Evaluation and management Flashcards
1
Q
Pancreatic cancer evaluation and management
A
Hx
- Obstructive jaundice
- > pale stools/dark urine
- > pruritus
- Exocrine dysfunction
- > steatorrhoea
- > weight loss
- Endocrine dysfunction
- > polyuria/polydipsia/fatigue
- Malignancy
- > smoking
- > family hx
- > peutz jeghers
- > autoimmune pancreatitis
Exam
- Raynaud’s pentad
- > fever
- > hypotension
- > mental status
- Advanced disease
- > epigastric mass
- > hepatosplenomegaly
- > courvoisiers sign (painless enlarged gallbladder + jaundice)
- > trousseau’s sign (migratory thrombophlebitis)
- > sister mary joseph nodule (erythematous umbilical mets)
Investigations
- FBC
- > platelets in DIC
- > anaemia
- > leukocytosis in cholangitis
- EUCs
- > AKI + electrolyte derangement in cholangitis
- Coags
- > prolonged PT (vitamin K dependent factors)
- LFTs
- > obstructive
- > transaminitis in cholangitis
- CA 19-9
- > baseline for treatment
- > pancreatic/cholangiocarcinoma/gastric
- CEA
- > cholangiocarcinoma/IBD
- CA-125
- > cholangiocarcinoma/ovarian
- Review CT + contrast
- > respectability (SMA/coeliac trunk/distant mets)
- Consider
- > endoscopic ultrasound guided FNA
- > ERCP + biopsy
Management
- Suspected cholangitis
- > call for help + ICU transfer
- > blood cultures
- > IV pip/taz + fluids
- > ERCP or percutaneous transhepatic cholangiography
- Approach determined by
- > tumour factors (stage/grade)
- > patient factors (age/comorbidities/ECOG)
- MDT
- > oncologists
- > surgeons
- > pain team
- > palliative care
- > psychological support
- Resectable
- > whipple (pancreaticoduodenectomy + antrectomy)
- > adjuvant chemo +- radiation
- > pancreatic enzyme replacement
- > 5 year survival = 20%
- Unresectable
- > endoscopic stent insertion or biliary bipass
- > consider chemo or radiation
- > pancreatic enzyme replacement
- > pain management + palliation
- > median survival = 3-6 months
2
Q
RIF pain evaluation and initial management
A
DDx
- Appendicitis
- > local abscess
- > plegmon
- Diverticulosis
- Volvulus
- Neoplasia
- Psoas abscess
- Inguinal hernia
- Infected haematoma
Hx
- PC
- > SOCRATES
- > change in bowel habits
- > fevers/nausea/vomiting
- > weight loss/fatigue
- Past hx
- > appendectomy
- > surgery on abdomen
- > diverticulosis
- > IBD
- Family hx
- > cancer
Exam
- Vitals
- > septic?
