Questions Flashcards

Question

A 5 year old is brought into the Emergency Department. Her father says she suddenly developed a high temperature and has now started to become very distressed. She has obvious stridor and you note that she is drooling. _What is the most likely diagnosis?_ Croup Anaphylaxis Peritonsillar Abscess Pharyngitis Epiglottitis

Answer 1

***_Epiglottitis_*** Epiglottitis is inflammation above the glottis. It is most often bacterial and presents with an abrupt onset of symptoms. They typically present with a fever followed by ***D***rooling, ***D***istress, ***D***ysphonia and ***D***ysphagia. The child would also have a fever. It is a medical emergency and requires urgent assessment form a paediatric anaesthesiologist to control the airway. If not treated quickly it can progress to respiratory arrest and death within a matter of hours.

Answer 2

***_TOXBASE_*** Toxbase is a widely used Internet resource (provided by the National Poisons Information Service (NPIS)) particularly in Emergency Departments across the UK. It is the primary clinical toxicology database and first line information resource for guidance in managing and treating any poisoning (accidental, overdose, child-related). Toxbase also provides a 24-hour telephone service for further clinical toxicological enquires.

Answer 3

***_Right mainstem bronchus_*** This is a very typical history for inhalation of a foreign object. This can quite quickly lead to death if the object is not removed. The right main bronchus enters the right lung at approximately the 5th Thoracic Vertebra and **lies more vertically than the left**. (The left main Bronchus enters the lung slightly lower down, approximately the 6th thoracic Vertebra). This anatomy predisposes the right lung to several problems including the above.

Answer 4

***_Nebulised salbutamol 5mg and soluble prednisolone 30-40mg_*** The SIGN guidelines state that the above treatment is essential in a child \>5 with a severe exacerbation of asthma (as above). O2 must always be given but on its own would not relieve the exacerbation. Puffs of a B2 agonist are given to children with a moderate exacerbation of asthma – SpO2 \>92%, PEF \>50% best or predicted, No clinical features of severe asthma. Prednisolone is a glucocorticoid, similar to cortisol. Anti-inflammatory.

Answer 5

***_Croup_*** Croup is common and primarily found in children. It is a viral respiratory tract illness which typically affects the larynx and the trachea. It is the most common cause of acute stridor in febrile children. Stridor is an audible harsh, high-pitched, musical sound on inspiration produced by turbulent airflow through a partially obstructed upper airway.

Answer 6

***_Vitamin K_*** Epistaxis can be idiopathic or follow minor/major trauma. When it occurs in patients with hypertension and coagulation disorders, haemorrhage can be severe with significant mortality. Check current medications, full blood count and clotting in older patients. INR or International Normalised Ratio is regularly measured in patients on Warfarin to ensure they are within the therapeutic window and determine the next dose. The target INR is usually 2.0-3.0, a range of factors can cause the INR to become unstable, for example missed doses or illness. If the INR becomes higher than the target range, coagulation is significantly slowed which can increase a patient’s risk of haemorrhage/prolonged bleeding. If major bleeding occurs at any time whilst on Warfarin, the patient should stop taking Warfarin and should be given Vitamin K 10mg via a slow IV and be referred to secondary care for factor replacement. Without major bleeding, if the current INR is between 5 and 9, guidelines indicate Warfarin should be stopped, INR tested daily until it has returned to therapeutic range and restart Warfarin with a reduced dose when INR is \<5. Give Vitamin K 1.0-2.5mg orally if INR fails to reduce or patient is at high bleeding/re-bleeding risk

Answer 7

***_Start Prednisolone 40-60mg_*** This patient has classical symptoms of Giant Cell Arteritis. This diagnosis must be considered in all patients over the age of 50 that present with a unilateral headache, jaw claudication, scalp/temporal tenderness, amaurosis fugax or sudden blindness, typically in one eye. ESR should be carried out (will appear raised) and if GCA is suspected, 40-60mg Prednisolone should be started orally, immediately. The risk is irreversible bilateral visual loss which can occur suddenly if not treated rapidly. A temporal artery biopsy should be carried out within three days of starting steroids. Pain relief is important and should be considered but will not stop progressive blindness. Visual test should also be carried out to clarify the extent of damage, but can be done after starting steroid treatment.

Answer 8

***_Epididymitis_*** This patient has epididymitis. It is often difficult to distinguish epididymitis from testicular torsion. Testicular torsion is a surgical emergency and therefore should be on the differential for a patient with scrotal pain and should be ruled out first. Testicular torsion is rare above the age of 25 and is caused by twisting of the spermatic cord, causing testicular ischaemia. Pain is often an acute onset and the whole testes may present as tender. Epididymitis in those above 35 years old is usually secondary to a UTI and can be associated with an underlying urinary tract pathology. Typically there is a gradual onset of progressive testicular ache with subsequent swelling. The patient may be pyrexic and may have a history of dysuria. The epididymis is acutely tender with the testis lying low in the scrotum. Treatment includes antibiotics, analgesia and rest. Testicular tumours can be mistakenly diagnosed as epididymitis. A Varicocele is a painless scrotal swelling that is caused by dilation of the veins in the pampiniform plexus. These individuals may be asymptomatic or complain of a scrotal pain or heaviness.

Answer 9

***_Escherichia Coli_*** Females are more prone to Urinary Tract Infections due to the short urethra. Acute pyelonephritis occurs when a UTI ascends to the kidney(s). The patient is systemically unwell with fever, loin/back pain (as the kidneys are retroperitoneal), rigors, headache, nausea and vomiting. The kidney(s) are tender on palpation. **E.Coli** is the most common causative organism (\>70% in the community but \<40% in hospital). Treatment of lower UTI includes antibiotics such as Trimethoprim or Nitrofurantoin. Patients with acute pyelonephritis usually require admission for IV antibiotics (broad spectrum-specific after causative organism is identified by blood cultures), fluid replacement and analgesia. Assess and treat for severe sepsis when appropriate.

Answer 10

***_Life threatening asthma_*** This young man has a life threatening exacerbation of asthma. Asthma can be unpredictable and dangerous for young and otherwise healthy men and women. A patient has a moderate exacerbation of asthma if they have increasing symptoms of breathlessness, a peak flow of 50-75% and no features of acute severe asthma (see below). _Acute severe asthma (any 1 of):_ Inability to complete sentences in one breath Respiratory rate less than or equal to 25 breaths/min Heart rate of more than 110bpm Peak flow 33-50% of best or predicted _Life threatening asthma (A patient with severe asthma with any 1 of):_ Cyanosis Exhaustion, confusion, coma Feeble respiratory effort SpO2 \<92% Silent Chest Bradycardia, arrhythmia, hypotension pO2 \<8kPa Normal pCO2 (4.6-6.0kPa) Peak flow \<33% of best or predicted Treatment is guided by regular Peak Expiratory Flow (PEF) measurements: Patients are treated with Oxygen and B2 agonist bronchodilators (e.g. Salbutamol) delivered by nebulizer or metered dose inhaler/spacer. Steroids are often also given to reduce small airway inflammation. Anticholinergics are used in severe cases of asthma. Non-invasive ventilation can be used to reduce the work of breathing without intubation where it can be avoided.

Answer 11

***_3780ml_*** Initial assessment and resuscitation of a patient who has been involved in any fire must follow the ABCDE protocol. Indications of airway burns may include carbon/soot in nostrils/mouth/sputum, singed eyelashes/nostril hair, facial burns, oropharyngeal swelling or redness, change in voice or stridor. Upper airway burns require urgent prophylactic intubation as the patient’s upper airway may swell a large amount within a few hours. Burns can be of varying thickness: superficial epidermal (red and painful but not blistered), partial thickness superficial dermal (pale pink and painful with blistering), partial thickness deep dermal (dry or moist, blotchy and red, and may be painful or painless. There may be blisters) and full thickness (dry, painless, no blisters white/brown/black/leathery/waxy). The ‘rule of nines’ is a quick way to estimate the relative percentage of the patient’s body surface that is burnt, for example: arm 9%, front of trunk 18%, head and neck 9%, leg 18%. Parkland’s formula is used to calculate the amount of IV fluid required for the first 24 hours after a patient has suffered burns injuries, to ensure they remain haemodynamically stable. The formula is only a guide and fluids should be adjusted according to urine output and clinical response.

