general surgical/urology +opthalmology+ENT emergencies Flashcards
(102 cards)
1
Q
4 principles of management of Anal fissures ?
RCEM Learning SAQ
A
- Prescribe stool softeners &bulking agents
- Prescribe analgesia +/- topical local anaesthetic
- Prescribe topical gtn/diltiazem
- Safety net/ arrange GP follow up
2
Q
What are the anatomical landmarks of the 3 zones of the neck?
RCEM Learning SAQ
A
ZONE 1: thoracic inlet inferiorly to cricoid cartilage
ZONE 2: cricoid cartlilage inferiorly up to the angle of
the mandible
ZONE 3: Angle of the mandible up to the base of the skull
3
Q
What are the anatomical structures that lie in the 3 neck zones?
RCEM Learning SAQ
A
ZONE 1: TOLungs, thyroid and thoracic duct
( trachea, oesophagus,Lungs,Thyroid, Thoracic duct )
ZONE 2: TOLarynx/ JV/CA/VA
( Trachea, oesophagus,Larynx, Jugular veins,Carotid
arteries,Vertebral arteries )
ZONE 3: TOG( glands-salivary&parotid ) / CN/JV/CA/VA
( Trachea,oesophagus, salivary glands, Parotid glands,cranial nerves )
4
Q
Differentiate the xray features of large bowel and small bowel obstruction
RCEM Learning SAQ
A
Large = peripheral , >5cm, presence of haustra, few loops
Small = central loops, <5cm , presence of valvulae coniventes, many loops
5
Q
Your first patient is a 9 year old boy with onset of left testicular pain over the last 2 hours. He is sore but feels otherwise systemically well. You note a blue discolouration on the skin in the region of the upper pole of the testes.
What is the most likely diagnosis ?
RCEM Learning SAQ
A
torsion of the hydatid of morgagni
testicular appendage
6
Q
- With regards to aortic aneurysm - what is the diameter for male and females that are normal?
- and can you list the indications for elective surgical repair?
RCEM Learning SAQ
A
- female = 1.5cm,
male 1.7cm, ( normal abdominal aortic diameter )> 3cm is aneurysmal - indications for elective surgical repair:
- female size > 5cm
- male diameter > 5.5cm
- rapid increase in size more than 1cm per year
- symptomatic AAA
7
Q
WHat other complications of a AAA (apart from rupture, haemorage and death ) can you name?
RCEM Learning SAQ
A
- aortic-enteric fistula ( suspected if patient presents with
UGIB ) - trash foot ( due to VTE )
8
Q
What is the Emergency management of acute angle closure glaucoma?
RCEM Learning SAQ
A
- Ophthalmology referral
- Carbonic anhydrase inhibitor Acetazolamide (Diamox)
initially 500 mg IV followed by 500 mg PO (1g max in 24
hours) - Parasympathomimetic -
Pilocarpine hydrochloride 1-2%% eye drops, one drop in the
affect eye up to 4 times a day - Beta blocker -
Timolol Meleate 0.5% eye drops, one drop twice daily
9
Q
Which Symptoms are suggestive of optic neuritis?
RCEM Learning SAQ
A
Sudden onset ( minutes to hours ) acute severe eye pain /headache
unilateral white eye:
- visual blurring
- decreased visual acuity
- decreased colour perception
- painful/discomfort eye movements
10
Q
A patient presents with knee effusion.
name 2 commonly used approaches to knee aspiration and explain the benefits of knee aspiration?
RCEM Learning SAQ
A
parapatellar ( medial or lateral ) , supra-patellar are the 2 common approaches.
the benefits to the procedure include:
- to remove as much aspirate to relieve the pressure from the knee
- to send fluid aspirate to the lab for microscopy, culture and crystal analysis to determine the cause
11
Q
What are the 3 main indications for surgery in a patient with traumatic retrobulbar haemorrage?
and give 1 contra-indication?
RCEM Learning SAQ
A
- Indications for surgical lateral canthotomy :
- decreased VA
- proptosis
- intra-occular pressure > 40mmhg ( acute orbital
compartment syndrome )
- contra-indication:
* globe rupture
12
Q
contact lenses can cause conjunctivits - which 2 bugs cause infections in the eye in contact lense wearers?