- Appearance
- > ill/well
- > moving/not moving
- > previous scars
- > distension/mass
- > erythema of overlying skin
- Abdo
- > acute abdomen/peritonitis
- Inguinal
- > lymphadenopathy
- > masses
- Scrotum
- > cryptocordism
- > masses
Investigations
- Urine dipstick
- > genitourinary mimics
- VBG
- > lactate/pH
- > electrolytes
- FBC
- > leukocytosis
- EUC
- > dehydration
- CRP
- > inflammation
- Blood group and hold
- Consider blood cultures
- Ultrasound
- > appendix enlarged
- CT
- > rule out alternative ddxs
Management
- Keep nil by mouth
- IV access
- > fluids
- > analgesia
- Gen surg consult
- > abscess = percutaneous drain + antibiotics
- > no abscess = antibiotics
- Delayed appendectomy
- > adhesions worst at 2 weeks
- > high risk for right hemi
3
Q
Bowel obstruction evaluation and management
A
Issues
- Peritonitis/pseudo-obstruction of caecum
- > perforation
- Dehydration/shock
- Electrolyte imbalance
Targeted hx
- PC
- > characterise obstipation
- > pain with jarring movements
- > vomiting (bilious)
- > blood or mucus in stools
- Past hx
- > abdo surgeries
- > IBD
- > malignancy
- > radiation
- > thyroid
- Medications
- > opioids/CCB/anti-depressants
Targeted exam
- Vitals
- > fever
- > haemodynamically stable
- Volume status
- Abdomen
- > signs of peritonism
- > mass
- > ascites
Investigations
- VBG
- > pH
- > lactate
- > electrolytes
- ECG
- > electrolyte disturbance
- FBC
- > leukocytosis
- CRP
- Urea/creatinine
- > dehydration
- LFTs
- Lipase
- Xray
- > evidence of obstruction
- > evidence of perforation
- CT abdomen
- > mechanical vs functional
- Endoscopy
- > best for left sided malignancy
Management
- Keep NBM
- IV access
- > fluids + electrolytes
- > analgesia
- Gastric decompression
- > NG with suction (ineffective if competent ileocaecal)
- Early gen surg consult
- > pseudo-obstruction = flatus tube +- neostigmine
- > ischaemia/perforation = laparotomy
- Monitor
- > lactate
- > WCC
- > CRP
- > fluid + electrolytes
4
Q
LUTS evaluation and management
A
Hx
- FUNWISE
- > frequency
- > urgency
- > nocturia
- > weak flow
- > intermittency
- > straining
- > emptying incompletely
- Late stage neoplasia
- > dysuria
- > haematuria
- > weight loss/anorexia
- > bone/back pain
- Family hx
- Medications
- > anticholinergics
- > α agonists
- > diuretic
- Social
- > diet and exercise
- > salt and water intake
Exam
- DRE
- > pain
- > symmetry
- > loss of median
- > consistency
- > nodules/induration
- Abdo
- > hepatomegaly
- > palpable bladder
- > lymphadenopathy
- Spine
- > boney tenderness
- > lower limb power/sensation/reflexes
Investigations
- PSA
- > 40’s = 2.5 (add 1 for every decade after)
- > cancer/BPH/prostatitis/DRE
- Urinalysis
- > UTI
- EUCs
- > ureter obstruction
- FBC/LFT/testosterone
- > baseline for androgen deprivation therapy
- Consider
- > bone scan with supportive X-ray
- > pelvic CT/MRI
- Ultrasound guided biopsy
- > elevated PSA + mass
- > gleeson group
BPH management
- Watchful waiting
- Behavioural management
- > fluid restriction
- > bladder training
- > avoid constipation
- Review medications
- > α agonists
- > diuretics
- Pharmacotherapy
- > α blocker (terazosin/tamsulosin)
- > 5 α reductase inhibitors (finasteride)
- > phosphodiesterase inhibitor (sildenafil)
- Surgery
- > transurethral needle ablation (TUNA)
- > prostatic urethral lift (PUL)
- > transurethral resection of prostate (TURP)
Prostate cancer management
- Choice determined by
- > life expectancy/goals of treatment
- > disease risk (GG/PSA/number of +ive biopsies)
- Observation
- > aim to palliate symptoms if they arise
- Active surveillance
- > aim to definitively treat disease when progressed
- Brachytherapy