Answer 12

***_Anterior Posterior Compression Injury_*** Anterior Posterior Compression injuries (also known as ‘open book pelvis’ make up 15-20% of pelvic trauma injuries. These injuries are often the result of a RTA (car vs pedestrian/motorcycle accident), direct crush injury or a fall over 12ft. Classically the pubic symphysis is broken and there is a risk of major haemmorhage as the direction of impact may rupture the venous plexus or internal iliac arteries. A large proportion of a person’s entire blood volume can insidiously enter into the pelvic cavity. A **lateral compression injury**, or ‘closed pelvis’ is the most common type of traumatic pelvic injury (60-70%). This can also occur as a result of a RTA and make cause damage to genitourinary organs but life threatening haemorrhage is less common. **Shear force** injuries are often caused by high energy mechanisms and falls onto one limb, creating major pelvic instability. A **combination injury** is where the patient has more than one type of pelvic trauma injury

Answer 13

***_Appendicitis_*** Appendicitis is the most common surgical emergency which classically presents as poorly localized peri-umbilical pain then moves to tenderness and guarding at McBurney’s Point (2/3 of the way from the umbilicus to a point midway along the inguinal ligament) in the right iliac fossa due to peritoneal irritation. Anorexia is also an important presenting symptom. Rovsing’s sign may also be present; pain that is worse in the right iliac fossa than the left, when the left iliac fossa is palpated. Treatment should be a prompt appendectomy to avoid perforation.

Answer 14

***_Subarachnoid haemorhage_*** Subarachnoid haemorrhages may be caused by ruptured saccular aneurysms (~80%), arterio-venous malformations, hypertension or trauma. Most commonly occurring between the ages of 40-60 years old, the classic symptom is a sudden ‘thunderclap’ (usually occipital) headache, sometimes described as the most severe headache the person has ever had. Vomiting, collapse, seizures and coma often follow if not treated promptly.

Answer 15

***_Status epilepticus_*** SE means seizures lasting for greater than 30 minutes, or if repeated seizures occur without consciousness returning between seizures. Management of status epilepticus involves initial treatment with intravenous lorazepam with two boluses given 10 minutes apart. If seizures continue then an intravenous infusion of either phenytoin or diazepam is given. If this does not stop the seizures then patient should be put under general anaesthesia, for paralysis and ventilatory support.

Answer 16

***_Atrial flutter_*** The ECG shows a typical **saw-tooth appearance** of Atrial Flutter in inferior leads II, III and aVF. Atrial flutter has many similarities to Atrial Fibrillation but is different in terms of mechanism and management. Some patients have both arrhythmias are associated with increased risk of thromboembolism. Atrial flutter is much less common than atrial fibrillation. Prevalence increases with age and is more common in men and during the first week after open-heart surgery. Presentation may be asymptomatic but is generally not tolerated as well as AF and most often presents with palpitations.

Answer 17

***_Wolff-Parkinson-White syndrome_*** WPW syndrome is the most common ventricular pre-excitation syndrome. It is important to diagnose because of it’s association with paroxysmal tachycardias that can potentially result in sudden death, in otherwise, healthy young people (more frequently, men). WPW syndrome is a congenital absnormality which can result in SVT by an AV accessory tract. Classic ECG findings of WPW syndrome include a **short PR interval** (less than 120ms) and a delta wave. Asymptomatic patients may just need periodic review. However, symptomatic patients, such as this, may require ablation of the accessory tract.

Answer 18

***_Torsades de Pointes_*** Torsades de Pointes is a **ventricular tachycardia** in which the QRS amplitude varies and the QRS complexes appear to twist around the baseline. It is a life threatening arrhythmia associated with a congenital (or acquired) long QT interval and may present as sudden cardiac death in patients with structurally normal hearts. Risk factors include congenital long QT syndromes or acquired long QT syndromes such as; MI, certain drugs (methadone, antipsychotics and erythromycin), electrolyte disturbances, AKI, anorexia etc. Episodes of torsades de pointes can spontaneously revert to sinus rhythm, to another ventricular tachycardia or ventricular fibrillation. Episodes may be triggered by stress, fear or physical exertion. Patients can present with recurrent episodes of palpitations, dizziness and syncope, alongside nausea, pallor, SOB and chest pain may also occur.

Answer 19

***_Subdural haemorrhage_*** Elderly and/or alcoholic patients who are more likely to fall are at risk of chronic subdural haematoma, especially if the patient is at increased risk of bleeding e.g. on anticoagulation. The elderly are also more susceptible due to brain atrophy, which can make bridging veins more vulnerable. Bleeding is from bridging veins between cortex and venous sinuses resulting in accumulating haematoma between dura and arachnoid mater. Most subdurals are from trauma but the trauma is often forgotten as it was so minor or long ago (up to 9 months). Symptoms often include a fluctuating level of consciousness, ‘slowing’, drowsiness, headache, personality change and unsteadiness.

Answer 20

***_Perforated diverticulitis_*** A **diverticulum** is an outpoutching of the wall of the gut. When these outpouchings become infected they are known as diverticulitis. **Diverticulitis** presents with abdominal pain, altered bowel habits, pyrexia, elevated inflammatory markers and a tender colon with either localized or generalized peritonism. One of the complications of diverticulitis is **perforation**, which may be picked up by the presence of air under the diaphragm on abdominal x-ray. A perforation must be managed as an acute abdomen and requires surgical treatment but still carries a mortality of 40%.

Answer 21

***_Ischaemic colitis_*** Ischemic colitis is the most common form of intestinal ischemia. The most common cause is an acute, self-limited compromise in intestinal blood flow. Patients may complain of mild abdominal pain and tenderness over the involved segment. There may be blood in the stool, but usually not enough to cause haemodynamic compromise. Supportive care is usual, although for the 20% who develop peritonitis or blood flow remains reduced, surgery will be required. Ischaemic colitis is the most likely diagnosis because of the hint about the ‘funny heart beat’. This is most likely atrial fibrillation, a common cause of emboli which can result in the ischaemia.

Answer 22

***_Ulcerative colitis_*** UC is a form of inflammatory bowel disease, which involves only the large bowel. Patients will predominantly complain of rectal bleeding, frequent stools, mucus in their stool, tenesmus, and lower abdominal pain. UC is associated with extra-colonic manifestations, including erythema nodosum as described in the question. Diagnosis is made using serological markers including **anti-neutrophil cytoplasmic antibodies** (ANCA) followed by imaging and endoscopy with or without biopsy. Management of UC depends on its severity. Acute, severe UC episodes may require hospitalization for IV corticosteroids. Surgery to remove affected bowel portions is curative.

Answer 23

***_Febrile convulsion_*** A febrile convulsion is a single tonic-clonic seizure that occurs in response to a rapid rise in temperature in a febrile illness. It is normal to occur in young children (less than 5) and is usually short-lived. Simple febrile convulsions do not require treatment but they can recur. Individuals who suffer from febrile convulsions are however more likely to have epilepsy than the general population.

Answer 24

***_Hypocalcaemia_*** Features of mild hypocalcaemia include cramps & perioral paresthesia. When severe, the patient may exhibit Trousseau’s sign (flexion of the fingers and wrist after inflation of a blood pressure cuff to compress the brachial artery) and Chvostek’s sign (twitching of the facial muscles when the facial nerve is tapped due to neuromuscular excitability). Causes of hypocalcaemia include chronic kidney disease, hypoparathyroidism (which is a common complication of thyroidectomy operations), rhabdomyolysis, vitamin D deficiency, hypomagnesaemia, osteomalacia, acute pancreatitis and over-hydration.

