Surgery, Ortho and Emergency Flashcards

Question

Atypical symptoms of GORD?

Answer 1

Chest pain, globus sensation, chronic cough, hoarseness, wheezing, and nausea

Answer 2

> 60y = Endoscopy <60y with alarm signs = Endoscopy without alarm features = Breath or stool test for H. pylori - Antimicrobial therapy: Amoxicilin 1g 2x/day + clarithromycin 500mg 2x/day + PPI for 14 days = TRIPLE THERAPY If no improvement: -- Proton pump inhibitor for 4-8w ! Tests to confirm eradication should be performed in all patients treated for H. pylori. Eradication may be confirmed by a urea breath test, fecal antigen test, or upper endoscopy performed four weeks or more after completion of antibiotic therapy.

Answer 3

Los Angeles classification – grades esophagitis severity by the extent of mucosal abnormality, with complications recorded separately. In this grading scheme, a mucosal break refers to an area of slough adjacent to more normal mucosa in the squamous epithelium with or without overlying exudate. -Grade A – One or more mucosal breaks each ≤5 mm in length -Grade B – At least one mucosal break >5 mm long, but not continuous between the tops of adjacent mucosal folds -Grade C – At least one mucosal break that is continuous between the tops of adjacent mucosal folds, but which is not circumferential -Grade D – Mucosal break that involves at least three-fourths of the luminal circumference

Answer 4

Only for solids = mechanical obstruction: > Nonprogressive = esophageal ring/eosinophilic esophagitis > Progressive: - Associated to chronic heartburn: Peptic stricture - If elderly, significant weight loss and/or anemia: Esophageal/Cardia cancer Solids and/or liquids = motor disorder: > If progressive: - Associated with heartburns: Scleroderma - Regurgitation and/or RESPIRATORY SYMPTOMS and/or weight loss: Achalasia !!! Might start with LIQUIDS ->SOLIDS >If intermitent Primary or secondary esophageal motility disorder

Answer 5

Eosinphilic esophagitis

Answer 6

Peptic stricture

Answer 7

<=1CM = Appendicectomy >1cm <=2cm: - Location at tip or mid appendix = appendicectomy - Location at base, mesoappendiceal invasion; mtx = right hemicolectomy >2cm = right hemicolectomy

Answer 8

Mesurement of ankle brachial index (ABI) ABI testing is useful as a screening investigation for high-risk patients and as a first-line diagnostic test for symptomatic patients. >>> The normal ABI range is 0.9–1.3. For patients with symptoms of PAD and an abnormal ABI, further diagnostic imaging is indicated. > Duplex ultrasonography is the first-line investigation, with stenosis >75% considered clinically significant. > Computed tomography angiography is a second-line investigation reserved for when concerns about aortoiliac disease arise following ultrasonography or for operative planning

Answer 9

>>>>>>>SMOKING hypertension, diabetes and hypercholesterolaemia,

Answer 10

>>>Smoking cessation: Recommended for all patients with PAD. - Antithrombotic (antiplatelet or anticoagulant) therapy: Single-agent antiplatelet therapy (with aspirin 100–150 mg or clopidogrel 75 mg daily) is recommended for symptomatic patients, or following intervention. Some patients may require dual antiplatelet therapy for a period (up to six months) after peripheral endovascular intervention or stenting. Dual pathway inhibition with aspirin (100 mg daily) and low-dose rivaroxaban (2.5 mg twice daily) may be indicated for high-risk patients. !! Anticoagulation (with warfarin or DOAC) IS NOT INDICATED for PAD treatment!! For patients who require long-term Ticagrelor is not indicated for treatment of PAD. - Antihypertensive therapy: Aim for blood pressure control of <140/80 mmHg in all patients with hypertension and PAD. ACEIs or ARBs are considered first-line antihypertensive therapy in PAD. Beta-blockers are not contraindicated but should be used with caution for patients with CLTI (chronic limb-threatening ischemia) - Lipid-lowering therapy: Statins are indicated for all patients with PAD, irrespective of serum cholesterol levels. Lower LDL-C to <1.8 mmol/L or decrease by 50% if baseline is 1.8–3.5 mmol/L. Prescribe the highest dose of statins tolerated to achieve LDL-C targets. Combination therapy with ezetimide may be required. Evidence for alternative, non-statin lipid-lowering agents is limited. - Glycaemic control: Aim for tight glycaemic control in patients with diabetes and PAD !!Exercise caution when prescribing SGLT-2 inhibitors to patients with PAD because of the increased risk of amputation in some studies!!! - Diet and exercise: Advice about healthy diet and physical activity is considered an essential part of PAD management. Consider the addition of a multivitamin supplement if there are dietary insufficiencies or poor wound healing.

Answer 11

CXR - Initial US of the leg - Most appropriate > If normal, with CXR normal - Low dose scintolography of the lungs > If normal, but CXR abnormal, CT Pulmonary Angiogram

Answer 12

Fever Peritonitis Leukocytosis

Answer 13

Bluebottle and Minor jellyfish AVOID VINEGAR Wash sting site with seater and remove the tentacles Hot water immersion (45º for 20 min) Major box jellyfish and other box jellyfish VINEGAR and remove tentacles For MBJ - consider antivenom if cardiovascular collapse

Answer 14

Mesentheric ischemia

Answer 15

2 cm (but in proximal ureteric stone = 1cm)

Answer 16

●Migratory right lower quadrant pain (1 point) ●Anorexia (1 point) ●Nausea or vomiting (1 point) ●Tenderness in the right lower quadrant (2 points) ●Rebound tenderness in the right lower quadrant (1 point) ●Fever >37.5°C (>99.5°F) (1 point) ●Leukocytosis of WBC count >10 x 109/L (2 points) Score of 0 to 3 indicates appendicitis is unlikely and other diagnoses should be pursued. Score of ≥4 indicates that the patient should be further evaluated for appendicitis.

Answer 17

Efferent loop syndrome

Answer 18

Afferent loop syndrome

Answer 19

Retrocecal peritonitis

Answer 20

Patients with a history of asthma, dermatitis, or eczema. Patients with food allergy, especially to avocado, kiwi, banana, mango, melon, pineapple, chestnut, or hazelnut. >>> Patients exposed to repeated bladder catheterization >>>> Eg. TSPINA BIFIDA Patients with a history of anaphylaxis of uncertain etiology. Healthcare workers who frequently wear latex gloves. Workers with occupational exposure to latex (e.g., hairdressers, greenhouse workers, latex glove manufacturers, housekeeping personnel, and textile workers). The identification of patients at risk for a latex allergy is an essential step before medical procedures that involve latex exposure occur.

Answer 21

The classic presentation of tension pneumothorax includes distended neck vein, hypotension, diminished or absent breath sounds and tracheal deviation to the other side

Answer 22

is an autosomal dominant condition caused by germline mutations in any one of the mismatch repair genes (MSH2, MLH1, MSH6, PMS2) ) or a deletion of the last few exons of the gene EPCAM that results in epigenetic silencing of MSH2 Surveillance colonoscopy every 1 to 2 years is recommended for individuals carrying a germline mutation or clinically at risk of carrying a mutation but in whom definitive testing is not possible. It should commence at age 25 or 5 years younger than the youngest affected family member if < 30 years. Annual surveillance is preferred in known mutation carriers. The risk of colorectal cancer is lower and the age of diagnosis is later in carriers of MSH6 or PMS2 mutations and surveillance starting at age 30 years could be considered. Aspirin at 600 mg/day reduced Lynch syndrome cancer incidence by 50–68% in the Colorectal Adenoma/Carcinoma Prevention Programme 2 (CAPP2) trial. Follow-up of the low-dose aspirin randomised controlled trials (RCTs) suggests low-dose aspirin (100 mg/day) also reduces cancer incidence by half. Reference: 1/ https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/genomics-in-general-practice/familial-colorectal-cancer/ 2/ https://lynchsyndrome.org.au/ 3/ https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/red-book/early-detection-of-cancers/colorectal-cancer

Answer 23

The left supraclavicular lymph node takes its supply from lymph vessels in the abdominal cavity. The finding of an enlarged, hard node has long been regarded as strongly indicative of the presence of cancer in the abdomen, specifically gastric cancer, that has spread through the lymph vessels. An enlarged right supraclavicular lymph node tends to drain thoracic malignancies such as lung and esophageal cancer, as well as Hodgkin’s lymphoma.