- > may be given as high or low dose rate
- External beam radiotherapy
- > daily therapy for two months
- > majority have erectile dysfunction
- > bowel dysfunction common
- Radical prostatectomy
- > only when localised to prostate/capsule
- > may not reduce mortality
- > erectile dysfunction in vast majority
- Metastatic disease
- > androgen deprivation therapy (surg/LDH antagonists)
- > denosumab prevents boney met complications
5
Q
Impotence evaluation and management
A
Hx
- Characterise specific issue
- > onset and duration
- > context (pervasiveness/specific)
- > difficulty with obtaining or maintaining
- > morning erections
- > erections with self-stimulation
- Associated symptoms
- > penile sensation (numbness/pain)
- > premature/delayed ejaculation
- > peyronies disease
- Psychosocial
- > partners and relationships
- > partner satisfaction/relationship issues
- > life stressors/mental health
- > libido
- > impact on quality of life/distress
- Past hx
- > Diabetes
- > CVD/HTN/dyslipidaemia
- > depression/anxiety
- > prostate disease/pelvic surgery or radiation
- > endocrine disorders
- > neuro disorders
- Medications
- > anti depressants/psychotics/hypertensives
- Substances
- > smoking/drinking/drugs
Exam
- General appearance
- > secondary sex characteristics
- > gynaecomastia
- Cardiovascular and peripheral vascular exam
- Thyroid exam
- Lower neurological exam
- Genital exam
- > deformities
- > plaques
- > angulation
- > tesicular size
Consider
- fasting blood glucose/HbA1c
- lipids
- TSH
- serum testosterone if low libido
Management
- Overall
- > treat underlying medical cause
- > shared decision making
- > dictated by invasiveness/safety/cost
- Lifestyle
- > weight loss/diet/exercise
- Psychological
- > couples/individuals psychotherapy
- Pharmacotherapy
- > phosphodiesterase 5 inhibitors (sildenafil)
- > intracavernosal prostaglandin injection
- > intraurethral prostaglandin suppository
- Surgery
- > peyronies = clostridium collagenase injection
- > vascular = vascular/uro for revascularisation/prosthesis
6
Q
Septic arthritis management
A
Primary survey
- Sepsis/septic shock
- Confirming diagnosis
- > red/hot/swollen/tender/fever
Focused hx
- pain
- involved joints
- recent trauma/surgery
- systemic illness
- hx of osteo/immunosuppression/joint replacement
Investigations
- FBC
- > leukocytosis common
- CRP/ESR
- > elevated
- EUCs
- > antibiotics
- Blood cultures
- Aspiration before abx (into blood culture bottle)
- > cell count = high WCC with neutrophils
- > culture = moderate sensitivity
- > gram stain = increased sensitivity/rapid results
- > polarised microscopy = crystals may co-occur
- Xray
- > usually normal
- > excludes ddx’s (fracture/osteomyelitis)
- Ultrasound
- > very high sensitivity
- > used to guide aspiration
Management
- Ortho consult urgent
- Keep NBM
- IV access
- > fluids
- > adequate analgesia
- Antibiotics
- > guided by gram stain (assume staph if none)
- Gram +ive cocci in clusters (s. aureus)
- > flucloxacilin 2g IV
- Gram +ive cocci in chains (strep) or gram -ive
- > cefotaxime 2g IV
- Drainage
- > needle aspiration
- > arthoscopic or arthrotomy (allows irrigation)
- > repeat drainage may be necessary
- Monitor
- > clinical condition
- > WCC and ESR/CRP
- > consider repeat synovial fluid analysis
7
Q
Pyelonephritis evaluation and management
A
Issues
- Complicated ureteric colic
- > pyelonephritis
- > UTI
- Risk of sepsis
Hx
- PC
- > pain (colick vs constant/loin vs groin)
- > dysuria/frequency/urgency
- > nausea and vomiting
- > dizziness/syncope
- > fluid intake
- > urine output
- Differentials
- > change in bowel habits
- > blood/mucus in stool
- > painful swollen testicle