Answer 25

***_Section 5(4)_*** Section 5(4) is the **nurses holding power**. This can only be applied by authorized psychiatric nurses enabling detainment of patients known to suffer from a mental illness. This section only lasts 6 hours, within this time the doctor in charge or their deputy is expected to see this patient to apply a section 5(2) which last for 72 hours.

Answer 26

***_Pulmonary embolism_*** In this case, the diagnosis is most likely to be a pulmonary embolism (PE), caused by an **emboli from a deep vein thrombosis** which formed as a result of long distance travel. Symptoms of pulmonary embolism are often limited to breathlessness, but they may also have pleuritic chest pain, haemoptysis, dizziness, leg pain. On examination a patient will be tachypnoeic and tachycardic. Other signs sometimes present include a raised JVP, pyrexia and hypotension. There are a variety of risk factors for developing a PE. Major risk factors include: recent major surgery, pregnancy, fracture, varicose veins, malignancy or previous DVT/PE. Minor risk factors include: oral contraceptive pill, hormone replacement therapy, long distance travel and obesity.

Answer 27

***_Pneumocystic pneumonia_*** Pneumocystic pneumonia (PCP) is a **pneumonia found in immunosuppressed patients**. This man is an intravenous drug user, meaning he is at increased risk of suffering from HIV. Patients are often diagnosed with HIV after presenting with PCP. A typical presentation would be with a dry cough, exertional dyspnoea, reduced oxygen saturation, fever and bilateral crepitations. Chest x-ray may show perihilar shadows or is often normal. A CT chest would show diffuse ‘ground-glass’ opacities. PCP is caused by the bacteria Pneumocystis Jirovecii.

Answer 28

***_Tuberculosis_*** The primary infection is usually asymptomatic; others have symptomatic haematological dissemination, which may result in military tuberculosis. 5% of patients develop to post-primary pulmonary tuberculosis, which, may again be asymptomatic, or present as this lady did with fever, malaise and weight-loss. Cough and haemoptysis may also be present. _Radiography findings are summarized below:_ \* Primary TB o Ghon lesion - caseating granuloma which has calcified o Cavitating lesions (10-30% of cases) o Pleural effusions (10-40% of cases) o Ipsilateral paratracheal lymphadenopathy \* Post-primary TB o Patchy consolidation o Poorly defined linear and nodular opacities o Hilar nodal enlargement (30%)

Answer 29

***_Cauda equina syndrome_*** Cauda equine syndrome is a pattern of neuromuscular and urogenital symptoms resulting from **compression of the cauda equina** (nerve roots at the end of the spinal cord). _Danger signs suggesting compression of the cauda equina are:_ \* Reduce sensation in the saddle region (buttocks, thighs and perineum) \* Urinary incontinence or retention \* Faecal incontinence \* Reduced anal tone \* Lower limb motor and sensory deficits \* Reduced or absent lower limb reflexes _Common causes of cauda equine syndrome are_ lumbar stenosis, herniated nucleus pulposus, neoplasm, spinal infection/abscess, spina bifida and subsequent tethered cord syndrome. In this case, his symptoms may have been caused by vertebral collapse secondary to malignancy. Cauda equina is a medical emergency so urgent MRI should be requested.

Answer 30

***_Idiopathic intracranial hypertension_*** Idiopathic intracranial hypertension (IIH) is a disorder of unknown aetiology, primarily affecting overweight women of child bearing age. The pathophysiology is poorly understood. Patients may present with headache of varying frequency, location and character. They may complain of diplopia (usually horizontal); or tinnitus. These patients may present with symptoms of increased ICP including papilloedema. Management resolves around preserving optic nerve function and acetazolamide and frusemide have been found as the most effective agents to lower ICP and thus preserve function. If vision deteriorates, surgery or other invasive techniques are available. Headache prophylaxis may be necessary - amitriptyline and propranolol are commonly used.

Answer 31

***_Migraine_*** Migraine classically presents with a **throbbing headache (typically unilateral)** with visual aura, nausea, vomiting and photophobia. Although not all of these symptoms are necessarily present. Other symptoms include allodynia and phonophobia. The **oral contraceptive pill** is a known trigger of migraines in some individuals. Other known triggers are: chocolate, cheese, alcohol, exercise and they can sometimes be related to the menstrual cycle or pregnancy. Whilst the presentation of migraine can be similar to a cluster headache the involvement of the visual field makes migraine the most likely diagnosis.

Answer 32

***_Section 136_*** Section 136 enables a police officer to arrest a person in a public place who they believe to be suffering from a mental disorder, in order to bring them to a place of safety (usually the Emergency Department). This section allows 72 hours for a full assessment by a psychiatrist and an approved social worker. After assessment the patient can either be discharged or detained under section 2 or 3 of the Mental Health Act.

Answer 33

***_72 hours_*** Section 4 of the Mental Health Act is to enable emergency treatment of an individual suffering from a mental illness. Admission under a section 2 is sometimes inappropriate as it would result in a significant delay (it requires the recommendation of two doctors and a social worker). A section 4 can be passed after the recommendation of only one doctor. Detainment under section 4 only lasts 72 hours. On admission, it is usually converted into a section 2 to enable long term treatment.

Answer 34

***_Superficial Partial Thickness (Superficial Dermal) Burn_***

Answer 35

***_Full Thickness Burn_***

Answer 36

***_Prolapsed intervertebral disc_*** Intervertebral disc prolapse commonly presents with severe pain on coughing, sneezing or with twisting of the spine. The patient is a builder suggestive of manual labor which may involve twisting whilst carrying heavy objects. Lumbar discs are those most likely to rupture therefore causing pain in the lumbar region. If the herniated nucleus pulposus compresses a nerve root this frequently results in the pain radiating to the buttock or leg (sciatica) which also rules out the diagnosis of mechanical back pain. The fact that the patient reports no other symptoms in reassuring that the prolapsed disc has not resulted in cauda equine syndrome.

Answer 37

***_Vertebral osteomyelitis_*** Osteomyelitis is an infection of the bone. Vertebral osteomyelitis is a rare condition which presents with back pain alongside symptoms of a significant infection (fever and night sweats) and weakness of vertebral muscles. Vertebral osteomyelitis is more likely in patients who are intravenous drug users (IVDUs) or immunocompromised (e.g. AIDS, long term steroid treatment). Staph. aureus and pseudomonas are common causative organisms in IVDUs.

Answer 38

***_Cluster headache_*** A cluster headache is a grouping of headaches, usually for a period of several weeks. Cluster headaches can be episodic or chronic. The pathophysiology is poorly understood. Vasodilators (e.g. alcohol), male sex, age over 30 and previous head trauma are risk factors for CH. The international headache society characterizes the headaches as unilateral pain (orbital, supraorbital or temporal) that lasts around 15-180 minutes. The pain may be associated with conjunctival injection, lacrimation, nasal congestion, rhinorrhea, forehead and facial sweating, miosis, ptosis or eyelid oedema. Preventative/prophylactic treatments include calcium channel blockers, mood stabilizers, and anticonvulsants.

Answer 39

***_4.5 hours_*** The 2015 NICE guidelines (pathways.nice.org.uk/pathways/stroke/acute-stroke.pdf) recommend that if a CT scan has ruled out a haemorrhagic stroke and no other contraindications are met, such as; previous stroke in past 3 months, major surgery or trauma in previous two weeks, past intracranial haemorrhage or neoplasm etc, thrombolysis with alteplase should be conducted within **four and a half hours**. Thrombolysis should only be conducted in a specialist trained centre in which there is immediate access to re-image the patient, if necessary. A good outcome 24 hours after thrombolysis tends to predict a good outcome at three months.

Answer 40

***_O (Rhesus -ve)_*** Group O-ve is considered the ‘Universal *_DONOR_*’ because it has **no surface antigens** and therefore should not cause a transfusion reaction. **Group AB** is considered the ‘Universal _RECIPIENT_’ because it contains **no antibodies** to cause a transfusion reaction to any blood type.

