventes, many loops
Your first patient is a 9 year old boy with onset of left testicular pain over the last 2 hours. He is sore but feels otherwise systemically well. You note a blue discolouration on the skin in the region of the upper pole of the testes.
What is the most likely diagnosis ?
RCEM Learning SAQ
torsion of the hydatid of morgagni
testicular appendage
- With regards to aortic aneurysm - what is the diameter for male and females that are normal?
- and can you list the indications for elective surgical repair?
RCEM Learning SAQ
- female = 1.5cm,
male 1.7cm, ( normal abdominal aortic diameter )> 3cm is aneurysmal - indications for elective surgical repair:
- female size > 5cm
- male diameter > 5.5cm
- rapid increase in size more than 1cm per year
- symptomatic AAA
WHat other complications of a AAA (apart from rupture, haemorage and death ) can you name?
RCEM Learning SAQ
- aortic-enteric fistula ( suspected if patient presents with
UGIB ) - trash foot ( due to VTE )
What is the Emergency management of acute angle closure glaucoma?
RCEM Learning SAQ
- Ophthalmology referral
- Carbonic anhydrase inhibitor Acetazolamide (Diamox)
initially 500 mg IV followed by 500 mg PO (1g max in 24
hours) - Parasympathomimetic -
Pilocarpine hydrochloride 1-2%% eye drops, one drop in the
affect eye up to 4 times a day - Beta blocker -
Timolol Meleate 0.5% eye drops, one drop twice daily
Which Symptoms are suggestive of optic neuritis?
RCEM Learning SAQ
Sudden onset ( minutes to hours ) acute severe eye pain /headache
unilateral white eye:
- visual blurring
- decreased visual acuity
- decreased colour perception
- painful/discomfort eye movements
A patient presents with knee effusion.
name 2 commonly used approaches to knee aspiration and explain the benefits of knee aspiration?
RCEM Learning SAQ
parapatellar ( medial or lateral ) , supra-patellar are the 2 common approaches.
the benefits to the procedure include:
- to remove as much aspirate to relieve the pressure from the knee
- to send fluid aspirate to the lab for microscopy, culture and crystal analysis to determine the cause
What are the 3 main indications for surgery in a patient with traumatic retrobulbar haemorrage?
and give 1 contra-indication?
RCEM Learning SAQ
- Indications for surgical lateral canthotomy :
- decreased VA
- proptosis
- intra-occular pressure > 40mmhg ( acute orbital
compartment syndrome )
- contra-indication:
* globe rupture
contact lenses can cause conjunctivits - which 2 bugs cause infections in the eye in contact lense wearers?
acanthamoeba nigricans
pseudomonas aeruginosa
What symptoms and signs would be important to elicit in a patient with suspected acute close angle glaucoma?
Symptoms:
*History of light halo’s (late sign)
Signs:
- Injected sclera, mid dilated pupil, watering eye, *photophobia
- Palpation of the orbits the left eye felt less *compressible than the right. This is easy to do without specialist equipment.
- Visual acuity
What are the components of the Fever PAIN score for Tonsillitis?
The FeverPAIN criteria are:
score 1 point for each (maximum score of 5)
Fever over 38 C.
Purulence (pharyngeal/tonsillar exudate).
Attend rapidly (3 days or less)
Inflamed ( severely ) tonsils
No cough or coryza
How would you use the FEVER PAIN score in managing a patient presenting with Tonsillitus to the ED?
score is 0 or 1:
Do not offer an antibiotic prescription
score is 2 or 3:
Consider a back-up antibiotic prescription .Tell the patient the antibiotic should only be used if symptoms have not improved in 3-5 days.
score is 4 or 5:
Offer an antibiotic prescription immediately
What potentially life-threatening complication of otitis externa must be considered?
malignant otitis externa
what are the complications of MOE?
and what is your management in the ED?
Complications of MOE include:
- meningitis
- brain abscess
- dural sinus thrombosis
Management includes -
- IV antibiotics
- urgent referal to ENT on call for admission
What would a suitable antibiotic regime be for treating acute bacterial prostatitis?
what other drug would you consider prescribing to relieve symptoms?
