eMedici- surgery Flashcards

Question

ddx of groin mass

Answer 1

\* 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

Answer 2

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.

Answer 3

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

Answer 4

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

Answer 5

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.

Answer 6

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

Answer 7

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.

Answer 8

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

Answer 9

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.

Answer 10

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.

Answer 11

Multi-parametric MRI is now becoming the standard of practice in the initial assessment of a patient with suspected carcinoma of the prostate.

Answer 12

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.

Answer 13

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

Answer 14

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.

Answer 15

IntracapsularFemoral headFemoral neck (sub capital) ExtracapsularTrochantericIntertrochantericSubtrochantericTypical fracture sites of the proximal femur

Answer 16

The presence of CSF can be confirmed by testing the fluid for beta-2-transferrin.

Answer 17

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!

Answer 18

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.

Answer 19

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

Answer 20

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.

Answer 21

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.

Answer 22

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.

Answer 23

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.

Answer 24

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.

Answer 25

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.

Answer 26

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.

Answer 27

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.

Answer 28

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.

Answer 29

Groin 'hernias' that are not clinically evident and only found on imaging are unlikely to be of any clinical significance.The pain that the patient experienced is almost certainly musculoskeletal in origin, especially with the finding of the area of tenderness. With a normal physical examination that does not find any clinically apparent inguinal hernia, all the patient needs is reassurance and the explanation that his pain will settle on its own accord. He should be advised that further heavy lifting or straining might aggravate things. Whilst an ultrasound examination is a very commonly performed examination in the assessment of patients with groin pain, the report in this case can be misleading. The deep inguinal ring has a normal diameter of 2 cm, so the report of a ' 1 cm defect' is of no clinical significance. Likewise herniation of some fat into the canal is very unlikely to be of clinical relevance. Unfortunately this scenario is all to common, with these patients being referred for a surgical opinion and consideration of a 'hernia repair.' ”. Even if this patient was found to have a hernia, recent studies have shown that small, minimally symptomatic, first occurrence hernias do not necessarily require repair; instead, they suggest counselling the patient on red-flag symptoms suggestive of incarceration and strangulation, with advice to seek prompt evaluation in these instances.

Answer 30

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.

Answer 31

Clinical featuresTender, firm, swollen, erythematous breast (generally unilateral)Pain during breastfeeding\* Reduced milk secretionFlu-like symptoms, malaise, fever, and chillsIn some cases, reactive lymphadenopathyDiagnosticsClinical diagnosisBreast milk cultures or imaging may be required if there is no response to initial treatment. TreatmentIn nursing mothers, breastfeeding with alternate breasts is recommended every 2–3 hours.Analgesics (e.g., ibuprofen)\* Cold compressesAntibiotic treatmentOral penicillinase-resistant penicillin or cephalosporin (e.g., dicloxacillin or cephalexin)In the case of methicillin-resistant Staphylococcus aureus (MRSA): clindamycin or trimethoprim-sulfamethoxazole (TMP-SMX) or vancomycin for severe cases In the case of inadequate response to initial treatment:Initiate treatment according to breast milk culture results.Consider an underlying breast abscess, which requires surgical drainage.

Answer 32

IPC includes sleeves/cuffs applied to legs and garmentswrapped around the foot (foot impulse devices) connected to an air pump that sequentiallyinflates to improve venous circulation in the limbs. IPC is more effective than GCS in preventing DVT in surgical patients. IPC is recommended over GCS in patients withmoderate to high VTE risk that are not receiving pharmacological prophylaxis or in patients at very high VTE risk that are on combined mechanical and pharmacological prophylaxis. GCS apply pressure on the leg muscles to squeeze the vein valves starting with the greatest degree of compression at the ankle and decreasing the level of compression up the leg. This helps ensure that blood flows upwards to the heart instead of refluxing downwards

Answer 33

inflammation around some local abscess formation in the wound. Escherichia coli and Bacteroides sp (usually fragilis) are the two most common causes of post-operative wound infection, particularly when some part of the gastrointestinal tract has been opened. Of all the organisms mentions, Escherichia coli is the most likely cause of the wound infection. Salmonella sp do not cause wound infections. Streptococcus epidermidis is a common cause of cellulitis rather than wound infection per se. Whilst Staphylococcal infections are a common cause of dermal and subnormal abscesses, in these circumstances the infection is most likely to be due to a gut-derived organism. Clostridium perfringens is a relatively common cause of food poisoning and when it does cause tissue infection, it usually leads to necrosis.Learning PointsEscherichia coli and Bacteroides sp (usually fragilis- grm - anaerobes) are the two most common causes of post-operative wound infection, particularly when some part of the gastrointestinal tract has been opened.

Answer 34

The two most common causes of acute pancreatitis are gallstones and alcohol. Gallstones are the most common cause of acute pancreatitis, being responsible for at least 40% of cases. Chronic alcohol consumption is the next most common cause, accounting for about 35% of cases. The third commonest cause of acute pancreatitis is iatrogenic (post ERCP or cardiopulmonary bypass), adding up to about 20% of all cases. The other recognised causes (eg hypertriglyceridaemia, hypercalcalcaemia) all total less than 5% of cases. Whilst some drugs can be associated with acute pancreatitis, the NSAIDs have yet to be incriminated. This patient has known gallstones and even though he might have enjoyed a few drinks the evening before his presentation, it would have been the documented gallstones that would have been likely trigger for this episode of acute pancreatitis.

Answer 35

motility disorder as the dysphagia initially worse with fluids rather than solids.

Answer 36

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

Answer 37

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.

Answer 38

Simple analgesia and mobility as tolerated - asap to encourage core musculature focal pain in her lower back from a sudden onset of lifting a heavy item. This is indicative of mechanical trauma, such as a vertebral compression fracture. Typically, compression fractures are fragility fractures common in patients with a background of osteoporosis - a common condition associated with the elderly population. This occurs when bone cortices are thinned and/or cancellous bone has decreased trabecular continuity. Minimal trauma would result in a compression or wedge fracture between each vertebral.The majority of patients can be treated with observation and adequate pain relief with the gradual return of activity/mobilisation. Physical activity should be resumed as quickly as possible if tolerated. This is useful for gait and core strengthening when the patient can tolerate the level of activity.Indications for and timing of surgical management (e.g. vertebral augmentation) remains controversial. There is a limited beneficial effect in vertebral augmentation, and most patients can be treated successfully with conservative management. Surgical management may benefit specific patient groups - debilitating pain and in those who are not improving with conservative management.

Answer 39

C5 -elbow flexionC6- wrist extensionC7- wrist flexion, fingers extensionC8 - finger flexionT1- finger abduction

Answer 40

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)

Answer 41

medial compartment osteoarthritis. This is supported by the chronic progression of the disease, clinical findings of limited flexion/extension, and presence of osteophytes on X-ray.Nonoperative measures which has proven to be beneficial includes simple analgesia (paracetamol and PRN NSAIDs), weight loss if indicated, and low impact exercises. A thorough non-operative program should be initiated prior to any surgical intervention.Learning PointsFirst line management of osteoarthritis includes simple analgesia, weight loss if indicated, and low impact exercise.NOTE-Tibial osteotomy is an available surgical option for treating varus alignment due to medial osteoarthritis, however non-operative measure should be initiated first.Platelet-rich plasma injection (PRP) is another option for symptomatic management of osteoarthritis. However most clinical guidelines do not include PRP as part of their treatment plan as it has limited evidence on its efficiency to improve patients' symptoms

Answer 42

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

Answer 43

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.

Answer 44

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.