Answer 41

***_Waterhouse-Friderichsen Syndrome_*** Waterhouse-Friderichsen Syndrome (WFS) is often a pre-terminal event associated with profound sepsis (often caused by Neisseria meningitidis) and coagulopathy/DIC. WFS is defined as bleeding into the adrenal glands resulting in failure, rapidly developing adrenocortical insufficiency and often death. A **Phaeochromocytoma** is a neuroendocrine tumour of the adrenal medulla and is an important differential for hypertension in a young patient without any obvious cause. **Conns Syndrome** or Primary Hyperaldosteronism is usually associated with an adrenal adenoma. Excessive *_aldosterone_* levels act at the distal renal tubule, promoting sodium retention, which results in water retention and volume expansion; thus hypertension. There is also increased excretion of potassium, resulting in hypokalaemia. **Nelsons Syndrome** is the rapid enlargement of a pituitary adenoma that occurs after the removal of both adrenal glands that is now very rarely conducted for Cushing’s syndrome. Common signs and symptoms would include muscle weakness and skin hyperpigmentation due to melanocyte stimulating hormone. **Addison’s Disease**, or chronic adrenal insufficiency is a rare, chronic disorder in which the adrenal glands do not produce sufficient steroid hormones. The fact it is chronic distinguishes it from acute adrenal insufficiency caused by Waterhouse-Friderichsen Syndrome.

Answer 42

***_Joint Aspiration_*** This man is likely to be suffering from **Septic arthritis**. Septic arthritis should always be considered in patients presenting with one (or less frequently, multiple) acutely inflamed joints. Often septic arthritis presents with a swollen, warm, tender joint (most frequently the knee) that is exquisitely painful on movement. Risk factors include: increasing age, diabetes, rheumatoid arthritis, joint surgery, joint prosthesis or concurrent skin infection. Septic arthritis is a medical emergency and if left untreated can destroy the joint in a period of days and may lead to widespread bacteraemia. In terms of investigations, **FBC** may reveal an elevate white cell count alongside raised inflammatory markers, although will not indicate a specific infection. A **plain radiograph** may indicate damage to the joint but, again, will not indicate the cause. **Blood cultures** are extremely important (you are required to take a minimum of two samples) to exclude bacteraemia, but joint aspiration is the most useful and specific investigation to support or refute a septic arthritis diagnosis, whilst in the ED. **Aspiration** is likely to produce a turbid, non-viscous fluid with highly elevated neutrophils and may provide some immediate relief to the patient, reducing the effusion. It is important to begin the patient on antibiotics before you have clarification from lab results if you have a high clinical suspicion of septic arthritis.

Answer 43

***_5th intercostal space, anterior to mid-axillary line_*** Needle thoracostomy (with a 14-16G intravenous cannula inserted into the second intercostal space, mid clavicular line) can be used to urgently decompress a tension pneumothorax, where there is not enough time to insert a chest drain. Chest drain placement is the definitive treatment of a tension pneumothorax. The position of the drain is determined by the location and the nature of the collection to be drained; however the **5th intercostal space anterior to the mid-axillary line** is generally used for most situations (the *_long thoracic nerve lies in the mid-axillary line_*). This is commonly known as the ‘safe triangle’ bordered by the anterior border of the latissimus dorsi, the lateral border of the pectoralis major, a line superior to the horizontal level of the nipple and an apex below the axilla. Signs and symptoms of a tension pneumothorax include: tachycardia, tachypnoea, hyperresonance on percussion and tracheal deviation away from the pneumothorax, seen on CXR.

Answer 44

***_Left Anterior Descending Artery_*** ST elevation across leads V1 to V6 suggests an **Anterior MI**, which would most likely involve the Left Anterior Descending (LAD) artery.

Answer 45

***_CRP raised_*** A patent with fever, cough and pleuritic chest pain has Pneumonia until proven otherwise. C=New onset **confusion** U=**Urea** \>7mmol/L R=**Respiratory Rate** \>30/min B=**BP** \<90/60mmHg Age **\>65**. One point is given for each criteria met. The CURB-65 scoring tool is helpful to predict the need for admission/intensive treatment. If a patient scores **0-1** they can be treated as an outpatient. A score of **2-3** would indicate a short stay in hospital or close monitoring as an outpatient. A score of **4-5** is highly suggestive that the patient needs to be admitted and should be considered for the Intensive Care Unit.

Answer 46

***_Necrotising Fasciitis_*** Necrotising Fasciitis is an uncommon but life threatening infection, defined as any necrotising infection (polymicrobial, gram-negative monomicrobial, fungal etc.) that involves any layer of the deep soft tissue compartment (dermis, subcutaneous tissue, fascia or muscle). NF is difficult to diagnose in its early stages as it mimics cellulitis. Important early clues and distinguishing features from cellulitis include: disproportionate pain and tenderness that extend outside the boundary of tissue decolouration. Systemic illness may also be out of proportion to the visible tissue damage. Bullae and ecchymotic skin lesions can also point to NF rather than cellulitis. A high index of suspicion is important. NF can be caused by Group A Strep, in otherwise fit and healthy individuals. NF signs and symptoms typically develop over a few days but can progress much more rapidly and be fatal within 48 hours for some. Disproportionate pain may be the first symptom with some mild erythema and swelling on one area of the body. The pain is disproportionate because of the extensive deep tissue injury. Day 2-4 bullae may appear alongside tense oedema. Skin will become discoloured, progressing to necrosis which can rapidly spread along fascia planes. Day 4-5 is usually when hypotension and septic shock develop. Urgent surgical debridement and often removal of affected areas is essential to survival, alongside high dose IV broad spectrum antibiotics. Mortality is generally considered to be \>25%.

Answer 47

***_ARDS_*** The CXR shows diffuse **bilateral consolidation** with a ground glass appearance; suggestive of **Adult Respiratory Distress Syndrome** (ARDS). Air bronchograms can also be seen (left and right). This is an (almost always pathological) phenomenon in which air filled bronchi (black) are highlighted by the opacification of surrounding alveoli (grey/white). On this CXR a central venous line and a nasogastric tube can also be seen. ARDS is a devastating condition which can affect adults as well as children. It occurs when non-cardiogenic pulmonary oedema (secondary to acute damage to the alveoli) leads to acute respiratory failure. Most common risk factors include; massive trauma with shock and multiple transfusions, hypovolemic shock (as was likely to be the case for Andrew), pneumonia or gastric aspiration. ARDS can be associated with direct or indirect lung injury. Overall mortality is 50-75% and prognosis varies with age and number of organs in failure and immediate admission to ITU to provide supportive care is vital to increase the likelihood of survival.

Answer 48

***_Thromboembolism_*** **Rehydration and insulin therapy** are the mainstays of **treatment in DKA** and should be instigated without delay. The average fluid loss in DKA is 100ml/Kg and it is important to bare in mind that dehydration is more lethal than hyperglycaemia. Insulin is infused at a fixed rate of 0.1u/kg/hr. This is reviewed and adjusted after one hour to ensure that blood glucose and ketones are dropping at a desired rate and correction of the acidosis is on track. It is incredibly important, in DKA, to stick to a strict regimen of insulin and fluid replacement with regular monitoring. Rapid reduction of glucose causes rapid changes in serum osmolality and may precipitate cerebral oedema (mainly in children). Furthermore, overzealous insulin replacement may lead to hypoglycaemia alongside hypophosphataemia and hypomagnesaemia as both magnesium and phosphate move intracellularly with potassium. Thromboembolism is not directly associated with rapid insulin and fluid replacement in DKA. It is predominantly associated with dehydration, increased plasma osmolarity and immobility and is therefore more of a potential complication of the pathology of DKA rather than a risk of rapid treatment.