Answer 24

Class I Hemorrhage means up to 15% of blood volume lost (up to 750 mL).Pulse rate less than 100, systolic blood pressure normal, respiratory rate is 14 to 20, urine output is greater than 30 mL/hour, mental status is slightly anxious. Class II Hemorrhage means from 15% to 30% blood volume loss (750 mL to 1500 mL).Pulse rate is from 100 to 120, systolic blood pressure normal, respiratory rate is 20 to 30, urine output is 20 to 30 mL/hour, mental status is mildly anxious. Class III Hemorrhage means from 30% to 40% blood volume loss (1500 mL to 2000 mL).Pulse rate is from 120 to 140, systolic blood pressure is decreased, respiratory rate is 30 to 40, urine output is 5 to 15 mL/hr, mental status is anxious and confused. This patient is suffering from class lll hemorrhagic shock. Class IV Hemorrhage means blood loss of greater than 40% (greater than 2000 mL). The pulse rate is greater than 140, systolic blood pressure is decreased, the respiratory rate is greater than 35, urine output is negligible, mental status is confused and lethargic.

Answer 25

– BMI above 40 with no co-morbidities – BMI above 35 with co-morbidities such as hypertension – BMI above 30 with poorly controlled type 2 diabetes – BMI above 30 with increased cardiovascular risk due to multiple risk factors such as hypertension, hyperlipidemia, strong family history of cardiovascular disease at a young age.

Answer 26

Celiac disease

Answer 27

Serologically (eg, antitissue transglutaminase antibody, anti-endomysial antibody) or by duodenal biopsy (eg, intraepithelial lymphocytosis, villous blunting). Management includes a gluten-free diet.

Answer 28

The Child-Pugh system is used to assess the prognosis of patients with liver disease and cirrhosis by calculating 1-year survival rate. This system takes into account the following 5 parameters for determination of the prognosis: The presence of ascites Bilirubin level Albumin level Prothrombin time Encephalopathy Class A (scores 5-6): well -compensated disease – one- and two-year survival are 100%and 85% respectively. Class B (scores 7-9): functional compromise – one- and two-year survival are 80% and 60% Class C(scores 10-15): decompensated disease – one- and two -year survival are 45% and 35% respectively.

Answer 29

Mucosal injury results from contact with the caustic substance (rather than from systemic absorption); therefore, patients often have immediate oropharyngeal, retrosternal, or epigastric pain as well as dysphagia and hypersalivation (eg, drooling). Vomiting and hematemesis may also occur. Patients should initially undergo assessment and stabilization of the airway, breathing, and circulation. Serial chest and abdominal x-rays should be obtained to identify any signs of perforation, such as pneumomediastinum, pleural effusions, or subdiaphragmatic air (none of which are seen in this patient). An upper gastrointestinal x-ray study with water-soluble contrast should be performed in patients with suspected perforation. The severity of esophageal injury cannot be predicted by either clinical symptoms or the extent of oral injury seen on physical examination. >> In the absence of perforation or severe respiratory distress, endoscopic evaluation within the first 24 hours is recommended to assess the severity of esophageal damage. Activated charcoal can decrease the systemic absorption of poisons; however, caustic ingestions cause immediate local damage on contact with the esophagus. In addition, charcoal would obstruct the view during endoscopy.

Answer 30

Chemical burn or liquefaction necrosis resulting in: Laryngeal damage: hoarseness, stridor Esophageal damage: dysphagia, odynophagia Gastric damage: epigastric pain, bleeding Management Secure airway, breathing, circulation Decontamination: remove contaminated clothing & visible chemicals; irrigate exposed skin Chest x-ray if respiratory symptoms Endoscopy within 24 hr Complications Upper airway compromise Perforation Strictures/stenosis (2-3 weeks) Ulcers Cancer

Answer 31

Heat exhaustion typically occurs after prolonged exercise (eg, soccer) in high ambient temperatures, particularly in the setting of high humidity, which limits evaporative cooling from sweat Risk factors Strenuous activity during hot & humid weather Dehydration, poor acclimatization Lack of physical fitness, obesity Acute illness (common in diseases like cystic fibrosis) Medications: anticholinergics, antihistamines, phenothiazines, tricyclics, antipsychotics Manifestations Hyperthermia ≤40 C WITH NORMAL MENTAL SATUS Profuse sweating Nausea/vomiting Headache, dizziness Tachycardia, hypotension Management Cool patient (eg, air conditioning, cool water shower) Salt-containing oral fluids

Answer 32

Plan for immediate decompression if the patient does not respond to initial measures Plan for biliary decompression on semi-urgent basis (<72 hours) if the patient is responding to initial resuscitation Plan for urgent decompression (within 24-48hrs) if the patient is older than 70 years The most appropriate method of biliary decompression is ERCP, sphincterectomy and stenting Acute ascending cholangitis is initially managed with aggressive fluid resuscitation and intravenous antibiotics fol lowed by biliary decompression. Since the infectious organisms responsible for acute ascending cholangitis are enteric gram negative bacteria, the selected antibiotic of choice should provide appropriate coverage against these germs. All patients with ascending cholangitis require biliary drainage. In about 85-90% of patients, there is respond to medical therapy. In this group decompression may be per formed semi-electively during the same admission (and ideally within 72 hours); however for the following patients urgent decompression may be considered: Patients older than 70 years Patients with diabetes Patients with other comorbid conditions Approximately 10% to 15% of patients (not the majority) fail to respond within 12 to 24 hours or deteriorate after initial medical therapy and need urgent biliary decompression. Delay t o do so increases the chance of an adverse outcomes.

Answer 33

infant has bilious emesis, abdominal distension, leukocytosis, and metabolic acidosis due to necrotizing enterocolitis (NEC). Pathogenesis of NEC involves inflammation and necrosis of intestinal mucosa with invasion of gas-producing bacteria. Premature and very low-birth-weight (<1.5 kg [3.3 lb]) infants are particularly vulnerable due to decreased bowel motility, increased intestinal permeability, and immature host defenses. Exposure to bacteria from enteral feeds, especially formula feeds, also increases the risk of NEC. Initial signs are often nonspecific (eg, lethargy, feeding intolerance), and neonates may be hypothermic (<36.5 C [97.7 F]) rather than febrile, as seen here. Bilious emesis and a tense, erythematous, distended abdomen are typical. Bloody stools are also a classic finding but may not be present in early stages. Leukocytosis and metabolic acidosis reflect inflammation and intestinal ischemia, respectively. The hallmark x-ray finding in NEC is air in the bowel wall, or pneumatosis intestinalis (red arrows). In addition, portal venous air (yellow arrows) is seen as branching areas of lucency over the liver due to gas-producing bacteria and the transmigration of gas from the bowel wall to the mesenteric and portal veins. Severe intestinal necrosis can also cause perforation and pneumoperitoneum. Management of suspected NEC includes discontinuation of enteral feeds and administration of antibiotics; surgery may be required in severe cases.