- Risk factors for complicated disease
- > previous stones
- > immunocompromised
- > kidney/bladder disease
- > recent catheterisation/instrumentation
Exam
- Vitals
- > febrile
- > haemodynamically stable
- Assess for evidence of shock
- Determine volume status
- Costovertebral tenderness
- Abdo
- > tenderness (ddx)
- > palpable bladder
Investigations
- Urinalysis
- > dipstick = leuks/nits
- > MSU for MCS
- VBG
- > lactate/pH
- > electrolytes
- FBC
- > leukocytosis
- CRP/ESR
- EUCs
- > AKI
- CMP
- Uric acid
- Blood cultures
- Imaging
- > xray + CT KUB (colic picture)
Management
- Admit
- > high risk for sepsis
- Urgent urology review
- IV access
- > adequate analgesia (NSAIDs have good evidence)
- > anti-emetic
- > maintenance fluids
- Empirical antibiotics
- > IV gentamicin + amoxicillin
- > switch to targeted/swab cetriaxone for gent after 72hrs
- > total course (oral + IV) = 14 days
- Monitor
- > fluid balance/kidney function
- > electrolytes
- > signs of sepsis/shock
- Stone
- > surgical intervention indicated due to complication
- > laser lithotripsy + stent
- > extracorporeal shock wave lithotripsy
- > percutaneous nephrolithotomy for large proximal stone
8
Q
Epididymitis evaluation and management
A
Hx
- Epididymitis
- > unilateral pain and swelling
- > UTI/STI symptoms (frequency/urgency/dysuria/discharge)
- Torsion
- > sudden onset/severe pain (important to determine timing)
- > several hrs after exercise or trauma/often at night
- > no relief with scrotal elevation
- > hx of intermittent pain/relief (torsion/de-torsion)
- > nausea/vomiting/abdo pain
- Past hx
- > prostate/bladder disease/instrumentation (non STI risk)
- > immunosuppression/diabetes (non STI risk)
- > past STI’s
- > abdo surgery/hernias
- Social
- > vaccination (mumps)
- > sexual hx (STI risk/insertive anal sex)
Exam
- Vitals
- > fever
- Epididymitis
- > swollen/erythematous/tender hemiscrotum
- > swollen/tender epididymus
- > diffuse enlargement = epididymo-orchitis
- > meatal discharge = urethritis
- > reactive hydrocele = fluctuance/transillumination
- > abscess = induration
- Torsion
- > bell clapper deformity
- > high riding
- > negative cremaster reflex
- > relief with detorsion away from midline
- Abdo
- > local tenderness
- > bowel sounds (including in scrotum)
- DRE
- > enlargement = increased risk non STI
- > tenderness = prostatitis
Investigations
- Urinalysis
- > dipstick leuks/nits = UTI
- > MSU for MCS
- > First catch for chlam/gon NAAT
- Urethral discharge
- > swab and culture for gonorrhea sensitivity
- Ultrasound doppler
- > whirlpool sign = torsion
- > reduced blood flow
- Consider STI risk
- > HIV/syphilis/hepatitis
Management
- Urgent urological consult
- > time is testicle for torsion
- > orchiectomy/orchidopexy for torsion
- > manual detorsion (open book)
- Analgesia
- > simple to morphine
- Simple epididymitis = symptomatic relief
- > discharge home
- > rest
- > scrotal elevation
- > simple analgesia
- Systemically unwell
- > admit
- > IV fluids
- > IV antibiotics
- Empirical antibiotics
- > STI risk = cetriaxone IM + doxycycline oral
- > insertive anal = cetriaxone IM + levofloxacin oral
- > suspected UTI = cefalexin oral + trimethoprim oral
9
Q
Gastric ulcer management
A
H pylori testing
- Biopsy at endoscopy
- > histology (neoplasia/NSAID/gastric metaplasia/MALT)
- > rapid urease test
- Non invasive testing
- > serology is inaccurate and not recommended
- > urea breath test/stool antigen (highly sensitive/specific)
- > sensitivity decreased by PPI/bismuth/antibiotics
- > cease bismuth/antibiotics for 4 weeks
- > cease PPI for 2 weeks (switch to H2 antagonist)
ZE testing
- Indication
- > multiple/refractory ulcers