Answer 49

***_Ectopic Pregnancy_*** A typical history of an ectopic pregnancy is a female with a history of **6-8 weeks amenorrhoea** who presents with **lower abdominal pain** and later develops **vaginal bleeding**. Shoulder tip pain (diaphragmatic irritation from a rupture) may be seen as well as cervical excitation. In this case, the patient is beginning to show some signs of **shock** as her pulse is rising and BP dropping. Appendicitis typically presents with pain initially in the central abdomen before localising to the right iliac fossa. Vomiting and anorexia can be present. Rovsing’s sign (more pain in RIF than LIF when palpating LIF) would be indicative of appendicitis. Pelvic pain, fever, dyspareunia, vaginal discharge, dysuria and menstrual irregularities would be more suggestive of **pelvic inflammatory disease**. Ovarian torsion is usually a very sudden onset unilateral lower abdominal pain. Onset may coincide with exercise. Nausea and vomiting are common. Often a unilateral, tender, adnexal mass can be felt on examination. A miscarriage is usually associated with less severe pain, more crampy lower abdominal pain and vaginal bleeding following a few weeks of amenorrhoea.

Answer 50

***_Swelling immediately after the injury and now_*** Ottawa rules help clinicians decide when an ankle X-ray is required. They have a sensitivity of approaching 100%. They suggest that an ankle X-ray is required only is there is any pain in the malleolar zone and any one of the findings in the question, apart from the presence of swelling, immediately after the injury or at present.

Answer 51

***_Scaphoid fracture_*** Scaphoid fractures are one of the most frequent sources of litigation in the ED. The history is usually **FOOSH** (Fall On Outstretched Hand) and clinical signs include **pain in the anatomical snuffbox** (between the extensor pollicis longus and extensor pollicis brevis), on axial thumb compression and on pressing over the scaphoid tubercle. An X-Ray should be performed and area immobilized with a splint/plaster. Even if the X-ray does not show a fracture, the patient should be sent home to have a definitive investigation (for example a repeat X-ray in 1 week) to prove or refute the diagnosis. 20% of scaphoid fractures are not visible until 1 week after injury. If the scaphoid fracture is missed, avascular necrosis and non-union can result in early osteoarthritis and disabling stiffness in the joint and therefore litigation.

Answer 52

***_14G_*** Colours can vary in hospitals/areas/over time but **the smaller the number, the larger the bore and higher the flow rate of cannulas**. A **20 gauge is small**, with a flow rate of approximately 50ml/min and may be used in non-urgent situations where it is difficult to get a line in. A **14-gauge cannula** has a flow rate of approximately 350ml/min. For resuscitation or when giving blood (viscous), a 16 G or larger cannula is preferred.

Answer 53

***_Acute Pericarditis_*** Acute Pericarditis is **inflammation of the pericardium**. It may be idiopathic, such as is likely in this case, or secondary to: viral infection (Coxsackie, flu, Epstein-Barr, mumps, varicella, HIV), bacterial infection, MI or autoimmune diseases such as Rheumatoid arthritis, SLE or sarcoidosis. Pericarditis can present with **central chest pain** or a **sharp pain** over the left chest, which is **worse on inspiration or lying flat**. Sitting forward often relieves the patient’s pain. A **pericardial friction rub** (high-pitched scratchy ‘sandpaper’) may be heard on auscultation. ECG classically shows ST segment ‘saddle shaped’ elevation across multiple leads. Troponin may also be raised. It is important to look for evidence of a pericardial effusion, such as dyspnoea, raised JVP, Ewart’s sign (bronchial breathing at the left base due to compression of the lung lobe) or cardiac tamponade. Cardiac tamponade is caused by an accumulation of pericardial fluid which raises intra-pericardial pressure and results in poor ventricular filling and fall in cardiac output.

Answer 54

***_Anterior dislocation of the shoulder_*** Anterior (subcoracoid) dislocation is the most common type of shoulder dislocation (this is in contrast to the hip where posterior dislocation is the most common). The usual mechanism of injury is a fall onto the outstretched arm when the arm is abducted and externally rotated. It can also result from various sporting injuries, commonly basketball and rugby. Pain is severe, and the patient is unwilling to attempt movements of the shoulder. A swelling may be noticed in the deltopectoral groove (displaced head) with an undue prominence of the acromion process. The arm is held in slight abduction and external rotation. There may be flattening and loss of contour of the shoulder just below the acromion process, and lowering of the anterior axillary fold. If the axillary nerve is damaged, patients may present with loss of sensation over the upper, outer aspect of the arm (Regimental badge area). Posterior dislocation of the shoulder, although uncommon, may occur as a result of direct blow to the shoulder joint causing the humeral head to be displaced from the glenoid cavity. It may result from violent trauma such as an electric shock or an epileptic convulsion.The arm is usually held (or fixed) in internal rotation (note: external rotation in anterior dislocation), which cannot be rotated outwards even as far as the neutral position. The normal shoulder contour is lost and the anterior aspect of the shoulder appears flat (in contrast to fullness observed in anterior dislocation).

Answer 55

***_Compartment Syndrome_*** Compartment syndrome is defined as an increase in the interstitial fluid pressure within an osseofascial compartment of sufficient magnitude to cause a compromise of the microcirculation leading to necrosis of the affected nerve(s) and muscle(s). It is a well-recognised and important complication of lower limb injuries, most commonly seen after fractures and crush injury, although it can occur in the absence of bony injury. The other causes for compartment syndrome include electrical injuries, deep thermal burns, venom from snake bites, restricting tourniquets, and fluid extravasation (e.g. intravenous regional anaesthesia). The patient may present with unremitting pain that is not relieved by high doses of opioid analgesics. Severe pain in response to passive stretch of the ischemic muscles is by far the most dramatic and reliable clinical sign of compartment syndrome. Sensory loss occurs before motor loss. Early in its development, the peripheral pulses are normal as is the colour and temperature of the affected part, since it is the microvasculature that is initially affected. Loss of peripheral pulses is usually a late and often sinister sign. With progression of the condition, the limb becomes tense and swollen, and if left treated, the muscle weakness may progress to total paralysis. Left untreated, irreversible myoneural necrosis occurs within 6-8 hours. Areas of muscle may also infarct, leading to rhabdomyolysis, hyperkalaemia, hyperphosphataemia, high uric acid levels and metabolic acidosis.

Answer 56

***_Boerhaave syndrome_*** This patient has got the classical clinical history, signs and symptoms of Boerhaave syndrome, which is the spontaneous rupture of a non-diseased oesophagus, usually caused after episodes of vigorous vomiting –frequently seen in alcoholics. The dramatically raised intra-oesophegeal pressure caused by vigorous vomiting and associated failure of the cricopharyngeal sphincter to relax may lead to sudden spontaneous rupture of the oesophagus. The most common anatomical location of the tear is at the left postero-lateral wall of the lower third of the oesophagus, 2-3 cm proximal to the gastro-oesophageal junction, along the longitudinal wall of the oesophagus. The signs and symptoms include, sudden pain in the thorax and epigastrium following forceful protracted vomiting, pain radiating to the neck, progressive dyspnoea, tachypnoea, cyanosis, hypotension and shock. Subcutaneous emphysema may be present, palpable in the neck or chest, but this sign may take time to develop. The triad of vomiting, chest pain, and subcutaneous emphysema is also known as ‘Mackler triad’; however, this should not always be relied on since only one or two of the above symptoms may be present in a majority of patients in the early stages. Examination of the chest may reveal decreased breath sounds on the side of perforation, usually the left. Chest X-ray may reveal an abnormal left cardiac border with free fluid within the left hemithorax, as well as air in the mediastinum and under the diaphragm. It is vital to recognise this condition early and treat appropriately, since it is associated with about 30% mortality.

Answer 57

***_Atropine_*** This patient has got the classical features of an anaphylactic shock. The clinical signs of anaphylactic shock include shortness of breath, increased respiratory rate, inspiratory stridor, wheeze, tachycardia, angioneurotic oedema (classically swollen lips, tongue, face and neck leading to breathing difficulties) and sometimes evidence of peripheral shutdown (such as a delayed capillary refill). Patients diagnosed to have an anaphylactic shock should be placed in a comfortable, reclining position. High flow of oxygen should be administered and intravenous access secured. If the patient is hypotensive, then intravenous fluids (such as colloids or crystalloids) may be administered. *_Adrenaline_* is the first choice drug in the management of anaphylactic shock. An anti-histamine drug such as chlorpheniramine may be effective in controllingthe symptoms. Hydrocortisone is useful in the treatment of anaphylactic shock although its role in limited in the acute stages due to its delayed action. An inhaled ß2 agonist such as salbutamol is useful to treat the bronchospasm associated with the anaphylaxis. Atropine does not have any role in the management of anaphylactic shock.