A
acanthamoeba nigricans
pseudomonas aeruginosa
13
Q
What symptoms and signs would be important to elicit in a patient with suspected acute close angle glaucoma?
A
Symptoms:
*History of light halo’s (late sign)
Signs:
- Injected sclera, mid dilated pupil, watering eye, *photophobia
- Palpation of the orbits the left eye felt less *compressible than the right. This is easy to do without specialist equipment.
- Visual acuity
14
Q
What are the components of the Fever PAIN score for Tonsillitis?
A
The FeverPAIN criteria are:
score 1 point for each (maximum score of 5)
Fever over 38 C.
Purulence (pharyngeal/tonsillar exudate).
Attend rapidly (3 days or less)
Inflamed ( severely ) tonsils
No cough or coryza
15
Q
How would you use the FEVER PAIN score in managing a patient presenting with Tonsillitus to the ED?
A
score is 0 or 1:
Do not offer an antibiotic prescription
score is 2 or 3:
Consider a back-up antibiotic prescription .Tell the patient the antibiotic should only be used if symptoms have not improved in 3-5 days.
score is 4 or 5:
Offer an antibiotic prescription immediately
16
Q
What potentially life-threatening complication of otitis externa must be considered?
A
malignant otitis externa
17
Q
what are the complications of MOE?
and what is your management in the ED?
A
Complications of MOE include:
- meningitis
- brain abscess
- dural sinus thrombosis
Management includes -
- IV antibiotics
- urgent referal to ENT on call for admission
18
Q
What would a suitable antibiotic regime be for treating acute bacterial prostatitis?
what other drug would you consider prescribing to relieve symptoms?
A
Ciprofloxacin 500mg po bd for 28 days
or ofloxacin 200mg po bd for 28 days
sympotmatic treatment with alpha blocker agent i.e. tamsulosin
19
Q
What is your ED management of a patient with corneal abrasion?
A
- oral analgesia
- regular topical antibiotics
- advise to return if the symptoms persists beyond 36 hours
20
Q
A patient presents with unequal pupil sizes.
Left pupil is more dilated than the right pupil.
Left pupil accomadates normally.
Left pupil is slow to react to light.
her right pupil is smaller than the left and reacts normally to accomadation and light.
Her eye movements, visual acuity and fields are all normal.
what is your diagnosis and what is the pathophysiology?
A
Diagnosis: Holmes -Adie syndrome
Pathophysiology: damage to the post-ganglionic fibres of the parasympatheitc innervation of the eye. likely due to viral infection.
Memory aid:
Come to Adie’s Ho(l)me/house.
He will normally accomadate you and your family in the left wing of the house. but when you switch the lights on , in that one side of the house - it will be slow to react because a virus attacked the west wing!
21
Q
70 yr old diabetic presents with sudden onset painless loss of vision in his right eye. his right eye is poorly reactive to light, but consensual light reaction is normal. he ahs an afferent pupillary defect.
- What is your most likely diagnosis?
- What findings would you expect to see on fundoscopy?
- What is your main priority of management in ED?
A
- central retinal artery occlusion
- Fundoscopy findings:
*Pale retina is due to oedema
*attenuated vessels ( thinned out )
*cattle-trucking ( is segmentation of blood columns in
arteries )
* optic atrophy ( over weeks )
* cherry red spot at the macula ( due to blood supply
from carotid arteries )
Memory aid:
pale - thin ( attenuated ) - cattle in trucks eating cherries eventually shrink
- Arrange urgent referral to opthalmology
22
Q
A squash player sustained an injury when a ball hit into his eye.
Can you list 4 complications of a traumatic hyphaema?
A
- acute glaucoma
- vitreous haemorrage
- retinal detachment
- permanent visual loss
- corneal staining
- concussion cataract
Memory aid: ball hits the blood vessels in the eye - causing sudden increase in occular pressure in the anterior chamber, and blood vessels in the vitreous burst and bleed, this results in the retina being pulled apart and worst case scenario is blindness, or best case scenario - you escape with either just corneal staining or a concussion cataract!