Answer 45

Learning PointsFacial nerve weakness in the presence of a swelling in the parotid region indicates malignancy until proven otherwiseThe parotid space contains both the parotid gland and external carotid artery, as well as the intra and extraparotid lymph nodes, retromandibular veins and extracranial branches of the facial nerve.The majority of pathologies related to the parotid space arise from the parotid gland, and may be benign or neoplastic in nature. pleomorphic adenoma- benignadenocarcinoma- malignantPhysical examination of these pathologies is often non-specific, however the facial weakness indicates invasion of the facial nerve, a strong indicator for an underlying malignant process. The facial nerve passes through the superficial and deep part of the parotid gland and facial nerve weakness in the presence of a parotid swelling suggests malignant infiltration and a parotid adenocarcinoma.Metastatic deposits do occur within the parotid gland, however are significantly less common than primary tumours of the parotid gland.

Answer 46

chronic non-allergic rhinitis (formerly called vasomotor rhinitis; renamed due to lack of evidence of vascular aetiology). His triggers of cold air and exertion suggest the most common subtype, termed non-allergic rhinopathy.In addition to trigger avoidance, management is symptom-directed:For patients with predominant rhinorrhoea (as in this case), intranasal ipratropium is first-line. It has a local action on the cells onto which it is sprayed and works by inhibiting the secretion of mucus, with onset within 15 minutes. If symptoms persist, intranasal corticosteroids or antihistamines can be added.For patients with predominant congestion, intranasal corticosteroids and/or antihistamines are first-line, with oral decongestants added if symptoms persist. If symptoms persist despite the above, allergy testing should be considered.

Answer 47

Patellar tendonitis refers to inflammation of the patellar tendon. Also called "jumper's knee", it is commonly seen in athletes, particularly those who play sports such as volleyball and basketball. In patellar tendonitis, the pain typically gets worse with repetitive movement and activity, rather than relieved . In addition, most patients will have localised tenderness over the patella tendon. if no focal tenderness, making patellar tendonitis a less likely diagnosis. Bursitis refers to inflammation of a pre-patellar bursa, the fluid filled sac superficial to the knee joint itself. Bursitis in the knee would likely present with a higher degree of swelling, along with erythema.

Answer 48

Vasospasm presents with focal and/or global neurological deterioration in the days following SAHDelayed cerebral ischaemia is caused by vasospasm, believed to be triggered by blood products in the subarachnoid space irritating the abluminal surface of blood vessels with subsequent ischaemia in the corresponding cerebral tissue. Symptomatic vasospasm occurs in ~30% of SAH patients, and this falls within the peak risk window of 3 - 14 days post SAH. Classic clinical features include confusion and/or increased sedation, plus or minus focal phenomena including territorial motor deficits or cranial nerve palsies.in scenario: The nurse calls you to see him and you find him drowsy and disoriented, complaining of new headache, and you notice a left-sided facial droop and 4/5 weakness of the left upper limb. He is haemodynamically stable, afebrile

Answer 49

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.

Answer 50

Two factors point away from chemical prophylaxis in this scenario: \* the patient has baseline low risk for VTE by virtue of age and lack of comorbidities, \* and increased risk of bleeding is especially concerning after neurosurgery as intracranial haemorrhage carries a poor prognosis. Intermittent pneumatic compression provides greater protection when the patient is immobile than graduated compression stockings, and are therefore the appropriate choice in this scenario.Learning PointsLocal compression devices alone can be used for the young, fit patient undergoing a minor procedure.Chemical prophylaxis must be weighed against the risk of bleeding in a high-risk procedure.

Answer 51

Patella bursitis is common in patients who kneels often. Symptoms may include generalised pain and swelling in the knee, which can be red or warm to touch.Osteochondroma of the proximal tibia is a common benign primary bone tumour. It is usually asymptomatic but can be painful and palpable near the ends of the long bones. X-ray findings include pedunculated or sessile lesions

Answer 52

Bulge sign positive- miniscal tear Medial joint line tenderness- Within jointant/post draw test negative- not cruciate ligamentsinability to fully extend- catching-- medial meniscus buckle handle characteristic of a meniscal injury, the findings of an inability to fully extend the knee supports the diagnosis of a bucket handle medial meniscus tear where the meniscal fragment can displace into the intercondylar notch and act as a physical block to full extension. Whist similar types of non-contact pivoting injuries can lead to cruciate tears, these types of injury are usually associated with a rapid swelling about the knee. In addition, there would typically be joint laxity and anterior or posterior displacement of the tibia.Learning PointsA medial meniscal tear is associated with an inability to fully extend the knee.

Answer 53

means of countering the confusion can be considered. Taking a patient out of their own familiar environment and routine can be disturbing for them and nocturnal confusion is common. Simple measures such as providing human contact and lighting the room may be all that is necessary to restore calm. If that does not work, some form of sedative or hypnotic may be required.Learning PointsSimple measures, such as keeping the patient in a well-lit room, will manage most cases of post-operative confusion.

Answer 54

In most instances it will settle of its own accord, with gut rest and intravenous fluid replacement. During pregnancy, women are at increased risk of gallbladder disease due to increased gallbladder stasis and production of bile with decreased chenodeoxycholic acid and increased cholesterol. This woman is presenting with an episode of cholecystitis, suggested by her prolonged right upper quadrant pain, low-grade fever and right upper quadrant tenderness. She also has a history suggestive of two prior episodes of biliary colic. Laparoscopic cholecystectomy should be considered for all pregnant women with symptomatic gallstones.Evidence has shown that conservative management compared with operative management is linked with significantly higher maternal-fetal complications, including preterm birth and low fetal growth. Patients in the first, second and third trimester who are managed nonoperatively will experience recurrent symptoms secondary to cholelithiasis in 92%, 64% and 44% of cases respectively. Additionally, 23% of patients managed nonoperatively will develop acute cholecystitis or gallstone pancreatitis, which is associated with a high rate of fetal loss. Operative management is therefore recommended, and a laparoscopic cholecystectomy can be safely performed during any trimester.

Answer 55

The most common presentation of a patient with a cerebrospinal fluid leak is clear rhinorrhoea that may be accompanied by a headache, described as ‘pressure-like’ that may be positional in nature. eg as the headache worsens throughout the day after changing position from supine to standing. Other supportive factors are the preceding event being traumatic, craniofacial trauma eg with a deviated nasal septum being evidence of this trauma. CSF leaks also present with clear rhinorrhoea, which is also present in this patient. The most common aetiology is structural compromise due to craniofacial trauma.A CSF leak can occur when there is disruption of the meninges, leading to an open communication between the subarachnoid space and other spaces.

Answer 56

Flexor tenosynovitis is a closed space infection of the flexor tendons and synovial sheaths. The four cardinal Kanavel's signs of flexor tenosynovitis are: (1) swelling over the affected tendon, (2) digit is held in partial flexion at rest, (3) tenderness over the affected tendon (whole tendon on flexor/extensor surface) and (4) pain along the tendon sheath on passive digit extension.Prompt diagnosis is required to prevent tendon necrosis and deeper spread of infection.Pyogenic flexor tenosynovitis is likely secondary to the bacteria being introduced from her prick on the rose thorn. Subcutaneous abscess will not have tenderness along the entire tendon.Cellulitis will present poorly defined erythema and swelling, without the flexor tendon findings. Felon is a subcutaneous infection of the distal fingertip pulp, a closed sac of connective tissue distal to the distal interphalangeal joint. Flexor tendon sheath haematoma is less common, particularly with history of a garden prick from a rose thorn which is likely to be the source of introducing an infection.Learning PointsFlexor tenosynovitis should be suspected in patients with fusiform digit swelling, held in partial flexion at rest and associated with significant pain on passive extension and tenderness on palpation the tendon.