Ciprofloxacin 500mg po bd for 28 days
or ofloxacin 200mg po bd for 28 days
sympotmatic treatment with alpha blocker agent i.e. tamsulosin
What is your ED management of a patient with corneal abrasion?
- oral analgesia
- regular topical antibiotics
- advise to return if the symptoms persists beyond 36 hours
A patient presents with unequal pupil sizes.
Left pupil is more dilated than the right pupil.
Left pupil accomadates normally.
Left pupil is slow to react to light.
her right pupil is smaller than the left and reacts normally to accomadation and light.
Her eye movements, visual acuity and fields are all normal.
what is your diagnosis and what is the pathophysiology?
Diagnosis: Holmes -Adie syndrome
Pathophysiology: damage to the post-ganglionic fibres of the parasympatheitc innervation of the eye. likely due to viral infection.
Memory aid:
Come to Adie’s Ho(l)me/house.
He will normally accomadate you and your family in the left wing of the house. but when you switch the lights on , in that one side of the house - it will be slow to react because a virus attacked the west wing!
70 yr old diabetic presents with sudden onset painless loss of vision in his right eye. his right eye is poorly reactive to light, but consensual light reaction is normal. he ahs an afferent pupillary defect.
- What is your most likely diagnosis?
- What findings would you expect to see on fundoscopy?
- What is your main priority of management in ED?
- central retinal artery occlusion
- Fundoscopy findings:
*Pale retina is due to oedema
*attenuated vessels ( thinned out )
*cattle-trucking ( is segmentation of blood columns in
arteries )
* optic atrophy ( over weeks )
* cherry red spot at the macula ( due to blood supply
from carotid arteries )
Memory aid:
pale - thin ( attenuated ) - cattle in trucks eating cherries eventually shrink
- Arrange urgent referral to opthalmology
A squash player sustained an injury when a ball hit into his eye.
Can you list 4 complications of a traumatic hyphaema?
- acute glaucoma
- vitreous haemorrage
- retinal detachment
- permanent visual loss
- corneal staining
- concussion cataract
Memory aid: ball hits the blood vessels in the eye - causing sudden increase in occular pressure in the anterior chamber, and blood vessels in the vitreous burst and bleed, this results in the retina being pulled apart and worst case scenario is blindness, or best case scenario - you escape with either just corneal staining or a concussion cataract!
- What organism is most commonly responsible for causing a dendritic ulcer of the eye?
- Other than topical aciclovir 5times/day for 10 days, which adjunct to treatment would you prescribe and why?
- Herpes simplex virus type 1 ( 80% )
2. High dose vitamin C ( can reduce healing time )
A young 30 year old female presents with an Eyelid rash with associated progressively worsening weakness of the arms and shoulders. What diagnosis would you suspect, and what rash is typically described on the eyelids?
Diagnosis is dermatomyositis.
Eyelid rash is described as a violacious discolouration of the upper eyelid.
What characteristic skin signs are associated with dermatomyositis?
*Gottrons papules
( scaly symmetrical erythematous rash over MCP’s )
- mechanics hands
( rough and fissuring of the skin on palms ) - Poikiloderma vasculare atrophicans
( well circumscribed violacious erythema on neck,chest,shoulders , back) - Shawl sign
( erythematous macular rash on shoulders and upper back ) - Heliotrope rash
( Violacous discolouration of the upper eyelids )
Memory Aid: gottron uses his mechanics hands to cover his lady poikiloderma with a shawl but it doesnt cover the heliotrope rash of the eyelids!
How would you confirm the diagnosis of dermatomyositis?
which antibodies are associated with this condition?
- muscle biopsy
- skin biopsy
- EMG
- blood tests: anti-MI-2 antibodies
A patient presents with sudden acute painless loss of vision in one eye. What is the typical retinal appearance of central retinal vein occlusion?
- cotton wool spots
- flame shaped haemorrages
- disc oedema
- engorgement of the retinal vessels
Memory aid: when cotton wool is set on fire and burns the house in flames - throw water from the engorged vessels of the river retina!
What are the risk factors for Central retinal vein occlusion?
- elderly population
- hypertension
- arteriosclerosis
- chronic glaucoma
- polycythaemia
On examination of a patient with sudden painless loss of vision. You do not have a fundoscopy available, what features on examination of the eye would lead you to suspect central retinal artery occlusion and not vein occlusion?
in central retinal artery occlusion there is an afferent pupillary defect.