Answer 58

***_Compartment syndrome_*** Compartment syndrome is defined as an increase in the interstitial fluid pressure within an osseofascial compartment of sufficient magnitude to cause a compromise of the microcirculation leading to necrosis of the affected nerve(s) and muscle(s). It is a devastating early complication seen after fractures and crush injury, commonly in the lower limb. It can also be caused by deep thermal burns, electrical injuries, restricting tourniquets, venom from snake bites and fluid extravasation (e.g. intravenous regional anaesthesia). Early in its development, the peripheral pulses are normal as are colour of the affected part (demonstrated by examining the digits of the affected limb), temperature and capillary refill since it is the microvasculature which is initially affected. Loss of peripheral pulses is usually a late and often sinister sign. The patient may complain of unremitting pain that is not relieved even by high doses of opioid analgesics. Severe pain in response to passive stretch of the ischemic muscles is by far the most dramatic and reliable clinical sign of compartment syndrome. Sensory loss (distal paraesthesiae) occurs before motor loss since the thin cutaneous nerve fibres are more susceptible to ischemia than the motor fibres. With progression of the condition, the limb becomes tense and swollen, and if left treated, the muscle weakness progresses to paralysis. Irreversible myoneural necrosis within 6-8 hours, even with compartment pressures in the range of 30-35 mmHg (taken in conjunction with the patient’s diastolic blood pressure; see below). The areas of muscle may also infarct giving rise to rhabdomyolysis, hyperkalaemia, hyperphosphataemia, high uric acid levels and metabolic acidosis. Classically, the compartment pressures are measured using a slit catheter device. The normal resting pressure within the compartment tissues is estimated to be about 3-4 mmHg. Compartment pressures in excess of 30-35 mmHg in a normally perfused patient suggested the need for open compartment fasciotomy. Recent evidence, however, suggests that fasciotomy should be undertaken if the difference between the diastolic pressure and the measured compartment pressure is less than 30 mmHg. Hence if the patient is in hypovolemic shock, as frequently happens in trauma victims, even a modestly increased compartment pressures warrants fasciotomy. Compartment syndrome can also affect the upper limb, commonly the forearm. In compartment syndromes affecting the anterior forearm, the greatest neurologic damage is to the median nerve as it is located in the centre of the muscle mass to be infarcted, whereas the ulnar nerve lies along the periphery of the compartment and is thus subject to less ischemia and damage.

Answer 59

***_Femoral nerve_*** The femoral nerve arises from the lumbar plexus **(L2-4)**. It exits the pelvis by passing beneath the medial inguinal ligament to enter the femoral triangle, after penetrating the psoas muscle. In the femoral triangle, it lies just lateral to the femoral artery and vein. It may be injured by gunshot wounds, direct penetrating wounds, traction during surgery, catheterisation of the femoral artery, massive haematoma within the thigh, nerve injury secondary to femoral nerve block, psoas abscess, fractured pelvis,or by dislocation of the hip. Apart from trauma, it may be affected in patients with diabetes mellitus (diabetic neuropathy) and lumbar spondylosis. The femoral nerve innervates the iliopsoas, which helps in flexion of the hip, and the quadriceps, which helps in extension of the knee. The motor branch to the iliopsoas originates in the pelvis proximal to the inguinal ligament and injury at or above this level leads to loss of hip flexion. The sensory branch of the femoral nerve, the saphenous nerve, innervates the skin over the medial aspect of the thigh and the anterior and medial aspects of the calf. Hence femoral nerve injury results in numbness over the medial aspect of the thigh and the antero-medial aspect of the leg. Motor loss includes weakness of the quadriceps muscle and decreased patellar reflex (knee jerk) (the ankle jerk is preserved since it is innervated by the tibial nerve [S1-S2]). In long-standing, sub-acute injuries, the patient finds that the knee gives way on walking and has difficulty climbing stairs.

Answer 60

***_Peri-prosthetic fracture_*** Peri-prosthetic fractures may be sustained during the insertion of the new femoral head and are relatively common. These fractures are frequently missed as they present with insidious post-operative pain and difficulty mobilising. Peri-prosthetic infections will typically present later (6 months to a year), with loosening of the joint leading to instability. _Dislocation_ is an acute and very painful condition. _Functional pain_ following insertion of any prosthesis should be a diagnosis of exclusion. Management of the patient’s expectations, however, regarding their new joint is important to avoid dissatisfaction with results, and to familiarise the patient with what to expect.

Answer 61

***_Salter-Harris fractures account for less than 5% of all fractures in children_*** ## Footnote The Salter-Harris classification system is for _fractures through the growth plate or the epiphysis_ (in Salter-Harris types II & IV, the metaphyseal fragment is also involved but the diaphysis is never affected). Salter- Harris types I & II do not involve the germinal layer and therefore growth disturbance is uncommon. In Salter-Harris types III & IV, the germinal layer is breached and growth disturbance is likely, although its incidence could be minimised by precise reduction of the fracture. Although not originally described, a Salter-Harris type V fracture is recognised as a crushing injury of the epiphysis following which growth arrest is common. This fracture is often diagnosed retrospectively, when disturbance of physeal growth is apparent as a limb deformity. Because of the weakness of the growth plate, these injuries are relatively common.

Answer 62

***_Basal skull fracture_*** This patient is manifesting the classical signs and symptoms of basal skull fracture. _Trauma_ is the commonest cause of such fractures. These fractures commonly involve the roof of the orbits, the sphenoid bone, or portions of the temporal bone. The commonly found signs and symptoms of basal skull fracture include, Raccoon eyes (periorbital haematoma), subconjunctival haemorrhage where the posterior margins cannot be seen, Battle’s sign (post auricular bruising and blood behind the eardrum; this sign may develop after 24-48 hours of injury) and rhinorrhoea/otorrhoea (blood with CSF & doesn't clot; this is caused by damage to the cribriform plate). The management of such patients depends on other associated injuries and the features found from relevant investigations such as a _CT or an MRI_. Some of the indications for a CT scan include a falling GCS or a GCS \<13, depressed skull fracture, lateralising neurological signs and convulsions. Patients with a GCS \<8 warrant intubation to protect their airway. With any skull fracture, especially basal fractures, prophylactic antibiotics are indicated to prevent meningitis. Some recognised complications of basal skull fractures include, high risk of infection (especially following CSF rhinorrhoea), facial palsy (usually responds well to steroids), and isolated VI nerve palsy.

Answer 63

***_Lumbar intervertebral disc prolapse_*** ## Footnote Lumbar intervertebral disc prolapse usually affects men in their middle age. It is mainly caused by sudden lifting of heavy weight or may be precipitated by trauma. Prolapse of the L4/5 and L5/S1 discs account for about 90% of the cases. The clinical presentation in acute cases includes acute back pain (with radiating pain along the legs), parasthesia and motor weakness in the event of nerve root compression. In severe bilateral nerve root compression, there may be bowel and bladder incontinence, and sexual dysfunction. On examination, the paraspinal muscles may be in spasm and the patient may lean away from the side of the pain with the hip and knee flexed in an effort to reduce the leg pain.