Answer 57

psuedoobstruction- occurs in the elderly, after surgery (especially ortho,cardiac and vertebral), electrolyetsMx - In most instances it will settle of its own accord, with gut rest and intravenous fluid replacement.pharmacological: DOC- neostigmine (erythromycin-prokinetic: Metoclopramide:A dopamine-2 receptor and serotonin receptor antagonist. Commonly used as an antiemetic and to promote gastrointestinal motility in patients with gastroparesis. Adverse effects include extrapyramidal symptoms (e.g., dystonia), likely secondary to dopamine antagonism.if ceacum massively distended (\>10cm) -decompression (colposcopy) If there is massive colonic distension, with the caecum measuring more than 10 cm or there is evidence of peritonism, then some form of active intervention is required. Decompression can often be achieved by colonoscopy and placement of a decompression tube. pseudo-obstruction. This is a well-recognised, but uncommon event, most often occurring in the elderly population. It has many different precipitating causes and typically occurs after pelvic or spinal surgery and can be a sequela of other orthopaedic surgery. It can also occur after trauma, cardiac events or with electrolyte imbalance. In most instances it will settle of its own accord, with gut rest and intravenous fluid replacement. If there is massive colonic distension, with the caecum measuring more than 10 cm or there is evidence of peritonism, then some form of active intervention is required. Decompression can often be achieved by colonoscopy and placement of a decompression tube.In instances where colonoscopy is not thought to be appropriate, pharmacological measures with a cholinesterase inhibitor (neostigmine) or a prokinetic agent may be used. Prokinetics such as erythromycin or metaclopramide are not as effective as neostigmine. Lactulose is contraindicated as this may worsen the situation by encouraging bacterial fermentation. Alvimopan (a peripherally acting opioid receptor antagonist) can be effective in the management of post-operative ileus, but its place in the management of pseudo-obstruction has yet to be shown. Medical therapies have less risk than mechanical instrumentation, but may be less effective.Learning PointsNeostigmine can be effective in the treatment of pseudo-obstruction which is not resolving of its own accord.

Answer 58

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'.

Answer 59

Rotator cuff tearTriggers- risk factors for rotator cuff injuries include age \>40 years, Overhead activities, and repetitive rotator cuff strain (e.g. repeated overhead movements over a long period).Rotator cuff injury most commonly presents with painful abduction and external rotation of the shoulder

Answer 60

The clinical picture fits for biliary pain and the abnormal liver function tests support this (raised billi and alp). She has a dilated common bile duct and now needs more detailed imaging of her biliary systemThis means that there is no easy way of passing an endoscope to her ampulla of Vater. Of the various imaging modalities provided, MRCP will be the least inconvenient and should give adequate definition of the biliary tree. She may well have a stone in her common bile duct. If a stone is found, then some form of laparoscopically-assisted ERCP may provide the solution to the problem.Learning PointsA Roux-en-Y gastric bypass alters the anatomy such that endoscopic access to the biliary tree can be very difficult.

Answer 61

discharge suggests a pathological cause. Whilst duct papilloma is the commonest cause of a pathological nipple discharge, the material is usually clear or bloody. The discharge in duct carcinoma in-situ is often either clear or bloody. In this case, the discharge is a greenish colour and the underlying cause is more likely to be duct ectasia. Mammary duct ectasia is the most common cause of greenish nipple discharge. Look at age of women The absence of breast tenderness or swelling makes mastitis less likely. Paget’s disease of the nipple is rare and typically features visible nipple changes such as scaling or retraction and not discharge. Regardless, tissue diagnosis is important for all pathological discharge to exclude carcinoma.Duct Ectasia- congealed/thickened luminal secretion, stasis leading to periductal inflammation and fibrous obliteration. Epidemiology: Most common in perimenopausal women Peak incidence: 40–50 years Risk factors: tobacco use, congenital nipple malformations Clinical features: Unilateral, sticky, multicolored discharge (e.g., gray, greenish or bloody discharge)\* Nipple inversion\* Firm, stable, painful mass under the nipple (may mimic breast cancer)May progress to a breast abscess Diagnostics: \* Mammography and/or ultrasound: can be used to determine mammary duct diameter Biopsy (if any suspicious or inconclusive imaging findings) . TreatmentUsually not necessary (most cases resolve spontaneously)Antibiotic therapy if infectedSurgical excision for persistent lesions

Answer 62

Definitive management is surgical (Table 1), however the specific procedures depending on the type of fracture sustained, amongst several other factorsFracture TypeSurgical OptionSummaryDisplaced subcapitalHip Hemiarthroplasty\*Replacement of the femoral head and neck via a femoral component fixed in the proximal femurInter-trochanteric and Basocervical\*Dynamic Hip Screw (or short IM nail)Consists of a lag screw into the neck, a sideplate, and bicortical screws. The lag screw is able to slide through the sideplate, allowing for compression and primary healing of the boneNon-displaced intra-capsularCannulated hip screws\*\*Three parallel screws in an inverted triangle formationSub-trochantericAnterograde Intramedullary Femoral NailThe titanium rod is placed through the medullary cavity of the femur for stabilisation Table 2 – Summary of Surgical Options for NOF Fractures; \*consider total hip arthroplasty in systemically well patient who was living independently prior to injury; \*\*can also consider hip hemiarthoplasty or total hip arthroplasty

Answer 63

Learning PointsPneumaturia is best investigated with a CT abdomen.This patient is describing pneumaturia indicated by symptoms of frothy, cloudy urine, interrupted urine stream and bubbling. Gas within the bladder is suggestive of a fistula and further direct visualisation will be required to determine the cause.Of the various potential causes of gas in the urine, the commonest is an enterovesical fistula. Of the many possible causes of fistulous communication between the gut and the bladder, the commonest is diverticular disease. This would be the most likely explanation in this case, particularly as the patient had an episode of undiagnosed pain preceding these symptoms, which could have been diverticulitis. The best investigation for pneumaturia and suspected enterovesical fistula is a CT abdomen. The CT is likely to identify any mass lesion adjacent to the bladder (eg diverticular or tumour mass).CT urogram is a useful investigation for visualisation of the urinary tract including collecting systems, ureters and bladder. This is especially helpful in diagnosing cancers of the bladder but not fistulas. (filling defects)Colonoscopy may show a cause of enterovesical fistula such as a diverticular disease but is less useful in assessing the full extent of the disease and path of the fistula.Cystoscopy allows direct visualisation of the bladder and biopsy of a lesion but does not identify extraluminal content.Pelvic ultrasounds do not provide detailed anatomical information regarding the complexity of a fistula.

Answer 64

plantar fasciitis – an inflammation of the aponeurosis of its origin at the calcaneus. Risk factors include obesity, weight-bearing endurance exercise i.e. running and dancing. Plantar fasciitis presents as insidious sharp heel pain, often when getting out of bed in the morning. Patients may prefer walking on their toes initially, and the pain gets worse at the end of the day after prolonged standing. Physical exam suggests tenderness of palpation at the medial tuberosity of the calcaneus, dorsiflexion of the toes and foot increases with palpation. There is limited ankle dorsiflexion due to tight Achilles tendon.The first-line management is primarily pain analgesia with physical therapy which involves stretching and self-massage. Heel insoles can also be used to provide support and relieve tension as the heel is raised.Extracorporeal shockwave therapy (ESWT) for plantar fasciitis would be second-line management. Surgical interventions are rarely performed and only indicated if conservative management has failed.Steroid injections should very rarely be used for the increased risk of plantar fascia rupture.