Answer 34

Bilious emesis and abdominal distension in a preterm neonate are highly suggestive of necrotizing enterocolitis. Abdominal x-ray findings include pneumatosis intestinalis (intramural air) and portal venous air. Pathogenesis Gut mucosal wall invasion by gas-producing bacteria Intestinal inflammation, necrosis Risk factors Prematurity Very low birth weight (<1.5 kg [3.3 lb]) Enteral feeding Clinical findings Nonspecific: apnea, lethargy, vital sign instability Gastrointestinal Abdominal distension Feeding intolerance, bilious emesis Bloody stools X-ray findings Pneumatosis intestinalis (air in bowel wall) Pneumoperitoneum (free air under diaphragm) Complications Sepsis, disseminated intravascular coagulation Late: strictures, short-bowel syndrome Management of suspected NEC includes discontinuation of enteral feeds and administration of antibiotics; surgery may be required in severe cases.

Answer 35

Pyloric stenosis presents with postprandial nonbilious emesis in an otherwise healthy 3- to 6-week-old infant. An olive-shaped abdominal mass may be palpable, and metabolic alkalosis is expected. Duodenal atresia, characterized by the double bubble sign (dilated stomach and duodenum) on x-ray, presents with bilious vomiting after initiation of feeds. Patients do not have yellow, seedy stools (as this infant does) because feeds cannot pass through the duodenum. Hirschsprung disease causes abdominal distension, feeding intolerance, and failure to pass meconium within 48 hours of birth. Milder disease may be diagnosed later in life, but patients typically have a history of chronic constipation and poor weight gain.

Answer 36

Rectal prolapse Risk factors Women age >40 with history of vaginal deliveries/multiparity Prior pelvic surgery Chronic constipation, diarrhea, or straining Stroke, dementia Pelvic floor dysfunction or anatomic defects Clinical presentation Abdominal discomfort - NOT PAIN Straining or incomplete bowel evacuation, fecal incontinence Digital maneuvers possibly required for defecation Erythematous mass extending through anus with concentric rings (full-thickness prolapse) or radial invaginations (non–full-thickness prolapse) Management Medical Considered for non–full-thickness prolapse Adequate fiber & fluid intake, pelvic floor muscle exercises Possible biofeedback therapy for fecal incontinence Surgical Preferred for full-thickness or debilitating symptoms (eg, fecal incontinence, constipation, sensation of mass)

Answer 37

Recurrent abdominal pain/discomfort ≥1 day/week for past 3 months & ≥2 of the following: Rome IV diagnostic criteria Related to defecation (improves or worsens) Change in stool frequency Change in stool form Alarm features Older age of onset (≥50) Gastrointestinal bleeding Nocturnal diarrhea Worsening pain Unintended weight loss Iron deficiency anemia Elevated C-reactive protein Positive fecal lactoferrin or calprotectin Family history of early colon cancer or IBD

Answer 38

Initial management of clinically stable patients (eg, normal vital signs) with bilious emesis includes cessation of enteral feeds, nasogastric tube decompression, administration of intravenous fluids, and diagnostic imaging. In patients with volvulus, an x-ray may identify dilated loops of bowel and air-fluid levels (due to intestinal obstruction) or pneumoperitoneum (due to intestinal perforation). However, x-rays may be normal and are insensitive for midgut volvulus; serial x-rays are unlikely to be diagnostic. Therefore, all hemodynamically stable infants with bilious emesis and a nondiagnostic x-ray, as seen in this patient, warrant an upper gastrointestinal (GI) series to evaluate for midgut volvulus. Diagnostic findings include an abnormally located ligament of Treitz on the right side of the abdomen (malrotation) and a duodenal corkscrew, or bird’s-beak, appearance (volvulus). A contrast enema is indicated for distal bowel obstructions, such as Hirschsprung disease and meconium ileus (microcolon). Bilious emesis can occur; however, these conditions usually present with failure to pass meconium within the first 2 days of life and dilated loops of bowel on x-ray. CT scan of the abdomen with intravenous contrast may identify midgut volvulus. However, an upper GI series is preferred for the evaluation of malrotation because it is more sensitive and has less radiation exposure. Pyloric stenosis, diagnosed by a hypertrophied pyloric muscle on ultrasound, typically presents at age 3-5 weeks with projectile vomiting, which is nonbilious due to gastric outlet obstruction. In addition, classic findings include visible peristaltic waves and a palpable abdominal mass, neither of which is seen in this patient The gold standard for volvulus diagnosis is an upper gastrointestinal series, which shows a right-sided ligament of Treitz and a corkscrew duodenum.

Answer 39

Indication for endoscopy Persistent symptoms despite an adequate trial of proton pump inhibitor therapy Treatment of complications such as dilatation of oesophageal strictures Evaluation of patients before and after anti-reflux surgical procedures Screening for Barrett’s oesophagus in high-risk patients (may be considered, e.g. in overweight men over 50 years, however evidence that screening improves outcomes is lacking) Eosinophilic oesophagitis should be considered in patients, particularly men, in their 20s and 30s with a history of food allergy or atopy who present with dysphagia or refractory symptoms suggestive of GORD. Biopsy may be needed to exclude eosinophilic oesophagitis. There is no evidence that routine screening for Barrett’s oesophagus improves mortality or is cost-effective. However, it may have a role in high-risk groups such as the overweight and Caucasian males over 50 years old with no previous endoscopic investigation. In the absence of alarm symptoms, a therapeutic trial is generally favored over more expensive diagnostic studies (endoscopy, CT scan). Classic symptoms of GORD do not mandate an evaluation for coronary artery disease unless other features suggest this diagnosis.

Answer 40

Red Flags in GORD which require further evaluation: Recurrent vomiting Dysphagia or odynophagia Weight loss Evidence of gastrointestinal blood loss e.g. haematemesis, iron deficiency or anaemia Duration of symptoms >5 years or <6 months Epigastric mass Age >50 years www.racgp.org.au/afpbackissues/2004/200411/20041128piterman.pdf

Answer 41

Oesophageal adenocarcinoma.

Answer 42

Pancreatitis pseudocysts are diagnoses with CT or ultrasound scan. Where the diagnosis is in doubt, the content can be aspirated (under endoscopic ultrasonography or CT scan) and examined. Surgical intervention should be considered if any of the following is present: Compression of large vessels (clinical symptoms or seen on CT scan) Gastric or duodenal outlet obstruction Stenosis of the common bile duct due to compression lnfected pancreatic pseudocysts Hemorrhage into pancreatic pseudo cyst Pancreatico-pleural fistula There are two main types of endoscopic drainage: Transmural drainage: in this method, using endoscopy, a small incision is made in the stomach (endoscopic cystgastrostomy [ECG]) or in duodenum (endoscopic cystduodenostomy [ECO]) to let the pseudocyst drain into the stomach or duodenum. ECO is preferred over ECG Transpapillary drainage: this method is safer and more effective than transmural drainage, but requires that the cyst communicates with the pancreatic duct because this method includes entering the pancreatic duct by ERCP, and from there,into the pseudocyst. Stents may be left in place to facilitated drainage. Generally, endoscopic drainage methods are preferred over open surgical treatment if eligibility is met and there is no contraindication because these methods are less invasive and associated with fewer complications. Laparotomy with cyst excision and internal and external drainage is still the gold standard management option; however it is ONLY considered first -line therapy for surgical Intervention in the following conditions: Complicated pseudocysts i.e. infected or necrotic Pseudocysts associated with pancreatic duct stricture and a dilated pancreatic duct Suspected cystic neoplasia Presence of pseudoaneurysm, unless it has been embolised before the procedure Coexistence pseudocysts and bile duct stenosis Complications such as compression of the stomach or the duodenum, perforation or pseudoaneursyms Endoscopic cystgastrostomy (ECG) or duodenostomy (ECO) are methods of choice if the pseudocyst is not communicating with the pancreatic duct. Laparotomy and surgical removal of the cyst is considered if endoscopic methods fail or there is a contraindication. Percutaneous catheter drainage has low success rate and high recurrent rates. It is never considered for treatment of a pancreatic pseudocyst. However, in infected pseudo cysts it is the procedure of choice for sampling and examining the material as the most appropriate initial step. Conservative management is not an appropriate option for symptomatic pseudocysts.