23
Q
- What organism is most commonly responsible for causing a dendritic ulcer of the eye?
- Other than topical aciclovir 5times/day for 10 days, which adjunct to treatment would you prescribe and why?
A
- Herpes simplex virus type 1 ( 80% )
2. High dose vitamin C ( can reduce healing time )
24
Q
A young 30 year old female presents with an Eyelid rash with associated progressively worsening weakness of the arms and shoulders. What diagnosis would you suspect, and what rash is typically described on the eyelids?
A
Diagnosis is dermatomyositis.
Eyelid rash is described as a violacious discolouration of the upper eyelid.
25
What characteristic skin signs are associated with dermatomyositis?
*Gottrons papules
( scaly symmetrical erythematous rash over MCP's )
* mechanics hands
( rough and fissuring of the skin on palms )
* Poikiloderma vasculare atrophicans
( well circumscribed violacious erythema on neck,chest,shoulders , back)
* Shawl sign
( erythematous macular rash on shoulders and upper back )
* Heliotrope rash
( Violacous discolouration of the upper eyelids )
Memory Aid: gottron uses his mechanics hands to cover his lady poikiloderma with a shawl but it doesnt cover the heliotrope rash of the eyelids!
26
How would you confirm the diagnosis of dermatomyositis?
which antibodies are associated with this condition?
1. muscle biopsy
2. skin biopsy
3. EMG
4. blood tests: anti-MI-2 antibodies
27
A patient presents with sudden acute painless loss of vision in one eye. What is the typical retinal appearance of central retinal vein occlusion?
1. cotton wool spots
2. flame shaped haemorrages
3. disc oedema
4. engorgement of the retinal vessels
Memory aid: when cotton wool is set on fire and burns the house in flames - throw water from the engorged vessels of the river retina!
28
What are the risk factors for Central retinal vein occlusion?
1. elderly population
2. hypertension
3. arteriosclerosis
4. chronic glaucoma
5. polycythaemia
29
On examination of a patient with sudden painless loss of vision. You do not have a fundoscopy available, what features on examination of the eye would lead you to suspect central retinal artery occlusion and not vein occlusion?
in central retinal artery occlusion there is an afferent pupillary defect.
30
What hormones are released by the anterior pituitary gland?
1. follicle stimulating hormone
2. growth hormone
3. thyroid hormone
4. prolactin
5. luteinizing hormone
Memory aid: follicles ( in the anterior pituitary Gland ) stimulate growth in the thyroid like a pro, not a luzer ( looser )
31
What are the causes of optic chiasm lesions?
1. pituitary tumour
2. craniopharyngiOMA
3. meningIOMA
4. optic gliOMA
5. internal carotid aneurysm
memory aid : OMA at the optic chiasm!
32
What are the distinguising features of branch retinal vein occlusion?
How would you manage this patient?
* retinal heamorages visible above the centre of the retina extending from close to the optic disc to near the macula represented by an " arc of haemorrages *
The patient should be referred within 24 hours for an opthamlology opinion for monitoring and consideration of photocoagulation therapy.
33
A 30 year old female with multiple sclerosis presents with sudden painful loss of vision. eye movements are very painful but there is no opthalmoplegia. you diagnose optic neuritis.
1. which part of her visual pathway has been affected?
2. What other diagnosis would you consider?
3. what medication would you prescirbe to treat her?
1. optic nerve ( a demyelinating inflammatory process )
2. *vitamin B12 deficiency
* drugs poisoning- methanol
* diabetes mellitus
* bugs- herpes zoster/lyme disease
3. 500mg IV methylprednisolone infusion over 4 hours daily for 5 days
34
You review a 7 year old with fever, eyelid swelling and conjunctival injection. what features would suggest orbital cellulitis rather than peri-orbital cellulitis?
features in favour of orbital cellulitis:
* painful eye movements
* proptosis
* diplopia
* red desaturation
* loss of vision
* optic neuropathy
* opthalmoplegia
Memory aid:
the infection is so bad it feels as though my eye will pop out ( proptosis ) , I cant even move my eye ball it hurts so bad like a bull that gets double mad when he sees red and loses his vision!