Answer 65

Tests for cruciate ligamentsAnterior drawer test and posterior drawer testProcedureThe examinee lies supine with hips flexed to 45° and knees flexed to 90°.The examiner sits on the examinee's feet to secure them in place, holds the leg at the upper ⅓ of calf with both hands, and pushes the leg forward (anterior drawer test) or backward (posterior drawer test).InterpretationLaxity at the endpoint represents a positive test.A positive anterior drawer test indicates anterior cruciate ligament tear.A positive posterior drawer test indicates posterior cruciate ligament tear.Lachman testProcedureThe examinee lies supine and flexes the knee 20–30° with the heel of the foot resting on the examining table.The examiner stabilizes the femur and moves the proximal tibia anteriorly.Interpretation: Excessive anterior movement indicates anterior cruciate ligament tear. Tests for collateral ligamentsValgus stress test and varus stress testDescriptionThe examinee lies supine with the knee flexed to 30°.The examiner holds the examinee's ankle with one hand and uses the other hand to apply pressure to the medial (valgus stress test) or lateral (varus stress test) aspects of the knee joint.InterpretationLaxity at the endpoint is interpreted as a positive test.A positive valgus stress test indicates medial collateral ligament injury.A positive varus stress test indicates lateral collateral ligament injury.

Answer 66

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.

Answer 67

The symptoms and physical findings fit for epididymitis - The commonest cause is reflux of infected urine - usually urinary retention in older men. The most common organism in men \>35 years old is E. coli. In men \<35, other causes must be considered including sexually transmitted infection where Chlamydia is one of the commonest infectious agents. Many patients have co-existing orchitis, but in this case the testis is not tender or swollen. Varicoceles (if thrombosed) can present with acute pain however on examination the engorged venous plexus will be visible/palpated which was not present in this patient. Testicular torsion presents over hours with acute onset severe pain, abnormal lying testes and absent of cremaster reflex. Torsion of hydatid of Morgagni presents similar but usually over a longer time frame and can have a classical 'blue dot sign'. The timeline and physical exam however, do not support these two diagnoses.

Answer 68

Amoebic abscess- protazoa -Entomoeba hystolytica \* Rx with Metronidazole (antiprotazoal) Hydatid cyst - Echinoccocus (tape worm, parasite) - \* Rx with Albendazole (anti Helminthics)

Answer 69

Salivary glands- benign \* pleomorphic adenoma\* warthins tumour malignant \* adenocystic carcinoma \* mucoeitheliod carcinoma \* note proportion of malignant tumours increases as the gland gets smaller.

Answer 70

An enlarged and painless supraclavicular lymph node (Virchow) can be a worrying sign, particularly in an older patient. This finding is often the first sign of metastatic spread from an intra-abdominal or intra-thoracic neoplasm Supraclavicular lymph nodesSupraclavicular fossa, closer to the sternal end of the clavicleRight supraclavicular nodes drain into the right lymphatic duct and collect\* Neck\* Right thorax\* Right upper extremityRight mediastinumLungsEsophagusLeft supraclavicular nodes (Virchow nodes) drain into the thoracic duct\* Left thoraxLungs\* Left upper extremity\* AbdomenPelvisLung carcinomaSarcoidosisLeft supraclavicular lymphadenopathy (Troisier sign) is usually indicative of a possible abdominopelvic malignancy (especially metastatic gastric or pancreatic carcinoma).An enlarged left supraclavicular lymph node. Classically associated with metastatic gastric cancer but can develop in other abdominopelvic malignancies (e.g., gallbladder, pancreas, kidneys, testicles, prostate, ovaries).

Answer 71

Low molecular weight heparin (LMWH), such as enoxaparin is the preferred option for venous thromboembolism prophylaxis. 40mg is the standard dose given no renal impairment. All adult orthopaedic patients undergoing total hip arthroplasty and knee arthroplasty require thromboprophylaxis. Total hip arthroplasty, requires 28-30 days of LMWH; whereas total knee arthroplasty requires 14 days of LMWH.Unfractionated heparin is an option for patients who have renal impairment and those at an increased of bleeding. Other options, particularly for total hip or knee arthroplasty are direct oral anticoagulants (DOAC), specifically rivaroxaban.Learning PointsMajor surgical procedures will usually require a period of anticoagulation for at least 14 days after discharge from hospital.

Answer 72

Up to 20–50% of patients with PAD are asymptomatic.Intermittent claudication\* Seen in approx. 10–35% of patientsPain, cramps, or paresthesia distal to arterial occlusionFemoropopliteal disease (most common): typically causes calf claudicationAortoiliac disease (Leriche syndrome)Level of the aortic bifurcation or bilateral occlusion of the iliac arteriesTriad of bilateral buttock, hip, or thigh claudication, erectile dysfunction, and absent/diminished femoral pulsesTibiofibular disease: typically causes foot claudication\* Worsens upon exertion ,\* Completely relieved by rest or lowering affected limbs\* Reproducible on asking the patient to walk the same distance at which symptoms typically occurRest painRest pain occurs as disease progresses and indicates severe ischemia.\* Typically occurs first in the toes and forefoot\* Worsens with reclining (e.g., while sleeping)\* Improves on hanging feet off the bed or on standingCritical limb ischemia (CLI) [3]\* Indicative of limb-threatening arterial occlusionCharacterized by the presence of any one of the following:Rest pain lasting ≥ 2 weeksNonhealing ulcersTissue loss (gangrene)Examination findingsTrophic changes↓ Skin temperature, ↓ perspiration↓ Hair on legs, ↓ nail growth, brittle nailsAtrophied musclesDry atrophic, shiny skin and/or bluish skin discolorationLivedo reticularis (advanced disease)Gangrene, ulcers, necrosis (end-stage disease): See also “Arterial ulcer.”Absent or diminished pulses: examine distal pulses bilaterally, includin

Answer 73

When the bowel is obstructed they become high pitched or tinkling as fluid drips from one distended and tympanic loop of bowel into another. In the presence of peritonitis, classically in association with a perforation, the abdomen becomes silent reflecting an absence of peristaltic activity, so called paralytic ileus.

Answer 74

presentation of acute sinusitis can be divided into major and minor symptoms. Major symptoms include purulent nasal discharge, nasal congestion or obstruction, facial congestion, fullness, or pressure, or fever. Minor symptoms include headache, halitosis, and ear pain.

Answer 75

highly resourced health care settings, in which patients are routinely screened, patients with primary hyperparathyroidism typically present with moderate hypercalcaemia and non-suppressed to high PTH levels. Up to 85% of cases are a result of a single parathyroid adenoma. What are the Complications of the disease? \* renal calculi, \* peptic ulceration,\* acute pancreatitis and \* fractures.Indications for surgery remain an area of controversy, however patients with complications, or at high risk of developing complications of primary hyperparathyroidism are routinely accepted for surgical intervention. Generally accepted indications for surgery include age \< 50 years, \* osteoporosis, ie T score less than 2.5 or fragility # (compressive vertebral or pathalogical #) presentcreatinine clearance \< 70% of age matched individuals,\* hypercalciuria \> 10mmol/day, \* hypercalcaemia \> 2.85 mmol/L and \* patients for whom medical surveillance is not possible, as these patients are at high risk of developing complications.Learning PointsOsteoporosis is an important indicator for surgery in cases of primary hyperparathyroidism. What is defined as Osteoporosis T-score is defined as the difference in standard deviations between the patient's BMD and the BMD of a young adult female reference mean.- Osteoporosis: T-score ≤ -2.5 SD- Osteopenia: T-score of -1 to -2.5 SD Osteoporosis is diagnosed if T-score ≤ -2.5 SD and/or a fragility fracture is present. Fragility fractures: pathological fractures that are caused by everyday-activities (e.g., bending over, sneezing) or minor trauma (e.g. falling from standing height) - Common locations: vertebral (most common) \> femoral neck \> distal radius (Colles fracture) \> other long bones (e.g., humerus)- Vertebral compression fractures- Commonly asymptomatic but may cause acute back pain and possible point tendernes