Answer 64

***_Median nerve_*** ## Footnote This patient has _carpal tunnel syndrome_, a very common mononeuropathy that results from _compression of the median nerve_ at the wrist in the carpal tunnel. _Females_ are most at risk because their tendons are a similar size to those in men, although their carpal tunnels are smaller. Patients with rheumatoid arthritis, diabetes, acromegaly, hypothyroidism, amyloidosis or who are pregnant are predisposed to carpal tunnel syndrome. The disease is often _bilateral_ and presents with pain, typically at night where the hand may be held in a hyperextended position, which compresses the carpal tunnel, increasing pressure on the median nerve. There is weakness in the hand of the pronator teres (pronation), flexor digitorum profundus and superficialis (flexion of the fingers), flexor pollicis longus (flexion of the thumb) abductor pollicis brevis (abduction of the thumb), opponens pollicis (apposition of the thumb and base of little finger). There is sensory loss in the distribution of the nerve, over the lateral aspects of the hand, particularly on the palmar side. _Tinel’s test is often positive_ where tapping over the carpal tunnel on the flexor aspect of the wrist reproduces paraesthesia in the distribution of the median nerve. _Phalen’s test_ is where there is r_eproduction of the pain_ or paraesthesia is produced on flexion of the wrist in less than 60 seconds. Treatment is with splints that keeps the wrist extended at night, steroid injections or decompressive surgery where the flexor retinaculum is divided, thereby increasing the space in the carpal tunnel.

Answer 65

***_Tension pneumothorax_*** ## Footnote The clinical presentation in this patient is suggestive of a tension pneumothorax, which may occur following _penetrating injuries to the chest_. Tension pneumothorax is a surgical emergency as it _may result in cardio-respiratory arrest_ if the tension is not relieved immediately. With each inspiration air is drawn into the pleural space and has no route to escape (acts as a one-way valve). Patients present with chest pain, respiratory distress (air hunger), tachypnoea, tachycardia, hypotension, distended neck veins and unilateral absence of breath sounds. The chest wall on the affected side is _hyper-resonant_ to percuss and the _trachea may be deviated to the opposite side_. The mediastinum may also be shifted to the contra-lateral hemi-thorax. Immediate management consists of ***insertion of a large bore needle (cannula) into the second intercostal space in the mid-clavicular line*** on the affected side. ***Once the tension is released***, definitive management includes ***insertion of an intercostal chest drain*** and connecting it to an underwater seal.

Answer 66

***_Diaphragmatic rupture_*** ## Footnote This patient is demonstrating features of a ruptured diaphragm. Diaphragmatic rupture occurs in _high-speed blunt abdominal traumas_ when the patient has got a closed glottis. It is more commonly diagnosed on the left as the liver, in addition to providing protection on the right, obliterates the defect. Blunt trauma produces large radial tears in the diaphragm that lead to _herniation of the bowel contents into the thoracic cavity_. Bowel sounds may be heard in the chest and X-ray may reveal bowel gas in the lung fields as the colon and stomach may herniate into the thorax. Diaphragmatic ruptures may be missed initially if the chest film is misinterpreted as showing an elevated diaphragm, acute gastric dilatation, subpulmonary hematoma or a loculated pneumohaemothorax. If a laceration of the diaphragm is suspected, a gastric tube should be inserted. When the gastric tube appears in the thoracic cavity on the chest film, the need for special contrast studies is eliminated. Magnetic resonance imaging is accurate in visualising the anatomy of the diaphragm (and diaphragmatic injuries), and thus the investigation of choice. The surgical approach (trans-thoracic or trans-abdominal) depends on the stage of recognition and the presence of associated injuries. If detected early in a patient with other intra-abdominal injuries, a trans-abdominal approach is acceptable.

Answer 67

***_Oesophageal rupture_*** ## Footnote Oesophageal perforation _caused by closed chest injuries or direct trauma to the oesophagus_ is rare and accounts for about 10% of all oesophageal ruptures. However, if unrecognized and untreated, this condition could soon turn out to be life-threatening. The clinical picture could be identical to that of post-emetic oesophageal rupture (Boerhaave syndrome). The perforation secondary to closed chest injuries is usually in the upper third of the oesophagus while Boerhaave syndrome is more common in the lower third. Oesophageal perforation _causes leakage of oesophageal/gastric contents into the mediastinum_. The patient presents with epigastric pain or shock out of proportion to the apparent injury. Presence of mediastinal air in plain radiography and subcutaneous emphysema suggests the diagnosis, which can be confirmed by contrast studies and/or oesophagoscopy. The resulting mediastinitis and immediate or delayed rupture into the pleural space could lead to emphyema. Oesophageal injury should be considered in any patient who: (i) has a _left pneumothorax or haemothorax without a rib fracture_; (ii) has received a _severe blow to the lower sternum or epigastrium_ and is in pain or shock out of proportion to the apparent injury, or; (iii) has _particulate matter in the chest tube_ after the blood begins to clear. Wide drainage of the pleural space and mediastinum with direct repair of the injury via a _thoracotomy_ is the most appropriate treatment. The prognosis is good if the repair is performed early (within a few hours of injury).

Answer 68

***_Compartment syndrome_*** ## Footnote This patient has got the classical features of a compartment syndrome. Compartment syndrome is defined as _an increase in the interstitial fluid pressure within an osseofascial compartment that leads microcirculatory compromise and later myoneural necrosis_. It is a serious and limb-threatening complication _seen after long-bone fractures_ (and after surgery for fixation of long-bone fractures), crush injury, deep thermal burns and other forms of trauma. It can also be caused by electrical injuries, restricting tourniquets, fluid extravasation (e.g. intravenous regional anaesthesia), snake venom (from bites) and infections such as meningococcal septicaemia. ***Severe pain in response to passive stretch*** of the affected group of muscles is a classical and a reliable clinical sign. ***Sensory loss*** occurs before motor loss since the thin cutaneous nerve fibres are more susceptible to ischemia than the motor fibres. ***The peripheral pulses are frequently normal*** during the early stages of the condition since it is the microvasculature which is initially affected. Loss of peripheral pulses is usually a late and a sinister sign. Left untreated, the ***limb becomes tense and swollen***, soon progressing to weakness of the affected group of muscles and later paralysis. Compartment pressures in excess of 30-35 mmHg (normal value is 3-4 mmHg) in a normally perfused patient suggested the need for open compartment fasciotomy although recent evidence suggests that fasciotomy should be undertaken if the difference between the diastolic pressure and the measured compartment pressure is less than 30 mmHg.

Answer 69

***_Secondary Sjogren's syndrome_*** ## Footnote Sjogren’s syndrome is _strongly associated with RA_ (50% of cases). The patient will typically suffer from a severe connective tissue disorder, associated with keratoconjuctivitis sicca (decreased tear production) and/or xerostomia (decreased production of saliva). Histologically, there is plasma cell and lymphocyte infiltration of the secretory glands. **Sicca syndrome** (meaning ‘dryness’), describes _dryness of the eyes and mouth_ which is not caused by an autoimmune disorder. **Felty’s syndrome** is a triad of longstanding RA, splenomegaly and leukocytopaenia.

Answer 70

***_Contact your senior urgently_*** ## Footnote The clinical signs and symptoms in this patient – **swelling**, **disproportionate pain** and **pain on passive movement** of the affected group of muscles - are typical of *_compartment syndrome_*, and cannot be ignored. (Paraesthesia, pulselessness and paralysis are late features). Although complaining patients can make a junior doctor’s life difficult, it cannot be assumed that they are making an unnecessary fuss. Compartment syndrome is a limb-threatening emergency that needs to be acted upon without undue delay.

Answer 71

***_Weight loss_*** ## Footnote The decision to operate is always guided by the degree of loss of function as opposed to radiological changes. However, knee replacement must always be approached with caution. First-line treatment for this gentleman will include **weight-loss**, **physiotherapy**, and **analgesia**. Obesity puts massive strain on the lower limb, and evidence suggests that the symptomatic improvement resulting from weight reduction exceeds that experienced after joint replacement.

Answer 72

***_Dynamic hip screw_*** An undisplaced **extracapsular** fracture, such as in this case, is _unlikely to result in avascular necrosis_ and can, therefore, be appropriately treated with a **dynamic hip screw**. An undisplaced intracapsular fracture can be treated with A-O Cannulated screws (or treated conservatively) and intramedullary nailing is usually used for displaced/unstable extra-capsular fractures (of the shaft). A displaced intra-capsular fracture of the neck of femur carries a high risk of avascular necrosis of the femoral head and is, therefore, more appropriately treated with a hemiarthroplasty.