35
What are the commonest causative organisms of orbital cellulitis?
* streptococcus pneumonia
* staphylococcus aureus
* streptococcus pyogenase
* haemophilus influenza
( bugs from a pneumonia in the lungs jump into the eye )
36
A 65 year old presents with a history of a shadow passing across his right eye like a curtain being drawn this morning. for the past 2 weeks he has been experiencing flashes and floaters around the periphery of his vision. he feels a heaviness in the right eye but no pain and his visual acuity has been reduced to finger counting.
1. what is the most likely diagnosis?
2. what happened 2 weeks ago?
and what are the main clinical features of this
1. retinal detachment
2. vitreous detachment occured 2 weeks ago.
then main clinical features are:
* flashes of light
* increased number of floaters
* A ring floaters to the temporal side of the vision
* feeling of heaviness in the eye
* WEISS ring ( irregular ring of translucent floating material in the vitreous )
37
How can you distinguish retinal detachment from posterior vitreous detachment?
Retinal detachment has the following features:
* a dense shadow in the periphery that spreads centrally
* a " curtain " drawing across the eye
* Strait lines suddenly appearing curved
* central vision loss and reduced visual acuity
38
Give 2 causes for ptosis of the eyelid?
1. horner's syndrome
| 2. occulomotor nerve palsy
39
How can you distinguish between horners syndrome from occulomotor nerve palsy which both cuase ptosis?
in CN III palsy:
* the ptosis is more marked ( LPS muscle weakness )
* there is midriasis ( dilated pupil )
* Absence of the other features of horners syndrome i.e. enopthalmos, anhydrosis and flushing
In Horners Syndroms:
```
* Ptosis is less marked compared to CN III palsy (
superior tarsal muscle weakness )
* apparent enophthalmos ( sunken eye )
* miosis
* Anhydrosis
* flushing
```
40
What is the pathophysiology of Horner's syndroms and which muscle is responsible for the ptosis seen ?
When the sympathetic supply to the head is lost.
Loss of superior tarsal muscle supply
but in CNIII palsy ptosis is due to loss of LPS ( levator palpebrae superiosis muscle ). this is the parger of the 2 muscles and is responsible for a greater degree of elevation of the upper eyelid.
41
What features on fundoscopy would you expect to find in a patient with retinitis pigmentosa?
* bony spicule shaped deposits in the periphery
* with sparing of the macula
( therefore peripheral vision is lost and patient will have tunnel vision )
42
Outline 2 important examination findings that would support a diagnosis of retinitis pigmentosa?
* loss of peripheral vision ( tunnel vision )
| * altered colour vision
43
What rare systemic disorders are associated with retinitis pigmentosa?
Laurence-moon-biedl-bardet syndrome
Friederichs ataxia,
usher disease,
Kearns-sayre syndrome
44
What clinical features are consistent with a diagnosis of blow out fracture?
* painful eye movements
* vertical diplopia
( inferior rectus muscle entrapment )
*enopthalmos
( due to increased orbital volume )
* hypoglobus
( Inferior displacement of globe into orbit )
* orbital emphasema
( if fracture extends into paranasal sinus )
* malar region numbness
(injury to inferior orbital nerve )
* CSF leakage ( ears/nose )
Memory aid:
when you get hit in the eye ball - and its painful to move your eyes - then double down and lie low, while air leaks into the soft tissues, and fluid leaks out your nose but your cheeks are numb and you wont feel it!
45
A 65 year old female presents with acutely painful unilateral red eye on the right associated with sudden loss of vision, headache and vomiting - what is your diagnosis?
Acute CAG - acute closed angle glaucoma
46
What 4 drugs could be prescirbed in the emergency department to treat acute closed angle glaucoma?
* timolol maleate drops topical 0.5%
* pilocarpine hydrochloride drops 2% topical
* morphine IV 2-10mg titrate
* metoclopramide IV anti-emetic
* acetazolamide IV 500mg
memory aid:
Timolol Maleate and Pilocarpine HCL -
met morphine and acetazolamide
47
What are the main clinical features on eye examination of acute (CAG) - closed angle glaucoma?
on eye examination:
* cornea - oedema
* circumcorneal - congestion&erythema
* pupil - fixed semi-dilated ovoid
* visual acuity - loss/decreased
48
Name 3 causes of a subconjunctival haemorage?