Answer 76

Charcot's triad present of right upper quadrant pain, jaundice, and fever. There is a risk of this progressing to Reynolds' pentad with additional features of shock and altered mental status. Biliary obstruction is most commonly due to choledocholithiasis, wThe most frequently isolated pathogens are gram-negative enteric organisms: Escherichia coli (25-50%), Klebsiella species (15-20%), and Enterobacter (5-10%); along with gram-positive Enterococcus (10-20%). Anaerobic bacteria such as Bacteroides fragilis and Clostridium perfringens are identified in approximately 15% of cases, and particularly if there has been previous biliary surgery or in the elderly population. This highlights the importance of empiric antibiotic therapy covering for gram-positive, gram-negative and anaerobic organisms.Learning PointsEscherichia coli is the most common organism associated with biliary sepsis

Answer 77

Medical therapy [17]IndicationsHistory of fragility fracturesT-scores ≤ -2.5Drug of choiceBisphosphonates: e.g., alendronate, risedronateSide effects [18]HypocalcemiaEsophagitis, esophageal cancerOsteonecrosis of the jawAlternative drugs [9]Teriparatide: parathyroid hormone analogRaloxifene: (selective estrogen receptor modulator, SERM) for patients with contraindications to bisphosphonates or those who also require breast cancer prophylaxis (but increases the risk of thromboembolismDenosumab (monoclonal antibody against RANKL)\* Indicated in patients with impaired renal functionHormonal therapy

Answer 78

A useful tool to utilise in presentations of acute knee injuries is the Ottawa Knee Rules- highly sensitive for detection of fractures. Under these guidelines, a knee x-ray is indicated if: (a patient has any of the following-patient age \> 55 yearshead of the fibula tendernessisolated patella tendernessinability to flex knee to 90 degreesinability to bear weight (ie. inability to take four steps) immediately after event and at time of presentation \* 55, 4 steps (WB), 90 degs, patella and fibula head Based on the patient's age, an x-ray of the knee is indicated. Further, considering this patient's age and the intermittent leg stiffness described, it is quite possible that this patient may have osteoarthritis. Both overuse and osteoarthritis can precipitate joint effusions and seem likely in this presentation.

Answer 79

An abdominal aortic aneurysm (AAA) is the abnormal focal dilatation of the abdominal aorta. Common risk factors for AAA are- smoking (most common),- advanced age (ie, \>60 years), - atherosclerosis, male gender and connective tissue diseases. Most cases of AAA are asymptomatic. Patients with symptomatic AAA present with abdominal or back pain, or pain due to distal embolisation. Although many studies have revealed a beneficial effect of screening for AAA, no screening protocol has been established in Australia despite being common in practice in other countries such as the UK. The management of AAA depends on the size, progression, and symptoms of the aneurysm. Patients with an asymptomatic AAA with size \<5.5 cm are followed up and advised against smoking. The indications for surgical management of AAA are as follows:\* Size \>5.5 cm\* Growth in size of \>1 cm/yearSymptomatic AAA This patient fulfils two of the three indications for surgical repair (ie, size \>5.5 cm and symptomatic AAA). The sudden onset of loin pain in the presence of a large AAA suggests that the aneurysm may have leaked or is likely to rupture, so an urgent surgical referral and repair is advised. Learning PointsLarge aneurysms (\>5.0 cm) need to be referred for a vascular opinion.

Answer 80

Measurement of exercise-induced ankle-brachial index (ABI) is the most appropriate next investigation. The history is very suggestive of intermittent claudication, but the examination findings do not bear this out. Current evidence suggests that, in patients with normal or borderline resting ABIs, the next most appropriate investigation is an exercise-induced ABI. This study is performed immediately following a patient walking on a treadmill at a reasonable pace and gradient (or, if unavailable, walking up and down stairs/a hallway) and assessing their ABI.Duplex ultrasound provides a sensitive and specific (90 and 95%, respectively) means of assessing the location and degree of stenosis. However, as this patient has demonstrated normal ABIs, the next most appropriate investigation is to repeat them following exercise.

Answer 81

This patient is most likely presenting with epididymitis with a key differential of testicular torsion.Whilst surgical exploration is of high priority in cases of suspected torsion, if arranged quickly, scrotal Doppler ultrasound can differentiate these two key diagnoses through assessing blood flow to the scrotum and avoid further unnecessary intervention. Epididymitis will typically show increased blood flow relating to acute inflammation, whereas torsion will demonstrate decreased blood flow.If this patient was younger or scrotal ultrasound was not readily available, surgical exploration would be required to exclude testicular torsion given the high risks associated with missed diagnosis.Urine culture and urine NAAT will be helpful in establishing a potential cause for this patient’s epididymo-orchitis, with a sexually transmitted infection such as Chlamydia trachomatis or Neisseria gonorrhoea more likely in a patient of this age group compared to older men where bacterial causes secondary to urinary stasis may be more likely.C-reactive protein may be elevated in many situations including both infection and torsion, and hence will not be helpful in reaching a diagnosis.Learning PointsEpididymitis is a common cause of acute scrotal pain and erythemaDoppler ultrasound is useful in differentiating key causes of scrotal painSurgical exploration should not be delayed in cases of scrotal pain with unclear diagnoses in young patients

Answer 82

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.

Answer 83

The following specific patient groups are recognised to be at increased VTE risk due to the risk factors related to their reason for hospitalisation and will require VTE prophylaxis. All other patients that are not covered in the list below will require an individualised VTE risk assessment to determine their VTE risk and need for VTE prophylaxis.Medical patients• Admitted following acute stroke with significant reduction in mobility• Critically ill patients• Hospitalised for decompensated heart failure• Active inflammatory bowel diseaseSurgical patients• Major abdominal-pelvic surgery for cancer• Total hip arthroplasty or total knee arthroplasty• Fragility fractures of the pelvis, hip and proximal femur• Major trauma surgery (including traumatic brain injury, acute spinal cord injury, traumatic spinal injury and complex traumatic pelvic / lower extremity injury)• Craniotomy• Cardiac surgery• Abdominal aortic aneurysm repair surgery• Thoracic surgery patients with primary or metastatic cancer• Elective spinal surgery (with hospital admission) resulting in reduced mobility• Bariatric surgery Ambulatory patients with isolated lower limb immobilisation• Ambulatory patients temporarily immobilised with above or below knee cast, or backslab with additional risk factors

Answer 84

Exercise treadmill ABI is performed for patients with intermittent claudication and a borderline ABI of 0.9. A post-exercise ankle SBP decrease \>30 mmHg or a post-exercise ABI decrease \>20% are diagnostic for PAD.

Answer 85

Patients with a ruptured AAA may initially present with no symptoms, but most (75%) will present with pain, which is typically located in the abdomen and radiating to the groin but may also be in the back, flank or pelvis. Signs of shock may also be present with the classic triad of pain, pulsatile abdominal mass and hypotension present in 50% of patients with ruptured AAA. Diagnosis of AAA depends on haemodynamic status. In unstable patients with a suspected ruptured AAA imaging is desirable but not essential prior to management. Bedside ultrasound may be used in this scenario to identify the AAA. In stable patients, urgent abdominal CT with contrast is preferable for diagnosis. Management of ruptured AAA involves emergency and immediate control of haemorrhage in theatre with laparotomy followed by repair of the aneurysm. Learning Points Leaking aneurysms require rapid resuscitation and intervention.