What hormones are released by the anterior pituitary gland?
- follicle stimulating hormone
- growth hormone
- thyroid hormone
- prolactin
- luteinizing hormone
Memory aid: follicles ( in the anterior pituitary Gland ) stimulate growth in the thyroid like a pro, not a luzer ( looser )
What are the causes of optic chiasm lesions?
- pituitary tumour
- craniopharyngiOMA
- meningIOMA
- optic gliOMA
- internal carotid aneurysm
memory aid : OMA at the optic chiasm!
What are the distinguising features of branch retinal vein occlusion?
How would you manage this patient?
- retinal heamorages visible above the centre of the retina extending from close to the optic disc to near the macula represented by an “ arc of haemorrages *
The patient should be referred within 24 hours for an opthamlology opinion for monitoring and consideration of photocoagulation therapy.
A 30 year old female with multiple sclerosis presents with sudden painful loss of vision. eye movements are very painful but there is no opthalmoplegia. you diagnose optic neuritis.
- which part of her visual pathway has been affected?
- What other diagnosis would you consider?
- what medication would you prescirbe to treat her?
- optic nerve ( a demyelinating inflammatory process )
- *vitamin B12 deficiency
- drugs poisoning- methanol
- diabetes mellitus
- bugs- herpes zoster/lyme disease
- 500mg IV methylprednisolone infusion over 4 hours daily for 5 days
You review a 7 year old with fever, eyelid swelling and conjunctival injection. what features would suggest orbital cellulitis rather than peri-orbital cellulitis?
features in favour of orbital cellulitis:
- painful eye movements
- proptosis
- diplopia
- red desaturation
- loss of vision
- optic neuropathy
- opthalmoplegia
Memory aid:
the infection is so bad it feels as though my eye will pop out ( proptosis ) , I cant even move my eye ball it hurts so bad like a bull that gets double mad when he sees red and loses his vision!
What are the commonest causative organisms of orbital cellulitis?
- streptococcus pneumonia
- staphylococcus aureus
- streptococcus pyogenase
- haemophilus influenza
( bugs from a pneumonia in the lungs jump into the eye )
A 65 year old presents with a history of a shadow passing across his right eye like a curtain being drawn this morning. for the past 2 weeks he has been experiencing flashes and floaters around the periphery of his vision. he feels a heaviness in the right eye but no pain and his visual acuity has been reduced to finger counting.
- what is the most likely diagnosis?
- what happened 2 weeks ago?
and what are the main clinical features of this
- retinal detachment
- vitreous detachment occured 2 weeks ago.
then main clinical features are:
- flashes of light
- increased number of floaters
- A ring floaters to the temporal side of the vision
- feeling of heaviness in the eye
- WEISS ring ( irregular ring of translucent floating material in the vitreous )
How can you distinguish retinal detachment from posterior vitreous detachment?
Retinal detachment has the following features:
- a dense shadow in the periphery that spreads centrally
- a “ curtain “ drawing across the eye
- Strait lines suddenly appearing curved
- central vision loss and reduced visual acuity
Give 2 causes for ptosis of the eyelid?
- horner’s syndrome
2. occulomotor nerve palsy
How can you distinguish between horners syndrome from occulomotor nerve palsy which both cuase ptosis?
in CN III palsy:
- the ptosis is more marked ( LPS muscle weakness )
- there is midriasis ( dilated pupil )
- Absence of the other features of horners syndrome i.e. enopthalmos, anhydrosis and flushing
In Horners Syndroms:
* Ptosis is less marked compared to CN III palsy ( superior tarsal muscle weakness ) * apparent enophthalmos ( sunken eye ) * miosis * Anhydrosis * flushing
What is the pathophysiology of Horner’s syndroms and which muscle is responsible for the ptosis seen ?
When the sympathetic supply to the head is lost.
Loss of superior tarsal muscle supply
but in CNIII palsy ptosis is due to loss of LPS ( levator palpebrae superiosis muscle ). this is the parger of the 2 muscles and is responsible for a greater degree of elevation of the upper eyelid.