* hypertension
* blood dyscariasis
* base of skull fracture
* spontaneous
49
What are the risk factors for acute closed angle glaucoma?
* asian
* female
* increasing age
* hypermetropia
* diabetic
memory aid:
( Old indian diabetic ladies )
50
A 40 year old woman presents with sudden onset right eye pain and double vision. examination reveals a fixed dilated pupil on the right hand side. the right eye is down and out resting position.
1. Which cranial nerve has been affected?
2. and what is the most likely underlying diagnosis?
3. what urgent investigation will you arrange?
1. Occulomotor nerve ( CN III )
2. posterior communicating artery aneurysm -is the most common cause of a painful cranial nerve 3 palsy.
3. urgent neurosurgical referal for angiography and surgical intervention.
51
What are the commonest clinical features of anterior uveitis?
* acutely painful red eye
* photophobia
* lacrimation
* reduced visual acuity
* hypopyon may sometimes be seen in the anterior
chamber
52
What are the causes of anterior uveitis?
1. rheumatology
* ankylosing spondylitis
* chronic joint disease ( spondyloarthropathies )
2. Inflammatory
* IBD
* sarcoidosis
* psoriasis
3. trauma
4. malignancy
* retinoblastoma
53
1. What are the hallmark clinical features of temporal arteritis?
2. What condition is it most commonly associated with?
1. Clinical features:
* headache
* scalp tenderness
* jaw claudication
* amaurosis fugax ( or sudden unilateral blindness )
2. Common associated condition:
* Polymyalgia rheumatica ( bilateral upper arm stiffness, aching and tenderness + pelvic girdle pain )
54
Can you list 4 indications for surgical management of a blow out fracture ( slightly different to indications in retro-bulbar haemorage ) ?
* large area of fractures
* muscle entrapment ( inferior rectus muscle )
* significant enophthalmos
* significant diplopia
* raised IOP > 40mmhg
Memory aid:
large areas of broken bone entraps the muscle and pulls the eyeball flat - everything looks double
55
Name 2 interventions in the ED that could be atempted in the emergency department to improve the outcome of acute central retinal artery occlusion?
* Occular massage
* 0.5% timolol drops topically
* IV acetazolamide 500mg
56
1. which eye drops can be used to dilate the pupils?
| 2. What advice would you give to a patient after dilating their pupils?
1. eye drops that dilate the pupils
* atropine
* phenylephrine
* cyclopentolate
* tropicamide
2. Advice to give patients:
* can blurr vision
* cause eyes to be sensitive to light
* can increase the intra-ocular pressure and trigger acute CAG so return immediately if symptoms of eye pain, redness,halo's around lights, nausea, vomiting.
57
What are the causes of a unilateral dilated pupil?
1. iatrogenic ( topical midriatic eye drops )
2. holme's - Adie pupil
3. CN III palsy
4. traumatic iris damage
58
A young male patient presents with a painful red eye , blurred vision, photophobia and watering eye. this is associated with back pain and sacro-iliitis.
what is your diagnosis?
DIagnosis - Anterior uveitis.
1. hazy anterior chamber
2. shallow anterior chamber
3. blood cells in the anterior chamber
4. white precipitation in the back of the cornea
5. hypopyon
59
What condition is anterior uveitis associated with?
what test can you perform in the ED to prove this?
what is your management of this condition?
1. ankylosing spondylitis. strong association between
HLA-B27 genotype.
2. talbots test
3. management:
*urgent referal to opthalmology.
* steroid eye drops
* pupil dilatation with cyclopentolate to prevent
adhesions
* analgesia
60
a patient with occular burns in his one eye. what type of chemicals are dangerous to the eye?
How would you manage a patient with this eye injury?