Answer 86

**hip hemiarthroplasty** requires **28-30 days of LMWH;** whereas total knee **arthroplasty requires 14 days of LMWH.** **Unfractionated heparin** is an option for patients who **have renal impairment** and those at an **increased on bleeding**. Other options, particularly for total hip or knee arthroplasty are direct oral anticoagulants (DOAC), specifically rivaroxaban. Learning Points **Major surgical procedures will usually require a period of anticoagulation for at least 14 days after discharge from hospital.**

Answer 87

clinical and radiological features consistent with a small bowel obstruction, including central colicky pain, early bilious vomiting, obstipation, abdominal distension and tinkling bowel sounds, with dilated loops of small bowel on the X-ray. gas in the biliary tree (pneumobilia) suggests either infection by gas-forming organisms in the portal venous system and/or free communication of the biliary tree with the gut. This is a picture seen with cholangitis; liver abscess with communication to the biliary tree; spontaneous biliary-enteric fistula from gallstone ileus or cholangiocarcinoma; and, most commonly, as a result of recent biliary instrumentation with endoscopic retrograde cholangiopancreatography (ERCP) or sphincterotomy. if liver abscess were the culprit, the patient would be expected to have right upper quadrant pain, jaundice, unintentional weight loss and more prolonged nausea and anorexia. cholangitis, which is characterised by the present of Charcot’s triad: fever, jaundice and right upper quadrant pain, With cholangiocarcinoma, the clinical picture would include jaundice, weight loss and anorexia small bowel obstruction with a communication to the bowel. The most likely cause is therefore gallstone ileus. ie the underlying problem has been cholelithiasis. There has been a fistulous communication between the gallbladder and the gut, with an eroding gallstone passing into the small bowel, where it has become obstructed. Air from the gut can enter the biliary tree through the cholecyst-duodenal fistula. A CT scan would help distinguish portal venous gas from pneumobilia. Learning Points Gallstone ileus is an uncommon, but well recognised cause of small bowel obstruction.

Answer 88

The correct answer is one litre isotonic saline over four hours. This patient is hypotensive and likely fluid-deplete. Whilst some of his hypotension could be due to vasodilatation associated with his recent anaesthetic, 100mL over 12 hours is relatively poor urine output, and this must be corrected. As his potassium is close to the upper reference range (of 4.5mEq/L), Hartmann's solution should be avoided, as it contains potassium and could precipitate hyperkalaemia. Ephedrine is the first-line treatment of intraoperative hypotension during general anesthesia. This is unlikely to be a major contributor to his hypotension at this stage post-operatively, and therefore this is inappropriate. As he is hypovolaemic, a diuretic, or continuing current management would be inappropriate. Learning Points Post-operative hypotension is often due to inadequate fluid replacement.

Answer 89

Postoperative hyponatraemia is a relatively common finding in the post-operative patient and can be due to a combination of fluid retention (secondary to non-osmotic ADH release) and infusion of hypotonic intravenous fluids. Another important cause of hyponatraemia is increased hypertonicity, with a dilutional effect brought about by a shift of water from the intracellular to the extracellular compartment. An elevated blood glucose concentration can do this. While all of the investigations are appropriate in the work-up of hyponatraemia, it is first important to check for hyperglycaemia and calculate the corrected sodium. As the patient is diabetic and has recently had surgery, it would not be unusual for his serum glucose to be high, causing an osmotic water shift from the intracellular to extracellular space and a resultant dilutional hyponatraemia. Learning Points Regular blood sugar monitoring is essential in patients with diabetes who are acutely ill.

Answer 90

This is a textbook description of a varicocele - ie a **dilatation of the veins of the pampiniform plexus**. In other words, **these varicosities can extend right up into the inguinal canal**. An i**nguinal hernia would have a cough impulse** and **unless very large** in size, can usually be r**educed to within the abdominal cavit**y. A **hydrocele envelopes the testis** - and if large and tense, the testis cannot be felt. An epididymal cyst is attached to the testis and when present, can be palpated posteriorly or at the upper pole of the testis. An hydatid of Morgagni is a common vestigial remnant and is attached to the lower pole of the testis. Learning Points Varicoceles are very common and usually of no clinical significance.

Answer 91

Perform carotid artery imaging in all patients with symptomatic carotid stenosis. * Clinically significant carotid stenosis: narrowing of the carotid artery ≥ 50% * **Moderate carotid stenosis:** narrowing of the carotid artery by 50%–69% * **Severe carotid stenosis**: narrowing of the carotid artery 70%–99% For severe symptomatic carotid stenosis. Balloon angioplasty, carotid stent and carotid endarterectomy are all surgical interventions to manage carotid stenosis. When indicated, carotid endarterectomy is the preferred of the three surgical procedures. It is indicated in symptomatic patients (TIA or stroke) with stenosis of 70-99% and those with symptomatic stenosis of **50-69% who are low surgical risks**. **Anti-platelets** and **risk factor modification** are recommended in **symptomatic patients with \<50% stenosis.** Patients with asymptomatic carotid artery stenosis should be treated with aspirin, and if they have an aspirin allergy, they should be treated with clopidogrel. In addition, risk factor modification plays an important role. The management of hypertension, dyslipidaemia, diabetes, and smoking is also recommended. For endarectemy * Periprocedural risk and patient life-expectancy, comorbidities, and preferences must also be considered. * * [Symptomatic carotid stenosis](https://next.amboss.com/us/article/ko0mXS#Zd3a746e96efe2d2e74ef95bb233731f6) ^[17] * [Severe carotid stenosis](https://next.amboss.com/us/article/ko0mXS#Z70f7ca4a6eeeded79a3e2e0f434b2cea): Revascularization is indicated if life expectancy is ≥ 2 years and if the operator'[s](https://next.amboss.com/us/article/rs0fwh#Z055402fb9c4dfb6ad6e800fd438a6a49) risk of procedural [morbidity](https://next.amboss.com/us/article/Js0sDh#Z2b1819a683edfddebfad28cb21d64b9f) and mortality is \< 6%. ^[15] * [Moderate carotid stenosis](https://next.amboss.com/us/article/ko0mXS#Z3a7f1ac4ac4e326a8323b430271537c6): The benefit of revascularization depends on patient-specific factors * * Asymptomatic patients with [severe carotid stenosis](https://next.amboss.com/us/article/ko0mXS#Z70f7ca4a6eeeded79a3e2e0f434b2cea): Consider revascularization if the operator'[s](https://next.amboss.com/us/article/rs0fwh#Z055402fb9c4dfb6ad6e800fd438a6a49) risk of procedural [morbidity](https://next.amboss.com/us/article/Js0sDh#Z2b1819a683edfddebfad28cb21d64b9f) and mortality risk is low (\< 3%). * * **Contraindications** ^[3][18] * Carotid stenosis \< 50% * Chronic complete carotid occlusion * Severely disabling [stroke](https://next.amboss.com/us/article/UR0bmf#Zdd37bc451d2e210ed3e03be192079b6c)