Answer 43

Dumping syndrome is a condition in which food, especially food high in sugar, moves from your stomach into your small bowel too quickly after you eat. Sometimes called rapid gastric emptying, dumping syndrome most often occurs as a result of surgery on your stomach or esophagus.

Answer 44

Early dumping Symptoms of early dumping syndrome occur 30-60 minutes after a meal and are believed to result from accelerated gastric emptying of hyperosmolar contents in to the small bowel. This leads to fluid shift from the intravascular compartment in to the bowel lumen resulting in rapid small bowel distention and increase in the frequency of bowel contractions. Even in healthy persons without gastric surgery, rapid instillation of liquid meals into the small bowel has shown to induce dumping syndrome Rapid shift of fluid into the intestinal lumen results in decreased circulating volume,triggering a vasomotor response presenting with tachycardia and lightheadedness. Late dumping Late dumping occurs 1-3 hours after a meal. The pathogenesis is though to be related to the early development of hyperinsulinemic {reactive) hypoglycemia. Rapid delivery of a meal to the small intestine results in an initial high concentration of carbohydrates in the proximal small bowel and rapid absorption of glucose.This is replied by a hyperinsulinemic response. The high insulin levels stay for longer period and are responsible for the subsequent hypoglycemia. Supplementation with dietary fiber has proven effective in the treatment of hypoglycemic episodes . Many medical therapies have been tested, including pectin, guargum. and glucomannan. These dietary fibers form gels with carbohydrates, resulting in delayed glucose absorption and prolongation of bowel transit time Dietary change to a low-carbohydrate, high protein diet, as well as the use of alpha-glucosidase inhibitors, may be useful to control the symptoms of dumping. This is preferential to subtotal or total pancreatectomy in those persons with severe symptoms Most patients have relatively mild symptoms and respond well to dietary changes. In some patients with postprandial hypotension,lying supine for 30 minutes after meals may delay gastric emptying and also increase venous return thereby minimizing the chances of syncope.

Answer 45

Perform immunochemical fecal occult blood test (iFOBT) every 2 years from 50 – 74 years of age.

Answer 46

Facing Major Deterioration: - Tranfer time >2h IOT, Mannitol, Moderate hyperventilation, Burr hole evacuation or craniectomy/otomy and then RETRIEVAL - Tranfer time < 2h IOT, Mannitol, Moderate hyperventilation,

Answer 47

Inguinal Hernia SILK GLOVE SIGN: Index finger is lightly rubbed over the cord from side to side over the pubic tubercle - cord structures are thickened (feels like two silk sheets rubbing against one another, reflecting the smooth peritoneal sac edges), Sensitivity = 93%, specificity = 97%

Answer 48

Primary - otherwise healthy person Secondary - evidence of underlying lung disease (>50a + smoking history)

Answer 49

Primary: >2cm and/or breathless: Aspirate with 16-18G cannula and review in 2-4weeks < 2cm: Review in 2-4weeks Secondary: >2cm or breathless: Chest drain 8-14fr and Admit 1-2cm: Aspirate with 16-18G cannula (<2,5l) and review in 2-4weeks If succes and size <1cm - Admit, high flow O2,observe 24h If no success = Chest drain <1cm Admit, high flow O2,observe 24h

Answer 50

PSA > 20 or distant Metastatic - Androgen deprivation therapy or orchiectomy. PSA > 20 and spinal Metastasis - androgen deprivation therapy or radiotherapy of the spine. Locally advanced T3b (seminal vesicle or capsule) - External beam radiotherapy for prostate cancer (EBRT) + ADT PSA < 10, without comorbidity, and foci found in Biopsy <10% or one out of 12 - active surveillance PSA even doubled, life expectancy <10 years - watchful waiting PSA doubled but under 10, foci <10% with lower urinary tract symptoms - radical prostatectomy

Answer 51

Read about it

Answer 52

Document the distal neurovascular examination first and stop obvious bleeding by direct pressure. Handle the wound – remove gross contamination – +/- photo – dressing. Handle the limb – gently felt the pulse – splinting (even in absent pulse). Abx and tetanus (open injuries). Imaging first – X-ray. Decide for further management – Close # CRIF – open

Answer 53

More often iatrogenic (endoscopy or related to surgery) or due to non-iatrogenic penetrating or blunt traumatic mechanisms. Other causes include tumors, foreign body or caustic ingestion, pneumatic injury, peptic ulceration, intrinsic esophageal disease such as pill esophagitis, Crohn disease, eosinophilic esophagitis or, more rarely, it is spontaneous (Boerhaave's syndrome)

Answer 54

Boerhaave syndrome

Answer 55

Sudden increase in intraesophageal pressure combined with negative intrathoracic pressure such as that associated with severe straining or vomiting results in a longitudinal (TRANSMURAL) esophageal perforation. Main Causes: Postemesis; Iatrogenic (most common). Clinical manifestations — The clinical features of Boerhaave syndrome depend upon the location of the perforation (cervical, intrathoracic, or intra-abdominal), the degree of leakage, and the time elapsed since the injury occurred. Patients with Boerhaave syndrome often present with excruciating retrosternal chest pain due to an intrathoracic esophageal perforation. A history of severe retching and vomiting preceding the onset of pain has classically been associated with Boerhaave syndrome, Patients may also have crepitus on palpation of the chest wall due to subcutaneous emphysema. MACKLER'S TRIAD - lower chest pain + Vomiting + Subcutaneous emphysema Patients with cervical perforations can present with neck pain, dysphagia or dysphonia. Patients may have tenderness to palpation of the sternocleidomastoid muscle and crepitation due to the presence of cervical subcutaneous emphysema. Antibiotics: Amoxicillin+clavulanate intravenously adult: 1+0.2 g 8-hourly. or Cefazolin 2 g (child: 50 mg/kg up to 2 g) intravenously, 8-hourly; for adults with septic shock or requiring intensive care support, use 6-hourly dosing PLUS metronidazole 500 mg (child: 12.5 mg/kg up to 500 mg) intravenously, 12-hourly.

Answer 56

DIAGNOSIS While thoracic and cervical radiography can be supportive of the diagnosis, the diagnosis is established by contrast esophagram or computed tomography (CT) scan. Thoracic and cervical radiography — Findings suggestive of an esophageal perforation on chest radiograph include mediastinal or free peritoneal air or subcutaneous emphysema Contrast esophagram — Contrast esophagography usually establishes the diagnosis of an esophageal perforation and reveals the location and extent of perforation by the extravasation of contrast material. Esophagram with water-soluble contrast (Gastrografin) should be performed in patients with suspected Boerhaave syndrome. If, however, the water-soluble study is negative, a barium esophagram should be performed. Although barium is superior in demonstrating small perforations as compared with Gastrografin, it causes an inflammatory response in mediastinal or pleural cavities and is therefore NOT USED AS THE INITIAL DIAGNOSTIC STUDY. Computed tomography — CT scan of the chest and, if needed, abdomen should be performed when a suspected esophageal perforation is difficult to locate or diagnose on contrast esophagram, when contrast esophagogram cannot be performed (eg, uncooperative or unstable patient), and in patients with free peritoneal air. We also perform a CT scan to look for intrathoracic or intra-abdominal collections that require drainage.

Answer 57

Because the mortality rate associated with esophageal perforation is high, intensive care unit admission should be considered not only for patients with evidence of hemodynamic compromise, but also for patients with multiple comorbid conditions . Regardless of the subsequent management approach (medical, endoscopic - to stent the rupture, or surgical), all patients with an esophageal perforation require the following: ●Avoidance of all oral intake ●Nutritional support, typically parenteral ●Intravenous broad spectrum antibiotics ●Intravenous proton pump inhibitor ●Drainage of fluid collections/debridement of infected and necrotic tissue, if present In addition, surgical consultation should be obtained for all patients, A subset of patients with Boerhaave syndrome have an underlying esophageal disorder (eg, eosinophilic esophagitis, Barrett's ulcer, medication-induced esophagitis). Upper endoscopy and biopsy of the esophagus should be performed upon recovery.