1. alkali's i.e. ammonia and sodium hydroxide
2. management:
* analgesia
*check the PH of both eyes
* topical local anaesthetic every 5 minutes
* copious irrigation of affected eye with 0.9% normal
saline
* Re-check PH and continue with copious irrigation untill
the PH is 7.4
* in addisiton to the above- refer for urgent
opthalmology
61
what features on the history and clinical examination would suggest a patient has eye globe rupture
1. History of a high velocity inury to the eye
2. Deep eyelid laceration
3. corneal/sclera laceartion
4. Anterior chamber- shallow and has a hyphaema
5. Tear drop shaped pupil
6. distorted globe
7. decreased visual acuity ( very sudden )
62
Name the complications of orbital cellulitis?
1. permanent visual loss
2. meningitis
3. cerebral venous sinus thrombosis
4. cerebral abscess
5. CRAO or CRVO
6. optic neuropathy
63
what are the differentiating features between orbital celluitis and peri-orbital cellulitis?
ORBITAL CELLULITIS:
* chemosis
* proptosis
* painful eye movement
* painfully tender to touch the orbit ( occular tenderness)
* reduced visual acuity
* opthalmoplegia ( paralysis of eye muscles- ptosis )
* Pyrexia with systemic features
Peri-orbital cellulitis:
* acute onset swelling
* normal visual acuity
* no proptosis
* no pain on eye movement
* no orbital tenderness
64
What are 4 early and 4 late complications of acute pancreatitis
Early complications of acute pancreatitis
1. Hypocalcaemia
2. ARDS
3. sepsis
4. circulatory shock
5. pancreatic encephalopathy
6. DIC
7. MODS
Late complications of acute pancreatitis
1. pancreatic pseudocyst
2. pancreatic abscess
3. insulin dependent diabetes
4. chronic pancreatitis
65
What are the NICE recommendations for admititng a patient with acute diverticulitis?
CKS NICE: diverticulitis management
1. PAIN not responding to regular analgesia
2. HYDRATION not maintatined with oral fluids
3. symptoms persistent after 48 hours despite
conservative mangement
4. FRAIL patient with significant SO-MORBIDITIES
5. any suspected COMPLICATIONS i.e:
* rectal bleeding requiring blood transfusion
* perforation and peritonitis
* intra-abdominal abscess
66
What clinical features on examination would you look for in a patient with acute diverticulitis
Fever and
1. left iliac fossa tenderness
2. left iliac fossa mass
3. PR bleeding
67
What complications other than rupture for a AAA can you name?
1. distal embolisation: trash foot
2. aorta-enteric fistula ( presents with GI bleed )
3. acute branch involvement causing ischaemia
4. rhabdomylisis
5. bacterial infection
68
What are the indication for elective surgical repair for a patient with a AAA
* diameter > 5.5cm
| * diameter >4.5 with increase in size by 0.5cm in 6 months
69
As per SIGN guidelines what are the admission criteria for lower GI bleed ?
Resource:
1. SIGN guideline: Lower GI bleeding
2. https://www.rcemlearning.co.uk/modules/lower-gastrointestinal-haemorrhage/lessons/clinical-assessment-35/topic/assessment-of-severity/
1. Age > 60
2. with significant co-morbidities
3. taking NSAIDS/Asprin
4. with evidence of gross rectal bleeding OR
haemodynamic disturbance
( any one of the above )
70
Using the BLEED criteria, which patients would be identified as high risk for lower GI bleeding?
https://www.rcemlearning.co.uk/modules/lower-gastrointestinal-haemorrhage/lessons/clinical-assessment-35/topic/assessment-of-severity/
BLEED Classification System
B – ongoing Bleeding,
L – Low systolic blood pressure
E – Elevated prothrombin time
E – Erratic mental status
D – unstable comorbid Disease.
71
What are the classical clinical fetaures of BOERHAAVES syndrome?
it is a spontaneous rupture of a non-diseased oesophagus brought on by vigorous vomiting presenting clinically as:
* respiratory distress
* subcutaneous emphasema
* acute abdomen
72
What bowel screening is available in the NHS?
FOB or FIT (faecal occult blood and Faecal immunochemical testing )
and
Bowel scope screening
73
What is the major constituents of staghorn calculi?
and what is the treatment?