Answer 92

**Familial adenomatous polyposis (FAP)** is the most **likely risk factor present** in this patient to cause him to have an **adenocarcinoma in his bowel.** FAP is caused by an **autosomal dominant mutation** in the **APC gene**, which is a **tumour suppressor gene located on chromosome 5q22**. Patients with FAP typically develop **polyposis (widespread bowel polyps)** in their **second or third decade of life**, with them most likely remaining asymptomatic until progressing to **colorectal cancer.** This is consistent with the presentation of this patient. These patients can have up to thousands of **colorectal adenomas** and a **100% risk of colorectal cancer in their lives**. Patients with FAP and patients with the Lynch syndrome have an **increased risk of developing small bowel cancer,** with the lifetime risk being about 5%. **Peutz-Jeghers syndrome** is another risk factor developing **colorectal cancer, due to an autosomal dominant mutation in the STK11 gene.** These patients typically develop **hyperpigmented macules around their lips, genitals, palms, soles, and buccal mucosa** – making this diagnosis less likely than FAP, as the patient does not have any of these overt signs. **Coeliac** disease is an **autoimmune disorder characterised** by an **intestinal hypersensitivity to gluten.** A complication of this is a moderately increased **risk of malignancies, such as enteropathy-associated T-cell lymphoma (EATL),** often located in the **proximal jejunum**. This is not consistent with the r**esection being a primary adenocarcinoma** in this patient. **Crohn’s disease is associated with increased risk of colorectal cancer.** These patients are also at risk of developing small bowel tumours, but the tumours tend to be in the **distal small bowel**. In this case, the clinical presentation is not consistent with Crohn’s disease. **Ulcerative colitis causes an increased risk of colorectal cancer.** However, it does not cause an **increased risk of upper gastrointestinal tumours,** as **ulcerative colitis impacts the rectum** and can extend in a proximal and continuous fashion to involve other parts of the colon.

Answer 93

The symptoms and physical signs add up to **peritoneal and diaphragmatic irritation** - and the **CT shows a rupture of the spleen.** This is a rare, but well-recognised **complication of colonoscopy**. More frequently encountered complications include **bleeding and perforation.** Neither of these complications are common. Bleeding may occur in up to 6% of cases after polypectomy, but less than 1% of cases will require any form of intervention. Perforation can be more serious, but again, it is an uncommon occurrence, being seen in less than 1% of diagnostic investigations and 5% of therapeutic procedures. Postpolypectomy syndrome occurs when there is an area of localised perforation following a polypectomy, where the damage has been brought secondary to diathermy-induced tissue necrosis. The perforation may occur immediately at the time of the procedure and later, when the necrotic tissue sloughs. In this case the CT imaging clearly demonstrates a splenic injury and the investigations and physical examination findings are consistent with acute haemorrhage. Learning Points Abdominal pain after a colonoscopy must always raise the possibility of a complication of the procedure.

Answer 94

**Endoscopy** is required in **high-risk presentations of foreign body ingestion.** This includes **patients with evidence of complete oesophageal obstruction,** objects larger **than 2.5cm and still in the stomach**, and o**bjects larger than 6cm in the proximal duodenum or above**. Button **batteries pose a risk of erosion and perforation. I**f swallowed and recognised, they should be **retrieved wherever possible**. Sharp objects **only require endoscopy if they are in the proximal duodenum or above; as this is when the greatest risk for perforation is, particularly as the object passes through the pylorus**. Although **colonoscopy** can be used for **extremely high risk, large, foreign bodies that are in the colon**, this is not the case in this patient as this foreign body will almost certainly pass without the need for intervention. In this patient's X-ray, there is a normal gas pattern in the colon and the foreign body can be seen immediately to the left of the second lumbar vertebra and is almost certainly in the transverse colon ([**Image**](https://emedici.com/storage/images/42cd7932-b5d4-4cec-be1b-f7e080ccd920.jpg)). Given his lack of symptoms and signs of perforation, the location of the foreign body, and the time since ingestion, there is a very high chance it will pass spontaneously and no intervention will be required, but **observation and review** are necessary; particularly a psychiatric screen for self-harm and suicidality. **CT abdomen** is not required as the location of the foreign body is clear in the x-ray and clinical presentation. If the object had multiple parts, was difficult to see on x-ray, or there was any doubt about its location, a CT scan may be justified. **Laparoscopy** is reserved for patients who have signs of perforation in foreign bodies. ![]()

Answer 95

The scan shows gas in the portal vein and areas of pneumatosis intestinalis in the mid small bowel. Taken together with the clinical picture, these radiological findings would fit for a diagnosis of mesenteric ischaemia with probable bowel infarction. Hepatic portal venous gas can have several different origins, including diverticulitis, gastroparesis, appendicitis and acute pancreatitis. However, these causes are uncommon and the most usual underlying problem is bowel ischaemia and/or infarction. This radiological finding is associated with a high mortality rate. Learning Points Gas in the portal vein must always raise the possible diagnosis of mesenteric ischaemia.

Answer 96

The most likely diagnosis is ischaemic colitis, making a contrast-enhanced CT scan the investigation of choice. Evidence of colonic wall thickening, pneumatosis and mesenteric stranding should be sought. CT has the added advantage of being able to identify other possible causes of the current problem, should the diagnosis not be ischaemic colitis. Mesenteric angiography would be most appropriate with suspected mesenteric ischaemia. Angiography allows direct visualisation of mesenteric vascular occlusion, the extent of the lesion which may be causing it and any possible therapeutic interventions.

Answer 97

Learning Points **Contrast-enhanced CT scans are the investigation of choice in ischaemic colitis** The most likely diagnosis is ischaemic colitis, making a contrast-enhanced CT scan the investigation of choice. Evidence of colonic wall thickening, pneumatosis and mesenteric stranding should be sought. CT has the added advantage of being able to identify other possible causes of the current problem, should the diagnosis not be ischaemic colitis. A plain abdominal X-ray would be appropriate in a suspected bowel obstruction, wherein it would demonstrate dilatation of bowel loops and air-fluid levels. Mesenteric angiography would be most appropriate with suspected mesenteric ischaemia. Angiography allows direct visualisation of mesenteric vascular occlusion, the extent of the lesion which may be causing it and any possible therapeutic interventions. Flexible sigmoidoscopy is useful for the diagnosis of lower gastrointestinal conditions, such as diverticulosis or malignancies, which will demonstrate the macroscopic apperance of the colonic mucosa. Colonoscopy are useful for similar reasons to flexible sigmoidoscopy, although extend further through the colon, and should be performed within 48 hours to exclude other types of colitis (tissue biopsies may be required). However, contrast-enhanced CT is a more appropriate in the setting of suspected ischaemic colitis.

Answer 98

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

Answer 99

This patient has been treated with corticosteroids for an acute flare-up of Crohn's disease. Thus, they should be initiated on maintenance therapy to prevent further relapses of Crohn's disease. This is done first line with azathioprine. In practice, a patient like the one described in this scenario, will get infliximab fairly rapidly after starting azathioprine. Infliximab is considered second-line therapy, and is added in addition to azathioprine if monotherapy alone fails. Data is appearing in the literature suggesting that patients who are started early on infliximab (\<2 years after diagnosis) have better endoscopic remission rates and less stricture formation compared with those are started later (\>2 years after diagnosis). Mesalamine is not recommended in the maintenance/prevention of relapse in Crohn's. Although corticosteroids are useful in acute flare-ups, they are not recommended in long-term prevention of relapse in Crohn's disease. Ustekinumab is considered third-line therapy, and is added if the addition of an anti-TNF agent such as infliximab fails to prevent relapse. Learning Points Azathioprine therapy is considered first-line in Crohn's disease maintenance of remission, to prevent further relapses.