Answer 58

TSH - If NORMAL or ELEVATED: 1. USG to assess need for FNA If doesn't meet criteria = monitor If meets = FNA - If DECREASED: Radioisotope scan and ultrasound If cold nodule => 1 If hot nodule => Consider radioactive iodine ablation, thionamide medication or surgery

Answer 59

- Very low suspicion (hiperecogenic or isoecogenic) Consider FNA if >=2Cm - Low suspicion (slightly hypoecogenic) FNA at >= 1,5cm - Intermediate suspicion (hypoechogenic) FNA AT >=1CM - High suspicion (hypoechogenic + alarm features - not oval, irregular margins, microcalcifications or trabecullae) FNA AT >= 1CM. If benign result = REPEAT IN 3 MONTHS

Answer 60

PLEURAL PROTEIN/SERUM PROTEIN > 0,5 PLEURAL LDH/SERUM LDH > 0,6 PLEURAL FLUID LDH > 2/3 ULN SERUM LDH OR > 60 U/L

Answer 61

Exudative stage– Tx – antibiotics Fibro purulent stage – Pus collection – chest/pleural drain Organization stage – Urokinase (dissolve the loculations/VATS)

Answer 62

absence of radial pulse ischemia of hand: pale, cool severe swelling in forearm and or elbow skin puckering or anterior bruising open injury neurological injury

Answer 63

Sciatic nerve Injury manifests as paralysis of the hamstring muscles (knee flexion weakness) and all the muscles below the knee. All seSnsation of the leg except the medial aspect is impaired. Absent or weak ankle reflex is most specific to sciatic nerve injury a

Answer 64

Gastric outlet obstruction is now the least common complication of peptic ulcer disease, occurring in approximately 2 percent of cases. Vomiting usually is described as non-bilious, and it characteristically contains undigested food particles.In the early stages of obstruction, vomiting may be intermittent and usually occurs within 1 hour after the meal. Both acute and chronic peptic ulcer disease can lead to gastric outlet obstruction.The principal sites of involvement in cases of obstruction are the pyloric channel and the duodenal bulb. Acute peptic ulcers can cause obstruction via inflammation-induced edema and tissue deformation.

Answer 65

All patients with venous eczema or ulceration, evidence of chronic venous insufficiency, thrombophlebitis, bleeding, or severe discomfort, should be referred to a vascular team for assessment. Leg Oedema is classified as Class 3 and does not warrant for a referral to vascular team. CEAP classification – C (clinical component only) C0 No visible or palpable signs of venous disease C1 Telangiectases or reticular veins C2 Varicose veins C3 Oedema C4 Pigmentation, eczema, lipodermatosclerosis, atrophie blanche C5 Healed venous ulcer C6 Active venous ulcer CA Asymptomatic CS Symptomatic

Answer 66

Supracondylar fractures are the most common type of elbow fracture in children The most serious complication of supracondylar fractures is Volkmann ischemic contracture. This occurs when high-pressure builds up in the forearm compartments leading to a compartment syndrome. It can also be caused by kinking of the brachial artery with subsequent ischemia if not repaired. If the condition is not addressed, there is potential for permanent damage to nerves and muscles of the forearm leading to contractures. Patients who develop pain upon passive extension of the fingers, forearm tenderness, or refuse to open the hand have a very high risk of developing this condition. Ulnar nerve injury is rare in supracondylar fractures. The most commonly injured nerve is the anterior interosseous nerve. Brachial artery transection is uncommon and generally results in a pulse deficit on examination. Malunion and arthritis are far less common and less serious sequelae than the contractures

Answer 67

infant presents with sudden onset of bilious emesis. An upper gastrointestinal (UGI) contrast series reveals a midgut volvulus with the site of obstruction at the third portion of the duodenum. The patient’s presentation and radiologic findings are most consistent with anomalies of intestinal rotation and fixation (aka malrotation). Rotational anomalies may present as a volvulus, duodenal obstruction, or intermittent or chronic abdominal pain

Answer 68

Vitamin B12 deficiency due to achlorhydria - if under proton pump inhibitors. A serum vitamin B12 test is usually diagnostic, but methylmalonic acid or homocysteine testing may be required for confirmation in inconclusive cases.

Answer 69

Definition Acute pancreatitis with organ failure (eg, respiratory, cardiovascular, renal) persisting >48 hr Predictors Patient factors: Older age (eg, age >55) Comorbidities, including obesity (BMI >30 kg/m2) Clinical findings: Altered mental status SIRS (eg, leukocytes >12,000/mm3, temperature >38 C [100.4 F]) Laboratory findings of intravascular volume depletion: ↑ BUN (>20 mg/dL) and/or ↑ creatinine (>1.8 mg/dL) ↑ HCT (>44%) Radiologic findings (demonstrating third spacing of fluid): CXR: pulmonary infiltrates, pleural effusions Abdominal CT scan: severe pancreatic necrosis Epigastric tenderness, voluntary guarding (ie, muscle contraction during palpation to minimize pain), and ileus (eg, mild abdominal distension, decreased bowel sounds) are relatively common findings in acute pancreatitis. These examination findings do not indicate severe disease, unlike rebound tenderness, involuntary guarding (ie, muscle rigidity regardless of palpation), or diffuse abdominal tenderness.

Answer 70

Requires all of the following: ●Symptoms related to esophageal dysfunction. ●Eosinophil-predominant inflammation on esophageal biopsy, characteristically consisting of a peak value of ≥15 eosinophils per high power field (HPF) (or 60 eosinophils per mm2). ●Exclusion of other causes that may be responsible for or contributing to symptoms and esophageal eosinophilia For patients treated with a PPI, initial treatment is suggested for eight weeks. For most patients, full dose PPI once daily is recommended and, if symptoms fail to improve after four weeks of therapy, we increase the dose to twice daily. An alternative dosing regimen is to initiate PPI with a twice daily dose. Hence, a 8-week course of proton pump inhibitors (PPls) is the best initial step in management. PPls may benefit patients with EoE either by reducing acid production in patients with co-existent GERD, or by other unknown anti-inflammatory mechanisms.

Answer 71

Results in sensory disturbances in the sensory territory of the ulnar nerve. In hand, the ulnar nerve provides sensation of the little finger and ½ of the ring finger, as well as ulnar part of the palm and dorsum of the hand. Motor involvement results in decreased ability to abduct/adduct finger (an action of interosseous muscles) as well as weak pincer grip.

Answer 72

Presents with disturbed sensation over the dorsal aspect of the thumb, index finger, middle finger and radial ½ half of the ring finger. Thumb opposition is provided by the action of opponens pollicis that is innervated by median nerve and is not affected in radial nerve injury.

Answer 73

It is a rare condition associated with entrapment of anterior interosseous nerve. It presents with forearm pain, inability to make an ‘O.K. sign’ with the thumb and index finger , and positive pinch test in which the patient pinches in between the thumb and index finger in a fashion similar to tongs rather than clamps. AIN is a pure motor nerve branching off the median nerve; hence, its injuries do not cause sensory symptoms.

Answer 74

T-score o f -2.5 of less indicates osteoporosis. T-scores between -1 to -2.5 suggests osteopenia. A T score of -1 or above is considered normal. For postmenopausal woman without evident bone loss, maintaining a high-calcium diet is the most appropriate advice for prevention of osteoporosis (grade A recommendation). Diet is the preferred source of calcium, and patients should aim for a total daily calcium intake of 1300 mg. Dairy products are rich in calcium and one of the best sources. Bisphosphonates are used for treatment of established osteoporosis in certain groups Calcium supplementation (with or without vitamin D, depending on the patient’s vitamin D status) is used when adequate calcium intake cannot be ensured solely through diet.