- > ulcers distal to duodenum
- > family hx
- Fasting serum gastrin
- > cease PPI before test
Additional investigations
- FBC and iron studies
- > anaemia due to chronic bleed
- EUCs
- > antibiotics
- Blood group
- > if active bleeding
Management
- Active bleeding
- > cease NSAIDs
- > adrenaline + cautery or clip
- > blood transfusion if Hb <70
- > IV esomeprazole 80mg then 40mg BD
- > monitor urine output/frequent obs
- H pylori negative
- > cease NSAIDs
- > swap celecoxib if needed
- > esomeprazole oral 20-40mg for 4-8 weeks
H pylori positive
- Overview
- > cease NSAIDs
- > triple therapy is first line (80% effective)
- > amoxicillin resistance is extremely rare in Aus
- > metronidazole resistance = approx 50%
- Triple therapy (antibiotics cure pylori) = 80% effective
- > amoxicillin 1g BD for 7 days
- > clarithromycin 500mg BD for 7 days
- > esomeprazole 20-40mg BD for 7 days
- Quadruple therapy (please boost my therapy)
- > failure/previous macrolide exposure/penicillin allergy
- > esomeprazole 20-40mg BD for 14 days
- > bismuth 120mg QD for 14 days
- > metronidazole 400mg TDS for 14 days
- > doxycycline 50mg QD for 14 days
- Eradication testing
- > urea breath test
- > cease bismuth/antibiotics for 4 weeks prior
- > cease PPI for 2 weeks prior
Benefits of h pylori treatment
- Peptic ulcer
- > promotes healing
- > reduces risk of relapse
- Dyspepsia
- > improves
- NSAID user
- > 60x peptic ulcer risk
- > 6x bleeding risk
- Atrophic gastritis/intestinal metaplasia
- > reduce progression to gastric carcinoma
- Long term acid suppression
- > reduced progression to metaplasia
- Low grade MALT lymphoma
- > induce regression
10
Q
Nipple discharge ddx
A
Lactation
-up to 6 months post partum
Physiological (galactorrhea)
- multiple ducts involved
- tends to be bilateral (can be unilateral)
- may be milky/white/clear
- > not bloody
- secondary to
- > meds (anti psychotics/tricyclics/methyldopa)
- > pituitary lactotroph
- > stress
Pathological
- General
- > often unilateral
- > persistent/spontaneous (not just with massage)
- > clear/bloody/serosanguineous
- Papilloma (most common pathological cause)
- > papillary tumour in lining of duct
- > benign but can harbour DCIS
- Duct ectasia (common)
- > benign
- > duct widening at the ampulla
- > thickened walls
- > most common in post menopausal
- Mastitis
- > purulent discharge
- > younger women/highly correlated with smoking
- > peri-areolar inflammation
- > may lead to abscess
- Cancer
- > most common to cause discharge is DCIS
- > mass
- > pagets disease
- > eczema like plaque on areola/nipple + copious exudate
11
Q
Evaluation and management carotid stenosis
A
DDx
- hyperdynamic flow hyperthroidism
- radiating aortic murmur
Bruit
- up to 50% have stenosis of any severity
- > approx 2% have severe stenosis
- benefit of follow up screening
- > asymptomatic bruit alone is controversial
- > definitely if presence of any high risk factor
Screening
- High risk factors
- > PAD
- > CAD
- > HTN
- > hypercholesterolaemia
- > smoker
- Duplex ultrasound
- > similar accuracy to MRA/CTA (approx 95%)
- CTA/MRA
- > use when ultrasound equivocal/moderate stenosis
- > anatomy proximal/distal to carotid + aortic arch
- > more accurate for ddx
- Degree of stenosis
- > North American Symptomatic Carotid Endarterectomy Trial criteria (NASCET) is most accepted
- Additional info
- > anatomy
- > collateral flow
- > ddx
Additional investigations
- MI workup
- > ECG
- > stress test
- > echo
- Urea/creatinine
- Lipids
- Fasting glucose/HbA1c
- Coags
- Group + hold
Management
- Asymptomatic
- > pharm/risk modification for <70% stenosis
- > consider endarterectomy for >70% stenosis