MAP : magnesium, ammonium, phosphate
Treatment is : Percutaneous nephrolithotomy
74
List 4 risk factors for the development of ischaemic bowel?
conditions causing arterial emboli:
(AF, MI, Mitral stenosis
conditions causing arterial thrombosis:
atherosclerosis, aortic aneurysm
non-occlusive mesenteric ischaemia:
hypotension
mesenteric venous thrombosis: tumours, trauma , surgery
75
what 1st line treatment would you use in patient with ureteric calculi for medical expulsive therapy?
```
alpha blockers ( tamsulosin )
calcium channel blocker ( nipedipine )
```
76
What is Hamman's sign?
in which condition do we expect to illicit this clinical sign?
Hamman's sign is when the Heart beat is audible as pericardium comes in contact with mediastinal air.
Crunching sound is heard in precordium synchronised with heart beat.
Boerhaaves syndrome
77
Can you name 2 complications of Boerhaaves syndrome?
1. mediastinitis
| 2. empyema
78
in adults - what are the risk factors for rectal prolapse?
Adult population
·Age
·Constipation
·Common in elderly
·Increased intra-abdominal pressure- COPD, Cystic fibrosis.
·Pelvic floor dysfunction.
·Parasitic infections- Amoebiasis, schistosomiasis.
·Neurological disease- pelvic trauma. Lumbar disc disease, cauda equine syndrome, spinal tumour, MS.
79
In Children - what are the risk factors for rectal prolapse?
·In paediatric population- Rectal prolapse is common with
·Ehlers- Danlos syndrome
·Hirschprung's Disease
·Cystic fibrosis
·Congenital megacolon
·Malnutrition
·Rectal polyps
80
What are the complications of rectal prolapse?
1. thrombosis,
2. mucosal ulcerations,
3. rectal incarceration,
4. strangulation,
5. ischaemia and necrosis of rectal wall.
81
What is the immediate treatment of rectal prolapse?
1. Conservative management- Manual reduction by gentle digital pressure.
2. Generous amounts of granulated sugar to the prolapsed segment, this results in reduction of oedema.
3. If surgically unfit- Subcutaneous circumanal rubber ring can be placed.
4. Treat contributing constipation.
82
A 20 year old lady presents with headaches and drowsiness. She is known to have a VP shunt (Ventriculo-peritoneal) which was recently revised.
Headache, lethargy, vomiting, irritability, behavioural changes, seizures are a few symptoms of shunt obstruction list any 2 common examination findings
· Cranial nerve palsy
· Pupilary dilation
· Papilloedema
· Upward gaze palsy (eye sunsetting)
· Cushing’s triad – Hypertension, Bradycardia and
apnoea or irregular breathing
· Altered mental status
83
What would be the side effect of excessive removal of CSF fluid from a VP shunt tap? (1)
1. postural headache
| 2. subdural haematoma
84
Name the deformity causing testicular torsion due to tunica vaginalis joining high on the spermatic cord? How is this treated? (1)
Bell clappers Deformity
Treatment is surgical by Orchidopexy.
85
Describe the ultrasound appearances in testicular torsion and the appearance in Epidydymo-orchitis
·Testicular torsion- Ultrasound Doppler shows absent or diminished blood supply.
·Epidydymo-orchitis shows increased blood flow signals.
86
Name 2 common acute clinical features of VP shunt blockade in a 5 month child?
· Feeding problem
· Irritability
· Lethargy
· Bradycardia
· Bulging fontanelle
· Meningism
· papilloedema
87
A 82 year old female presents with a sigmoid volvulus but is not suitable for intra-operative surgical correction, what is the immediate surgical management options of this patient?
Decompression- Sigmoidoscopy and Flatus tube- relieves obstructed loop.
Flatus tube is left in place for 24 hours to maintain decompression, prevent recurrence and recovery of vascular supply to bowel.
88
A 82 year old man presents with back pain radiating to the back and collapse. on arrival he has passed blood PR in resuscitation room what is the pathophysiology
Aortoenetric fistula- Most common in duodenum.