Answer 75

PCS affects between 10-15% of patients with cholecystectomy and is characterized by a heterogenous group of symptoms including: Upper abdominal pain Nausea and vomiting Diarrhea Jaundice Bloating Excessive gas Dyspepsia. These symptoms can be the continuation of symptoms thought to be caused by gallbladder pathology, the development of new symptoms normally attributed to the gallbladder, or symptoms caused by removal of the gallbladder. In 90%of the time an etiology can be found. The most common etiologies are: Choledocholithiasis – stones remained or formed in the common bile duct or cystic duct remnant Biliary dyskinesia Continuously increased bile flow to the GI tract Dilation of cystic duct remnant NOTE – choledocholithiasis is the most common cause of PCS. It can involve the common bile duct of the cystic duct remnant. Choledocholithiasis is classified as retained, if found within 2 years of cholecystectomy or recurrent. if the stone id found 2 years after the surgery. Recurrent stones formed as result of the biliary stasis are often caused by strictures, papillary stenosis, and biliary dyskinesia. NOTE – ultrasonography is the initial imaging study of choice for patients with suspected PCS. PCS is a provisional diagnosis and the presentation should be renamed after a specific cause as an explanation for the symptoms is clinched. Cystic duct stump syndrome or cystic duct remnant syndrome refers to gastrointestinal symptoms of bloating, dyspepsia, nausea, etc caused by dilation of the remnant cystic duct. It is among the etiologies for PCS. The patient is likely to have PCS either due to this condition or other causes. Unless further studies establish the exact etiology, it cannot be said that cystic duct stump syndrome is the most likely cause to this presentation. Retained stones can also be an etiology for PCS and the presentation; however an intra-operative cholangiogram has been clear, making this condition less likely, yet not impossible.

Answer 76

It encompass congenital malformations of the aortic arch system that encircle the trachea and/or esophagus and cause compressive symptoms. Tracheal compression leads to biphasic stridor that increases with increased work of breathing (eg, crying, feeding). Vascular rings can also present with esophageal compression symptoms, as in this patient with severe solid-food dysphagia. She was gaining weight well as an infant likely due to being on an all-liquid diet (requiring less esophagus distension). With the introduction of solid foods (around age 6 months), dysphagia became more pronounced and the patient’s growth rate slowed due to increasing reliance on solid foods for her caloric needs. She had recurrent food impactions at the site of esophageal compression, seen on fluoroscopic esophagography at around the level of the aortic arch (eg, T3-T4). Her episodes of middle-lobe pneumonia were possibly due to aspiration. Barium esophagography reveals a deep impression on the posterior aspect of the esophagus at about the level of T4. CT scan can delineate the anatomy forming the vascular ring and evaluate associated tracheal abnormalities. Due to possible concurrent cardiac and airway abnormalities, patients require direct laryngoscopy, bronchoscopy, and echocardiogram. Treatment is surgical division of the structures creating the ring.

Answer 77

Stage I and II breast cancer: Women with stage 1 and II tumors are referred to as having early stage of localized breast cancer. A stage I breast cancer refers to a tumour less than 2 cm in size that is node negative. Stage II tumours are those with spread to the axillary lymph nodes (and/or a tumour size larger than 2cm but not larger than 5cm. Metastatic work-up: LFT, ALP, Calcium, Chest X ray. Stage I and II breast cancer: breast conserving therapy with sentinel lymph biopsy, followed by radiation after wound healing (risk of recurrence reduced to 8%). Chemotherapy plus hormonal therapy: If ER positive tumor - Tamoxifen/ Anastrazole If HER2 positive tumor - Trastuzumab. Chemotherapy no need for carcinoma in situ.

Answer 78

Six monthly clinical review. Mammography yearly from 40 years or 10 years earlier than younger relative with breast cancer. Refer to familial cancer clinic (genetic consultation to reveal mutations of the BRCA1 and BRCA2 due to strong predisposition for both breast and ovarian cancer).

Answer 79

Women < 26 bilateral US, MRI if suspicious. Women < 35 years bilateral US, bilateral Mammography if US suspicious. Women 35 50 years bilateral Mammography plus bilateral US. Women > 50 years bilateral Mammography, consider US.

Answer 80

Lipoma: soft, mobile, painless. Breast cancer: painless lump, or thickening, or swelling. Plus skin dimpling, nipple inversion. Papilloma: oval or round mass under the nipple, often bloody discharge, sometimes clear discharge. Fibroadenoma: round rubbery solid lump, smooth borders, painless. Breast cyst: smooth and firm lump under the skin. Painful or painless. Nipple discharge may present.

Answer 81

Mammary duct ectasia

Answer 82

The most common tumour in young women (younger than 35) and adolescence. Well defined, smoothly contoured, rubbery, firm, nontender, freely moveable masses. Usually 2 2.5 cm in diameter, but not more than 4 cm. In 25% can be bilateral. Investigation: Sonography with FNA and cytology. Treatment: Periodic review (fibroadenoma does not increase the risk of developing BC): if a patient wants excision of the lump.

Answer 83

Spironolactone induced gynaecomastia: firm, concentric, mobile mass with the nipple areolar complex. Mass painful and tender on palpation. May be unilateral or bilateral Pseudogynaecomastia: subareolar fatty tissue without evidence of a discrete subareolar mass on palpation. Bilateral.

Answer 84

Investigation: US (anechoic well defined mass with smooth walls). Mammography cannot establish the cyst. Treatment: If asymptomatic and typical features on US no aspiration required. No follow up. If symptomatic, needle drainage under US control. The goal of cyst aspiration is complete drainage of the cyst with collapse of cyst wall. If the fluid is clear or greenish, it is a simple cyst. No further work up. The excisional breast biopsy is recommended: Cellular bloody cyst fluid on aspiration; Failure of a suspicious mass to disappear completely upon fluid aspiration; No aspirate; Complex cyst (internal echoes, thick wall, irregular margin); Atypical or suspicious cytology; Recurrence of cyst within 1 month.

Answer 85

Excision of the lesion (open biopsy using hook wire if lesion is non palpable) for further assessment as some will prove to be DCIS, or may be adjusted to foci of DCIS. If an open biopsy specimen shows atypical ductal hyperplasia no need for further management. Due to risk of cancer annual mammography and clinical examination are required as follow up.

Answer 86

Stage IV breast cancer - Mastectomy (palliative). In bone mts local radiotherapy plus bisphosphonates. In brain mts local radiotherapy. In local chest wall lesions local radiotherapy. In liver mts chemotherapy. In lung mts chemotherapy.

Answer 87

– Irreversible end-organ dysfunction. – Cirrhosis with portal hypertension. – Medical problems precluding general anaesthesia. – Centrally mediated obesity syndromes such as Prader-Willi syndrome or Craniopharyngioma.

Answer 88

Familial adenomatous polyposis is an autosomal dominant disease that results from mutations in APC gene.One copy of the altered gene can lead to the disease. The incidence of malignancy in these cases approaches 100%. An affected person with FAP has a 50% chance of passing the condition on to each of their children.

Answer 89

True gynecomastia is characterized by palpable breast tissue exceeding 0.5 cm, usually bilateral and tender. 💡👐 Diagnosis involves a thorough history (medications, medical conditions, puberty, etc.) and physical examination (differentiating from other conditions, breast cancer, etc.). 📋🔍 Further evaluation is needed for macromastia, tender lumps, signs of malignancy, testicular concerns, or specific conditions (e.g., renal or liver disease). ⚠️🏥 Serum chemistry panel for renal or liver disease if suspected. Hormone levels (testosterone, LH, estradiol, etc.) for feminization syndrome evaluation. Thyroid tests if hyperthyroidism is suspected. 🩸🔬 Ultrasonography can help diagnose true gynecomastia, assess size, and rule out other conditions like cancer or lipoma. Scrotal sonography is recommended for testicular concerns. 🌡️📸

Answer 90

7 documented episodes of sore throat in the past year 5 documented episodes in each of the past 2 years 3 documented episodes in each of the past 3 years These criteria help identify children who may benefit from tonsillectomy.