- > expert option split 50/50 for asymptomatic intervention
- Symptomatic
- > pharm/risk modification for <50% stenosis
- > endarterectomy for >50% stenosis
- Bilateral
- > endarterectomy for any >70%
- > approx 1 month apart if both >70% (handedness first)
- Pharmacotherapy
- > aspirin 300mg
- > second line = clopidogrel 75mg
- > continue anti-coagulation without aspirin if already on
- Risk factor modification
- > smoking cessation
- > exercise
- > high intensity atorvastatin (LDL <1.8)
- > anti-hypertensive
- Endovascular stenting
- > riskier in elderly (stroke/death)
- > unfavourable anatomy/very high lesion/restenosis
12
Q
Arterial vs venous vs neuropathic ulcer
A
Hx
- Venous
- > heavy legs
- > fatigue
- > aching (worse in arvo or standing/better elevated)
- > prior DVT/standing/family hx/smoking/older
- Arterial
- > claudication/rest pain
- > ulcer painful
- > smoking/diabetes/dyslipidaemia
- Neuropathic
- > painless
- > diabetes/peripheral neuropathy
- Other
- > trauma
- > bites
- > medications (heparin/warfarin)
- > autoimmune disease
Exam
- Venous
- > gaiter distribution/medial or lateral malleolus
- > shallow/irregular borders with yellow exudate
- > telangiectasia/reticular/varicose
- > eczema/pigmentation
- > lipodermatosclerosis/atrophie blanche
- > oedema
- > normal pulses
- Arterial
- > pressure areas (heels/distal toes/shin/malleoli)
- > well demarcated/punched out
- > overlying necrotic eschar
- > shiny atrophic skin with hair loss
- > weak pulses/cap refil/positive beugers
- Neuropathic
- > same location as arterial
- > punched out with surrounding callous
- > dry scaly feet
- > decreased sensation
Investigations
- Duplex ultrasound
- > obstruction
- > reflux
- ABI
- > ratio <0.9 = PAD
13
Q
PAD evaluation and management
A
Hx
- Claudication
- > reproducible pain on exertion/relieved by rest
- > buttock/hip = aorta/iliacs
- > thigh = common femoral
- > calf = superficial femoral/popliteal
- Additional symptoms
- > rest/night pain relieved by hanging off bed
- > non healing ulcers/wounds
- > paresthaesia/paralysis
- > erectile dysfunction
- Past hx
- > diabetes/dyslipidaemia/HTN
- > CAD/stroke
- Family hx
- > CVD disease
- Medications
- > statins/anti-platelet/anti-hypertensives
- Social
- > smoking/drinking/drugs
Exam
- Chronic limb ischaemia
- > weak pulses
- > gangrene
- > ulcers
- > muscle atrophy
- > shiny hairless skin/nail dystrophy
- > beurgers positive
- Acute limb ischaemia
- > pallor
- > pulseless
- > perishingly cold
- > paresthaesia
- > paralysis
- > pain
- Additional
- > check all peripheral pulses
- > listen for bruits
- > cardiovascular exam
ABI
- Measure
- > SP of brachial artery both arms
- > SP of posterior tibial and dorsals pedis both legs
- Calculate
- > highest leg pulse on each side/higher of left and right arm
- Diagnose
- > PAD <0.9
- > false negative if severely occluded
- > less accurate in diabetics
Additional investigations
- FBC
- > anaemia
- EUCs
- > contrast
- > CKD
- Lipids
- Fasting glucose
- Duplex
- > if ABI positive
- > assess location and degree of stenosis
- DSA
- > if duplex positive
- > most accurate for degree/location of stenosis
- Exercise ABI
- > if claudication but resting ABI normal
- MI risk
- > ECG
- > stress test
Management
- Everyone
- > aspirin
- > statin
- > beta blockers
- > diabetes control
- > some evidence for ACEI
- Acute limb ischaemia
- > urgent assessment of viability with duplex/ABI
- > UFH
- > paracetamol + opioid
- > viable limb = endovascular revascularisation
- > non viable limb = amputation
- Chronic limb ischaemia
- > exercise
- > cilastazol/pentoxiflline
- > surgical/endovascular revascularisation
- Endovascular revascularisation