Massive GI bleed with a history of Aortic graft top differential is Aortoenetric fistula.
89
What clinical features would suggest a posterior nasal bleed in a patient presenting with epistaxis?
Clinical clues to a posterior nasal bleed:
1. bleeding from both nostrils
2. unable to identify bleeding vessel on inspection
3. continous bleeding
90
What are the complications of streptococcal pharyngo-tonsillitus?
SYSTEMIC COMPLICATIONS OF Strep tonsillitus:
1. toxic shock syndrome
2. post-streptococcal glomerulonephritis
3. scarlet fever
4. rheumatic fever
LOCAL COMPLIOCATIONS
1. otitis media
2. sinusitis
3. retropharyngeal abscess
4. Paraphyryngeal abscess
5. peri-tonsillar abscess
91
how do you classify post tonsillectomy bleed?
primary ( within 24 hours )
| secondary ( up to 28days )
92
How do you treat post tonsillectomy bleed in the interim in ED after you have made the urgent referral to ENT on call?
1. Ice pack to back of neck
2. hydrogen peroxide gargle
3. adrenaline soaked guaze applied to the bleeding
point
4. 1g tranexamic acid IV
```
Memory aid:
Grab ice
Gargle Hydrogen peroxide
Give me gauze soaked with adrenaline
Give 1g tranexamic acid IV
```
93
How would you treat acute attack of vertigo vs treatment to reduce the severity or frequency of attacks
1. -treat acute acttack with :
* prochlorperazine - buccal/oral
2. in between attacks - treatment to delay recurrence:
* betahistine
94
what is the antibiotic regime for treating ludwigs angina ( nec fac )
(a bilateral infection of the submandibular space that consists of two compartments in the floor of the mouth )
Benzylpenicillin + clindamycin + gentamycin
95
What is the difference between:
| vestibular neuronitis and labyrinthitis?
ACUTE VESTIBULAR NEURONITIS:
* only nausea and vomiting with vertigo
* hearing unaffected,
* and no tinnitus
ACUTE LABYRINTHITIS:
* there is nausea and vomiting with vertigo
* hearing loss and
* tinnitus
MENIER'S DISEASE:
* there is nausea and vomiting with vertigo
* hearing loss
* tinnitus
* and aural fullness
```
Memory aid:
# vestibular nerve is a branch of the 8th cranial nerve that controls balance. isolated vertigo with N&V
```
```
# Labyrinthitis -
Labyrinthitis is inflammation of the part of the inner ear called the labyrinth. The labyrinth is made up of fluid-filled channels which control balance and hearing.
```
96
How do you document the findings on rinnes and weber tests?
Rinnes test: it is positive in AC>BC
it is negative if BC>AC
Webers test:
sound is either loudest in left or right ear or
equal in both ears
97
What is the Fever PAIN score in acute tonsillitus?
```
Fever in the last 24hours
Purulent discharge on tonsills
Acutely presented within 3 days
Inflamed tonsils
No cough/coryza
```
score 0-1 no antibiotics
score 2-3 delayed antibiotics
score >4 immediate antibiotic
98
What test can you use in the ED to differentiate between a central and peripheral cause of vertigo?
head impulse test
99
name indications for prescribing antibiotics ( amoxicillin ) in a child with acute otitis media?
CKS NICE otits media
1. bilateral AOM in child under 2 years old
2. purulent discharge in patient with perforation
3. systemically unwell ( fever & vomiting )
4. recurrent infection
100
What are the 3 complications of septal haematoma?
1. septal abscess
2. cartilage necrosis
3. collapse of nasal bridge ( saddle nose deformity )
101
Indications to refer a patient with otitis externa to ENT?
1. concurrent skin infections ( cellulitis )
2. presence of necrotizing otitis externa ( osteomyelitis )
3. failure to respond to first line therapy
4. aural toilet is required
102
Differentiate between peripheral VS central vertigo?
PERIPHERAL VERTIGO:
```
sudden onset
more severe vertigo symptoms
more severe nausea and vomiting
intermittent
positional
nystagmus away from the side of the lesion
```
CENTRAL VERTIGO:
opposite to peripheral