Answer 91

aradise Criteria for tonsillectomy in children aged 1-18 years ≥7 documented episodes of sore throat in the previous year 😷 ≥5 documented episodes in each of the previous 2 years 😓 ≥3 documented episodes in each of the previous 3 years 😩 Indications: Recurrent tonsillitis requiring antibiotic treatment (as per Paradise Criteria) 🦠💊 Recurrent quinsy (peritonsillar abscess) 🤒 Obstructive sleep apnea in children due to tonsillar hypertrophy 😴 Suspected neoplasm (tumor) of the tonsils 🩺🦠 Recurrent tonsillitis and halitosis (persistent bad breath) 🤢

Answer 92

Common in swimmers due to water exposure 🏊 Red flags for antibiotic therapy in AOM: Children <6 months, immunocompromised, Aboriginal background, only hearing ear, cochlear implant, or possible suppurative complications 🚩 If the patient is mildly unwell and no red flags are present, initial management includes analgesia, and antibiotics are not needed for the first 48 hours. If the child is unwell or red flags are present, antibiotic treatment is initiated 🚫💊 Treatment for AOM with analgesia and Amoxicillin 30mg/kg/dose twice daily for 5 days. Consider higher doses for Aboriginal peoples if needed 🩹💊 If there is no improvement in symptoms within 48 hours, consider alternative diagnoses. If none are found, switch to Amoxicillin + Clavulanic Acid 22.5mg/kg/dose twice daily for 5 days 🤒💊

Answer 93

Advise parents to seek medical review in 2-3 months for any ear or hearing-related symptoms and to check for persistent effusion 🏥👂 Emphasize the importance of monitoring the child's condition and ensuring timely medical attention when needed 🕒

Answer 94

Allergic rhinitis, often known as hay fever, is the most common allergic disorder in Australia 🇦🇺 It is a significant risk factor for the later development of asthma, affecting 20-30% of individuals with allergic rhinitis 🌾🌫️ Many patients can manage hay fever symptoms at home without visiting their General Practitioner (GP) 🏠 However, patients experiencing persistent symptoms (lasting > 4 days per week for at least 4 weeks) or symptoms that significantly impact their sleep and daily activities may require further investigations and medical attention 🛌👨‍⚕️

Answer 95

Skin prick tests are usually conducted by specialists 👨‍⚕️ These tests involve introducing allergen extracts into the skin to observe allergic reactions 🩸 Skin prick tests help identify allergens that trigger allergic reactions in patients 🌡

Answer 96

Initial urological assessment typically encompasses history and examination. This assessment may result in additional urological investigations, such as uroflow and post-void residual volume measurement. The decision to undertake further investigation with cystoscopy would be based on factors such as haematuria, UTI and progressive or non-responsive symptoms. Formal urodynamic studies may be required if neurological symptoms are present and in selective cases where bladder or sphincteric function need to be formally assessed.

Answer 97

Ejaculated or exercised vigorously during the previous 48 hours. An active urine infection Had a prostate biopsy in the previous 6 weeks, as this investigation can cause PSA levels to rise temporarily.

Answer 98

Five or more follicles over the tarsal plate In areas where trachoma is prevalent, regular face washing and treatment of household contacts is recommended. Community-wide treatment may be required in areas where prevalence is high. For further information on public health management of trachoma Conjunctival swabs for nucleic acid amplification testing (NAAT) (eg polymerase chain reaction [PCR]) are recommended in all neonates, and in patients with persistent conjunctivitis when C. trachomatis is suspected. Systemic treatment is necessary. There is no evidence that concomitant topical therapy improves outcomes. For adults and children older than 1 month, use: azithromycin 1 g (child: 20 mg/kg up to 1 g) orally, as a single dose. For neonates, use: azithromycin 20 mg/kg orally, daily for 3 days. Approximately 50% of neonates with chlamydial conjunctivitis have associated chlamydial pneumonia

Answer 99

Stage 1: no apparent retinopathy Stage 2: mild NPDR, characterised by the presence of a few microaneurysms Stage 3: moderate NPDR, characterised by a greater number of microaneurysms and intraregional haemorrhages than seen at Stage 2 Stage 4: severe NPDR, characterised by haemorrhages across the entire retina or venous beading or intraretinal microvascular abnormalities Stage 5: PDR, characterised by neovascularisation of the disc or elsewhere and can be complicated by vitreous haemorrhage or tractional retinal detachment.

Answer 100

Oral phosphodiesterase type 5 (PDE5) inhibitors are accepted as the first-line therapy for ED in men 🍆💊

Answer 101

Initially administer oral PDE5 inhibitor medications at the maximum dose to improve or guarantee erection, then decrease to a lower dose based on the adverse profile 👨‍⚕️💊 Lack of response to one PDE5 inhibitor doesn't mean refractoriness to all; it's recommended to try at least two different types of PDE5 inhibitors 💡

Answer 102

Encourage the patient to take the PDE5 inhibitor medication on four separate occasions, preferably initially by himself to minimize any psychological distress related to sexual intimacy with another person 🧠🔒 Discuss sexual health and safe sex practices as part of the duty of care for the patient 🩺🪞 Daily tadalafil therapy may offer greater sexual spontaneity and reduce psychological distress associated with taking medication for sexual dysfunction 🗓️🤗

Answer 103

Headache 🤕 Facial flushing 😳 Indigestion 🍽️ Nasal congestion 🤧 Dizziness 🌀 Visual disturbances 👁️ Myalgia (muscle pain) 🏋️‍♂️

Answer 104

Systemic chemotherapy 💊 Superselective Intra-arterial Chemotherapy (SIAC) 🩸 Intravitreal chemotherapy 💉 Radiotherapy 📻 SIAC delivers drugs directly to the eye via the ophthalmic artery, minimizing systemic side effects compared to systemic chemotherapy 🚫💊 It provides a targeted approach for drug delivery 🎯 Retinoblastoma with vitreous involvement represents a significant treatment challenge 🤯 SIAC often provides limited penetration and efficacy of drugs in the vitreous, making treatment difficult 🩸👁️ Intravitreal injection is an additional therapeutic option in these cases 🪄 Radiation therapy is considered for selected patients, especially those with recurrent or residual tumors following chemotherapy 📻💊 Enucleation (removal of the eye) remains the standard of care for advanced tumors, including those that have penetrated the extraocular tissue 🏥👁️

Answer 105

📣 The Rinne test is a hearing assessment tool. 🔊 It compares a patient's ability to hear sounds conducted through the air (AC) and through bone (BC). 🧏‍♂️ Results help diagnose types of hearing loss: normal hearing, sensorineural hearing loss (SNHL), or conductive hearing loss (CHL). 🦻 In a normal Rinne test, AC (air conduction) is greater than BC (bone conduction). 🦻 In SNHL, BC may be better than AC. 🦻 In CHL, AC remains greater than BC.

Answer 106

📣 Weber's test is a hearing assessment tool used to evaluate hearing balance between the ears. 🔊 To perform the test, a tuning fork is struck to produce sound vibrations. 🧏‍♂️ The tuning fork is then placed on the midline of the patient's head or forehead. 🎵 Patients are asked to indicate in which ear they hear the sound more loudly. 🎯 If the sound is louder in one ear, it may indicate hearing loss or a conductive issue in that ear. 👂 If the sound is equally heard in both ears or centered, it suggests normal hearing or equal hearing loss in both ears. 🩺 Weber's test helps identify potential hearing imbalances that can guide further diagnostic evaluation.