Answer 73

***_IV fluids to normalise haemodynamic status_*** ## Footnote Vascular injury can accompany open fractures of the lower limb and may require urgent exploration. However, when a patient is hypotensive, it is not possible to diagnose a vascular injury of the leg. The first line of management of any trauma patient should be along ATLS guidelines and in this patient **intravenous fluids** are the immediate first step in the management. Once the patient is haemodynamically stable, the vascular status of the leg should be reassessed. The underlying cause of hypovolemia needs to be urgently investigated.

Answer 74

***_Ligamentous laxity_*** ## Footnote Systemic lupus erythematosis (SLE) is an _autoimmune disorder_ characterized by involvement of various organ systems in the body including skin, kidneys, central nervous system, musculoskeletal and cardiovascular system. A _malar rash_ (butterfly rash) is one of the pathognomic clinical sign of this condition. These patients also develop polyarthritis, mainly of the proximal and interphalangeal joints (Jaccoud’s arthritis). The primary pathology is the _laxity of ligaments_, _which causes secondary joint deformity_. Wrist and small joints of the hand are affected and the involvement is usually symmetric. The _articular cartilage is unaffected_ in the initial stages.

Answer 75

***_Rupture of the extensor pollicis longus tendon_*** ## Footnote Colle’s fracture was first described by Abraham Colle in 1814. Originally described as low-energy extra-articular fracture of distal radius, _it results from a fall on an outstretched hand_ with an impact on the palm. The fracture typically occurs through the distal metaphysis approximately 4 cm proximal to the distal end of the radius. There is dorsal displacement of the distal fragment, described as the dinner fork deformity. These fractures can be treated conservatively in Plaster of Paris cast following reduction. _One of the complications is rupture of the extensor pollicis longus tendon_, which winds around the dorsal tubercle of Lister. This is believed by many to be an attrition rupture over the fracture callus. However, some hold the view that it is due to an avascular necrosis of the tendon due to disruption of its periosteal blood supply.

Answer 76

***_Torn supraspinatus tendon_*** ## Footnote Tear of the supraspinatus tendon commonly occurs in elderly patients. _With advancing age the tendinous cuff of the shoulder degenerates_ and is _liable for rupture if subjected to sudden movement or stress_. Major tear in the tendon leads to a loss of action of the supraspinatus muscle (tendon). The patient is _unable to initiate shoulder abduction_ as the early phase of abduction requires the action of the supraspinatus muscle. However, the patient may be able to hold the arm in the abducted position (after passive abduction) _since this is supported by the action of the deltoid_.

Answer 77

***_Femoral nerve_*** ## Footnote The femoral nerve arises from the lumbar plexus **(L2-4)**. It exits the pelvis by passing beneath the inguinal ligament to enter the femoral triangle. The femoral nerve innervates the ***iliopsoas***, which helps in flexion of the hip, and the ***quadriceps***, which helps in extension of the knee. The motor branch to the iliopsoas originates in the pelvis proximal to the inguinal ligament. The sensory branch of the femoral nerve, the ***saphenous nerve***, innervates the skin over the medial aspect of the thigh and the anterior and medial aspects of the calf. Motor loss includes weakness of the quadriceps muscle and decreased patellar reflex (knee jerk). The ankle jerk is preserved, since it is innervated by the tibial nerve [S1-S2].

Answer 78

II This is Salter-Harris II because the fracture **involves the metaphysis only**, with no apparent disruption to the epiphysis. These fractures are only found in people with immature bone.

Answer 79

***_Osteoarthritis_*** ## Footnote The signs and symptoms in this patient are most likely to be due to Osteoarthritis. If affecting the hip, it frequently presents with _pain in the groin_. The reduced internal rotation at the hip is also an early indicator of this diagnosis. The presence of _Bouchard’s and Heberden’s nodes_ suggest that the diagnosis is primary generalised nodal osteoarthritis, which is the most common form of osteoarthritis and is more prevalent in women (female: male = 10:1). ***Paget’s disease*** of bone results in increased bone turnover with progressive deformation. Although this condition may result in secondary osteoarthritis this is much less common than primary osteoarthritis. ***Rheumatoid arthritis*** is a chronic inflammatory condition. Joint involvement is highly variable but is classically symmetrical, affecting the proximal joints of the hand and wrist. Large weight-bearing joints can be affected, resulting in erosions visible on plain radiography and soft tissue swelling.

Answer 80

***_An open wound does not exclude compartment syndrome_*** ## Footnote _The leg has four compartments_: anterior, lateral, superficial posterior and deep posterior. All these compartments can be decompressed through two incisions. One incision is made 2cm posterior to the medial border of tibia and through this the posterior two compartments (superficial and deep) are decompressed. The second incision is made 2cm lateral to the lateral border of tibia and through this the anterior and lateral compartments can be decompressed. An open wound in the leg does not indicate released or decompressed compartments. There are _ten compartments in the hand_: thenar, hypothenar, adductor pollicis, four dorsal interossei and three volar interossei. These can be released with longitudinal incisions over the dorsum of the index and ring metacarpals, the ulnar aspect of the little finger metacarpal and the radial side of the thumb metacarpal or in first dorsal web space. Normal tissue pressure varies from 2 – 7 mmHg. ***Most surgeons agree that a compartment pressure of \>30 mmHg is an indication for treatment*** although a rise in pressures over serial measurements is more significant. In addition, the diastolic pressure of the patient has to be taken into consideration since a fall in diastolic pressure may decrease the threshold for a fasciotomy.

Answer 81

***_Osteoporosis_*** The aetiology for the neck of femur fracture in this patient is most likely to be due to osteoporosis. This is not an unusual story for a pathological fracture, occurring with very minimal force. The patient’s age, sex and smoking history are all risk factors for osteoporosis. Whilst bone metastases can also cause pathological fractures, they are much less likely than osteoporosis. Osteogenesis imperfecta is a rare condition that presents during childhood.

Answer 82

***_Pneumonia_*** ## Footnote It is very likely that this patient has developed pneumonia _due to her poor mobilisation post- operatively_. Pneumonia is the one of the _common complication in post-operative patients_. Patients who are immobile are at increased risk of pneumonia, as well as thrombus formation. DVT/PEs tends occur later, typically around 10 days, although this diagnosis must be excluded. Urinary tract infections are also a common complication, and will commonly present with confusion followed by sepsis, especially in the elderly. ***Fat embolism*** is a rare but serious complication in which respiratory failure is associated with neurological symptoms as well as a petechial rash of the conjunctiva and mucosae. Empyema and bronchiectesis do not fit in with the clinical history.

Answer 83

***_Excessive vomiting_*** This patient is suffering from _metabolic alkalosis_. We know that he is alkalotic because his ***pH is greater than 7.45*** and we know that ***the cause is metabolic because the bicarbonate is also raised*** (this should be between 22 and 26). The PaCO2 is also slightly raised (should be between 35 and 45), which shows that there is an element of respiratory compensation. ***The causes of metabolic alkalosis include profuse vomiting, NG suction and antacid overdose.*** A - DKA is a form of metabolic acidosis, and there is usually significant respiratory compensation with Kussmaul breathing, so the typical ABG values here would be decreased pH, PaCO2 and bicarbonate C - These are two causes for respiratory alkalosis. Others include any condition that causes hyperventilation, such as pain and pneumonia. The typical ABG values would be increased pH, decreased PaCO2 and normal bicarbonate D - Severe asthma, alongside many other respiratory disorders including COPD and interstitial lung disease, is a cause of respiratory acidosis and would therefore produce decreased pH, increased PaCO2 and normal bicarbonate E - This is one of the many causes of metabolic acidosis, which would produce decreased pH, normal PaCO2 and decreased bicarbonate on ABG