- > percutaneous angioplasty/stenting/thrombus extraction
- > supported with thrombolysis
- Surgical revascularisation
- > endarterectomy
- > bypass
14
Q
Varicose vein evaluation and management
A
Hx
- Typical CVI symptoms
- > heavy legs/fatigued
- > worse with prolonged standing/in evening
- > relieved by elevation
- > restless legs
- > burning/itching over veins
- > cramps (often nocturnal)
- Past hx
- > DVT
- > trauma
- > ulcerations
- > bleeding from varicosities
- Family hx
- > strong genetic link
- Additional
- > smoking
- > pregnancy
Exam
- Inspection
- > body habits
- > presence and location of varicosities (>3mm)
- > tenalgectasia/reticular veins
- > oedema
- > eczema/haemosiderin staining
- > atrophie blanche/lipodermatosclerosis
- > wounds/ulcerations
- Palpation
- > non visible varicosities
- > hard varicosities = thrombosis
- > peripheral pulses
- > temperature
- > cap refill
- > cough impulse at saphenofemoral valve
- Auscultation
- > bruits
- Trendelenburg
- > elevate leg and drain veins
- > pressure/tourniquet on saphenofemoral valve
- > stand while maintaining pressure
- > empty = incompetent saphenofemoral valve
- > full = incompetent calf/thigh valves (do Perthes)
- > repeat progressively distally to find lesion
- Perthes
- > repeat trenedeleburg but release small amount of blood
- > calf pumps
- > empty = competent perforator valves/deep veins
- > full = incompetent deep venous system
Duplex
- Assess for reflux
- > deep/perforator/superficial/tributaries
- > valve closure > 0.5s for superficial and >1s for deep
- > valsalva for proximal/compress thigh for distal
- Rule out DVT
Management
- Assign CEAP class
- Lifestyle
- > weight loss
- > elevation
- > leg exercises
- > compression stockings
- Superficial tributary disease only
- > phlebectomy by stab avulsion
- > foam sclerotherapy
- Saphenous insufficiency
- > endovenous thermal ablation
- > ultrasound guided foam sclerotherapy
- > stripping + ligation
- Deep vein insufficiency
- > phlebectomy or sclerotherapy
- > lifelong compression
- Ulcer
- > wound debridement
- > multi-layer dressing (may be absorptant)
- > pentoxyfylline (phosphodiesterase inhibitor)
- > barrier cream
- > no evidence for growth factors/antibiotics
- Analgesia
- > simple
- > horse chestnut seed extract
- Eczema/dry skin
- > cleansing
- > moisturiser
- Consider perforator treatment
- > surgery/sclerotherapy/thermal ablation
15
Q
Necrotising fasciitis
A
Hx
- Cellulitis symptoms
- > fever/chills/mailaise
- Necrotising fasciitis symptoms
- > presyncope/dizziness
- > confusion
- > palpitations
- > nausea/vomiting
- > pain out of proportion to skin changes
- Risk factors
- > MRSA (past/inpatient/incarcerated/IVD/military)
- > wounds/trauma/surgery
- > immunocompromised/diabetes
- Exposure
- > freshwater
- > saltwater
- > human/animal bite
Exam
- Vitals (SIRS)
- > febrile
- > tachycardia
- > tachypnoea
- Cellulitis signs
- > macular erythema/erysipelas
- > indistinct borders
- > oedema
- > tender
- > lymphadenopathy
- Necrotising fasciitis signs
- > bullae
- > blisters
- > crepitations
- > greyish discolouration
Investigations
- VBG
- > lactate elevated
- FBC
- > leukocytosis with polymorphs
- EUCs
- > high creatinine/low Na = third spacing
- CRP
- > elevated
- CK
- > elevated
- Blood cultures
- CT
- > soft tissue gas in fascial plane
- Microbio (culture and microscopy)
- > wound swab/skin aspiration
- > tissue sample at surgical exploration is best
Management
- Surgical emergency
- > immediate consult
- > urgent exploration and wide debridement
- Antibiotics
- > urgent ID consult
- > IV vancomycin + meropenem + pip/taz
- Fluid resuss
- > intensive support usually required
- Analgesia
- > IV morphine
