Miscellaneous 2 Flashcards
What is gynaecomastia and what causes it? What is the difference between this and galactorrhoea?
Gynaecomastia is abnormal amount of breast tissue in males usually due to increased oestrogen:androgen ratio Galactorrhoea is different and due to actions of prolactin on breast tissue
Key questions in gynaecomastia history?
Duration, progression Systemic symptoms - visual disturbance? Any new medications PMH - liver disease, testicular issues Family history Drug/alcohol use
Which testicular issues are associated with gynaecomastia?
Previous orchidopexy for cryptorchidism could predispose to hormone-secreting testicular tumours
Investigation of gynaecomastia?
Clinical exam - breast and testicular Testicular US if indicated Bloods - inlc BHcG and prolactin
9 causes of gynaecomastia?
Physiological e.g. in puberty Androgen deficiency - Klinefelters Testicular failure e.g. mumps Testicular cancer e.g. HcG secreting seminoma Liver disease Ectopic tumour secreting HcG Hyperthyroidism Haemodialysis Drugs e.g. spironolactone, digoxin, cannabis, cmietidine, finasteride, steroids and oestrogens
Management options for idiopathic gynaecomastia?
Conservative Medical - tamoxifen Surgical - liposuction (better than subareolar incision and excision of tissue)
What is acute pancreatitis? Underlying mechanism of damage?
Acute inflammation of the pancreas gland causing interstitial oedema, cellular destruction and release of pancreatic enzymes Presumed mechanism is premature activation of enzymes within the gland itself
Investigating/diagnosing pancreatitis?
Largely clinical Amylase can be acutely raised up to around 48 hours before falling again, if over 3x greater than normal = suggestive. Lipase less prone to false negative as elevated for longer CT not routinely done unless delayed, severe or uncertain diagnosis All patients need CXR and US to look for stones
How to identify severity of pancreatitis?
Clinical factors including obesity, hypoxia, haemodynamic compromise and signs of haemorrhage Biochemical factors including age, liver enzymes, urea, glucose, LDH, albumin, O2 sats, WCC
What scoring systems are there for acute pancreatitis? What is the difference? What constitutes a severe attack?
Glasgow Ranson Difference is when parameters are measured - on admission or at 48 hours Severe attack = derangement of 3 or more parameters, or CRP over 150 at 48 hours
What is the mortality of a severe attack of pancreatitis?
20-50%
Complications of acute severe pancreatitis?
Early - ARDS, renal failure, haemodynamic instability and shock Mid (1 week) - local complications e.g. necrosis, fluid collections, peripancreatic abscesses, haemorrhage, effusion, splenic vein thrombosis Later (over 4 weeks) - pseudocyst, chronic pancreatitis
When and why would you CT an acute severe pancreatitis routinely?
Around 1 week - to look for necrosis
Management of pancreatic necrosis?
Conservative - enteral nutrition, monitoring If infected - radiologically aspirate for MC+S and start antibiotics, usually minimal invasive Surgical necrosectomy as rescue procedure
Management of pancreatitis associated with gallstones?
US - if stones do MRCP Do ERCP or cholecystectomy when well in same admission or soon after Alternative would be cholecystectomy an on table cholangiogram +/- transcystic CBD exploration
Management of fluid collections in pancreatitis?
Generally percutaneous - drain if exerting significant pressure or if infected
Manage of haemorrhagic pancreatitis? Where does the blood come from?
May be managed with IR if bleeding from retroperitoneal vessels
What clot complication may occur in severe pancreatitis?
Portal or splenic vein thrombosis, which may cause portal hypertension
Managing pancreatitic pseudocyst?
If over 6cm, persists over 12 weeks and symptomatic can either do cystogastrostomy or minimally invasive alternative
What is the most common extra-intestinal complication of Crohn’s in GI tract? Why?
Gallstones - because of impaired bile salt resorption in terminal ileum
4 reasons why diarrhoea may occur in Crohn’s disease?
Inflammation in acute phase causing wall inflammation and secretion of mucous into bowel lumen Terminal ileal disease and bile acid malabsorption Patients with extensive resection or extensive disease causing short gut syndrome due to decreased absorption Entero-colic fistulas - small bowel contents straight into distal colon
What is this?
Erythema nodusm
What is this and where may it be found in IBD patients?
Pyoderma gangrenosum - around stoma sites
What is this? What is it made of and how is it managed?
Ganglion cyst - soft mobile compressible lesion usually on dorsal aspect of wrist- cyst wall of epithelial cells containing fluid from underlying tendon or joint - may occur due to ligaementous strain or embryological remnant of synovial tissue
Usually conservative - usually resolve spontaneously
If excise, risk of recurrence
Usually excise volar ganglia but consider where radial artery is
From what do dorsal ganglia arise? What about volar?
Scapholunate articulation
Volar more from radiocarpal joint and adhere to radial artery
What is a Maisonneueve injury?
spiral fracture of fibula extending inferiorly to inveolve syndesmosis with injury to malleolus
2 mechanisms of traumatic pneumothorax?
Penetrating trauma - flap of lung issue creating one-way valve
Blunt injury cauing rib fracture which may pierce pleura
What should you do for lung penetrating trauma with even very small pneumothorax? Why?
Chest drain
May progress to tension
How are flat feet typically managed?
Conservatively, with insoles/shoe inserts
How is ankle arthritis managed?
Symptomatically, can consider arthoplasty or arthrodesis
What are the 3 main ankle ligaments that you can assess clinically? How?
Deltoid - felt at medial malleolus - evert foot
Lateral - felt at lateral malleolus - invert foot
Tibiofibular (inferior) ligament - anteriorly around joint - dorsiflex and move talus laterally, if disrupted talus moves
What is pes planus and what causes it in adults?
Flattening of arches - in adults degenerative, obesity
What is plantar fasciitis?
Tearing of calcaneal attachment of plantar fascia - thick and tender on examination
What is hallux valgus?
Lateral deviation of great toe where first metatarsal head moves off sesamoids to increase intermetatarsal angle, causing corns and calluses
What is Charcot foot?
Markedly deformed foot with lack of sensation and hyperaemia, stigmata of arterial insufficiency. Secondary to diabetes, neuropathy
What is a Morton’s neuroma?
Plantar digital neuroma of plantar nerve between 3rd and 4th metatarsal heads, causing burning pain and paraesthesia of affected toes.
Examinatino findings for Morton’s neuroma?
Palptaing between and just distal to metatarsal heads is painful
Metatarsal comperssion may cause Mulder click
What deformities and exam findings may be seen in CMT?
Symmetrical elevation of arches with plantar flexed first ray, hindfoot varus, claw toes and flat foot
Heel-toe walking (Marionette gait) and absent ankle jerks
What is anterior metatarsalgia and what is on exam?
pain under metatarsal heads with associated widening of foot, flattened medial arch, claw toes and calloses
Describe this? How would you manage?
Distal radial transverse fracture of left wrist with dorsal angulation of fracture fracgment, associated ulnar styloid fracture
Manage with reduction and casting with haematoma block, or consider fixing given styloid fracture
What would make you surgically manage a fracture?
Young person, high energy mechanism of injury
Suggestive of instability:
Dorsal tilt of more than 20 degrees
Communited fractures
Ulnar styloid injury, neck of femur injury etc.
Intra-articular disruption
How much of the cardiac cycle is normally made up of diastole?
2/3