Answer 100

* **LHRH antagonist-** ***drug of choice for immediate castration (2-3 days),*** reduced risk of a ***tumor flare - especially important in patients with spinal metastasis.*** * **LHRH agonist- initial spike of testosterone can drive tumour flare** * **Non-steroidal anti-androgen-** not monotherapy used with LHRH agonist to reduce tumour burden * **Corticosteroid-** adjunct after chemotherapy * **5-alpha reductase inhibitor-** used in BPH treatment!!! This **patient presents with metastatic prostate cancer.** This disease is incurable and treatment must be focussed on symptomatic control. Some form of androgen deprivation therapy would be appropriate. The choice of androgen deprivation in this case is based on the **mechanism of action and the subsequent risk of causing a tumour flare.** ``` The most a**ppropriate choice of treatment in this scenario is an LHRH antagonist**. Unlike LHRH agonists, **this particular drug class is not associated with a tumour flare**. Castrate levels of **serum testosterone will be reached within 2-3 days**. **Degarelix is an example of an LHRH antagonist.** ``` **LHRH agonists** acts on the pituitary gland, i**nitially increasing the serum testosterone** **transiently** before causing it to fall to castrate levels. This **starts 2-3 days** after initial administration and lasts for **approximately one week**. In patients with symptomatic **metastatic disease there is a risk of causing worsening local symptoms**. With s**pinal metastases this means a heightened risk of pathological fractures** or **malignant spinal cord compression.** Given that the bone scan demonstrates **malignant spread** to the **vertebral column**, **LHRH agonist is not the best answer**. Agents of the **non-steroidal anti-androgen** class are sometimes given at the same time as **LHRH agonists**, in order to **prevent the tumour flare.** As such, the role of this drug class is **synergistic-these medications** should **not be given as monotherapy** as they have reduced **overall survival when compared with LHRH agonist/antagonists.** The most appropriate choice of treatment in this scenario would be degarelix, a LHRH antagonist that is not associated with a tumour flare and leads to castrate levels of serum testosterone within 2-3 days. The **5-alpha reductase inhibitor drug** class is not the best answer option. Whilst these medications have a proven and valuable r**ole in the treatment of benign prostatic enlargement and lessening the troubling symptoms of this condition**, their value in the management of prostate cancer is far more uncertain. For metastatic disease, they are likely to be of little benefit. **Corticosteroids** are widely used in the setting of **metastatic castrate-resistant prostate cancer,** often in combination with **chemotherapeutic agents**. Their anti-inflammatory properties also makes them useful in the **palliative care setting**. Whilst this patient does indeed have metastatic disease, it is more appropriate to **attempt chemical castration to lessen progression of disease** before moving onto alternative therapies such as corticosteroids. As such, corticosteroids is not the correct answer. Learning Points Choice of androgen deprivation is based on the mechanism of action and risk of tumour flare.

Answer 101

1. Androgen deprivation therapy 1. **LHRH antagonist** (GNRH atagonists) - no tumour flair: metatstatic Prostate Ca, e.g., [degarelix](https://next.amboss.com/us/article/AT0Rt2#Z46dd17f5112c2045a969dd4550e8fcee) 2. **LHRH agonist** (GNRH agonists) e.g., [leuprolide](https://next.amboss.com/us/article/zk0rqT#Z62c949565ba8f06653d32cecf71fb8a0), [goserelin](https://next.amboss.com/us/article/AT0Rt2#Ze53284f6555cd8331b5f9354f8442777), 3. GnRH **receptor** antagonist (e.g., relugolix) 2. Androgen synthesis inhibitors / Andrgen Receptor Antagonist 1. **Non-steroidal anti-androgen- (Andrgen Receptor Antagonist)** _apalutamide and enzalutamide (second-generation, stronger Receptor affinity)- adjunct to LHRH agonists ( luperilide and goserelin)_ 2. ASI- inhibits glucocorticoids, increases adrenal mineralocorticoids- Commonly used agent: abiraterone

Answer 102

**An unexplained change in bowel habit in an older patient should always raise the possibility of malignancy.** **Adhesional obstruction** and **volvulus** tend to b**e 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**.

Answer 103

* **IgE-mediated mast cell degranulation**- **T1 Anaphalaxis** * **Antibody-mediated** immune reaction- **T2** antigen on APC→ antibodies * **Antigen-antibody _complex formation_** **T3** ( SLE/Lupus nephritus and serum sickness) * **CD8+ T lymphocyte-mediated hypersensitivity**- **T4 delayed hypersensitivity** reaction and does not present as acutely (poison Ivy) * **Complement-mediated** **cytotoxicity**- **IgG and IGM-** Complement-mediated cytotoxicity is caused by IgM and IgG antibodies, not IgE antibodies (anaphalaxis) Anaphylaxis is a **type I hypersensitivity reaction characterized by IgE-mediated cell degranulation.** On initial exposure to an antigen, the antigen stimulates antibody class switching to IgE antibodies. These IgE antibodies bind to IgE receptors present on the surface of basophils in the blood and mast cells in the tissues. On subsequent exposure, the antigen binds to the **IgE antibodies present on the surface of basophils and mast cells** and cause aggregation of the receptors by cross-linking of antibodies. This leads to degranulation and release of histamine and other inflammatory cytokines that are implicated in vasodilation, bronchoconstriction, vascular permeability, and other features seen in anaphylaxis. Antibody-mediated immune reaction is a type II hypersensitivity reaction that is characterised by antibody binding to the antigen being presented by antigen-presenting cells. After binding, these antibodies release several enzymes that lead to cell lysis and death. Antigen-antibody complex formation is a type III hypersensitivity reaction that is seen in systemic lupus erythematosus or serum sickness. It is not associated with anaphylaxis. Complement-mediated cytotoxicity is caused by IgM and IgG antibodies, not IgE antibodies. It is not seen in anaphylaxis. CD8+ T-lymphocyte-mediated cytotoxicity is a type IV delayed hypersensitivity reaction and does not present as acutely as seen in this patient. One common example of type IV hypersensitivity **reaction is poison ivy hypersensitivity reaction.**

Answer 104

* **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 typica**l 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.

Answer 105

This patient has end-stage achalasia with severe dilatation of his oesophagus on a background of a 4-year history of dysphagia. Current guidelines recommend cardiomyotomy with fundoplication for patients with severe achalasia. Botulinium toxin injection is first-line treatment for achalasia in patients that are unfit for surgical intervention; however, this patient is otherwise well and surgically fit. Pneumatic dilatation is an accepted initial treatment for achalasia, but would hardly be acceptable in this case of end-stage disease. Stents are currently not recommended for the treatment of achalasia. Oesophagectomy is reserved for patients with end-stage achalasia who fail other interventions such as cardiomyotomy or pneumatic dilatation. It is very likely that at some stage this patient will benefit from an oesophagectomy.

Answer 106

* 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.

Answer 107

history alone, it is clear that this patient has oesophageal dysphagia. His weight loss should always raise the possibility of malignancy, but a two year history would be unusual. Coughing up particles of food and other small materials such as tablets is very suggestive that the material is getting caught in the upper oesophagus and being inadvertently inhaled. This clinical picture would fit very well for a pharyngeal pouch (Zenker's diverticulum). Whilst these diverticula can be visualised with **endoscopy**, a much more accurate assessment is made with a contrast study (**barium swallow**). If the presumed diagnosis was one of oesophageal malignancy, then an endoscopy would be the most appropriate first-line investigation. Apart from viewing the lumen of the upper digestive tract, any suspicious lesion could be biopsied. However, in this case the length of the history would make malignancy a very unusual diagnosis.

Answer 108

**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. ![]()

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