Answer 107

Pneumothorax is classified as small (distance <2 cm) or large (distance ≥2 cm) at the hilum level, with some preferring alternate thresholds (e.g., 3 cm laterally and 4 cm apically). 📏 Small pneumothoraces are often asymptomatic, while larger ones can cause pleuretic chest pain (referred to the shoulder tip) and shortness of breath. Clinical findings may include decreased breath sounds, hyperresonance, decreased tactile fremitus, and tracheal deviation. 🩺💨

Answer 108

For PSP, consider discharge and regular review if asymptomatic with a pneumothorax size less than 15% of the affected lung or if the distance between the chest wall and visceral pleural line is ≤2 cm. 🏡 Needle aspiration may be performed if the patient is symptomatic (pleuretic chest pain or dyspnea) or if the pneumothorax size is ≥15% of the affected lung or if the distance between the chest wall and visceral pleural line is >2 cm. 🩺 Chest tube insertion is indicated if the aspirated air volume is ≥3 liters or if the distance between the chest wall and visceral pleural line remains >2 cm on a post-aspiration chest X-ray taken 4 hours later. 📈

Answer 109

In SSP, all patients need admission. Needle aspiration is considered if there are no significant symptoms and the pneumothorax size is less than 15% of the affected lung or if the distance between the chest wall and visceral pleural line is ≤2 cm. 🏥 Chest tube insertion is indicated if the patient is symptomatic (pleuretic chest pain or dyspnea) or if the pneumothorax size is ≥15% of the affected lung or if the distance between the chest wall and visceral pleural line is >2 cm. 📏 For traumatic pneumothorax, chest tube insertion is typically necessary unless the patient is asymptomatic with a pneumothorax size less than 15% or if the distance between the chest wall and visceral pleural line is ≤2 cm. Close observation for spontaneous resolution is an option in such cases. 🚑 Regardless of pneumothorax type and size, chest tube insertion is recommended if the patient undergoes general anesthesia, planned intubation, mechanical ventilation, or air transport. ⚠️

Answer 110

Byssinosis is an occupational lung disease primarily seen in workers exposed to unprocessed raw cotton, especially in open bales of cotton or cotton spinning/carding rooms. 🌾 It can develop after at least 10 years of exposure or acutely in a matter of hours or days. 🕒 The disease is suggested to be caused by a bacterial endotoxin in cotton dust, leading to acute bronchoconstriction and, with longer exposure, chronic bronchitis and gradual pulmonary function decline, especially in genetically susceptible individuals. 🦠 Byssinosis differs from asthma (Option E) due to its unique temporal pattern of symptoms: chest tightness and dyspnea develop at the start of the workweek and improve by the week's end. 📅 Physical findings include tachypnea and wheezing with acute exposure and crackles with chronic exposure. 🩺 Pulmonary function tests during attacks show reversible air flow obstruction and reduced vital capacity, while at other times, tests are inconclusive unless chronic disease has developed, in which case a restrictive pattern is more likely. Hyperresponsiveness to methacholine is often observed. 📈

Answer 111

Exposure to beryllium, a metal used in various industries, can lead to two pulmonary syndromes: acute chemical pneumonitis and chronic beryllium disease (CBD) or berylliosis. 🛠️ Acute beryllium disease results from beryllium acting as a direct chemical irritant, causing nonspecific inflammation (acute chemical pneumonitis). 🫁 Chronic beryllium disease (CBD) presents with symptoms such as shortness of breath, unexplained cough, fatigue, weight loss, fever, and night sweats. Symptoms may vary in severity and onset time among individuals. 🤒 While some workers may experience severe symptoms quickly, others may not show signs until months or years after beryllium exposure. 📆 Notably, berylliosis can continue to progress even after exposure has been removed. If there is no history of beryllium exposure, it is unlikely to be the cause of the presented symptoms. Additionally, the clinical picture and temporal course of symptoms should be consistent with berylliosis for diagnosis. 🚫

Answer 112

Silicosis is an irreversible and incurable fibrotic lung disease caused by inhaling respirable crystalline silica dust. 🫁 There are three types of silicosis: Acute silicosis, resulting from short-term (<3 years) exposure to high silica levels, leading to rapid dyspnea and high mortality. Accelerated silicosis, caused by 3-10 years of high silica exposure, with features of both acute and chronic silicosis and faster progression. Chronic silicosis, developing after over 10 years of exposure, can be simple (asymptomatic with small nodules) or complicated (massive nodules >1cm) leading to impaired lung function, dyspnea, and potentially respiratory failure and death. 📆 Complicated silicosis, also known as progressive massive fibrosis (PMF), involves the conglomerate nodules, calcification, and lymph node involvement. 🦴

Answer 113

Characteristics: 🫁 Colonic volvulus occurs when part of the colon twists around its mesentery, leading to colonic obstruction. Common Sites: 🫁 Sigmoid colon is most frequently affected, followed by the right colon and terminal ileum, including cecal or cecocolic volvulus. Transverse colon or splenic flexure involvement is rare. Patient Profile: 🫁 Patients with colonic volvulus are typically elderly, debilitated, and bedridden. Neuropsychiatric impairment or dementia is often present. Symptoms: 🫁 Symptoms can be acute (more than 60-70% of cases), subacute, or chronic. They include cramping abdominal pain, distention, constipation, and/or obstipation. Abdominal Findings: 🫁 Abdominal distention, often with a tympanic quality over the gas-filled, thin-walled colon loop. Tenderness or rebound tenderness may indicate peritonitis. Complications: 🫁 Nausea, vomiting, and constant abdominal pain can develop, signaling closed-loop obstruction, ischemic gangrene, and bowel wall perforation. Imaging: 🫁 Plain abdominal films reveal massive sigmoid colon dilation, creating a beaklike appearance.

Answer 114

Nausea/vomiting (60-80%): The vomitus can often be bilious in nature and PRECEDES the development of other signs (EARLIEST SIGNS) Constipation/absence of flatus (80-90%): Typically, a later finding of SBO. Abdominal distention (60%) Fever and tachycardia: Late findings and may be associated with strangulation.

Answer 115

Postcholecystectomy Syndrome (PCS): 🏥🔪🤔 Definition: 📝 Persistent abdominal pain or dyspepsia after cholecystectomy: 💔🪶 Causes: 📦 Biliary causes: 🤢🪶 Retained common bile duct (CBD) stone: 🟠🫁 Retained cystic duct stone: 🟠🪶 Biliary dyskinesia: 🤢⚙️ Extra-biliary causes: 🫁🫁🫁 Eg, pancreatitis, peptic ulcer disease, coronary artery disease: 📊🩺🦠

Answer 116

Laboratory findings in PCS: 🩸🪶 Elevated alkaline phosphatase: 📈 Mildly abnormal serum aminotransferases: 📈🫁 Dilated common bile duct (CBD) on abdominal ultrasound: 📏🟠🫁 Diagnostic methods for PCS: 🏥🔍 Next step: 🏁 Endoscopic ultrasound, endoscopic retrograde cholangiopancreatography (ERCP), or magnetic resonance cholangiopancreatography: 🫁🪶🔍 Final diagnosis and guiding therapy: 🎯💡 Treatment for PCS: 💊🩸🏥 Directed at the causative factor: 📚🪶🎯

Answer 117

Abdominal pain and hematuria with a renal mass is concerning for renal cell carcinoma (RCC) until proven otherwise. 🚫 Small renal masses (<4 cm) are often found incidentally or during urinary symptom evaluation by ultrasound, with follow-up 4-phase contrasted CT scans if feasible. 🏥 Solid, complex, or contrast-enhancing cystic masses are suspicious for malignancy. 📊 For fit patients with a life expectancy >5 years, initial management is surgical resection (partial nephrectomy for <7 cm, non-centrally located masses). 🏥 Total nephrectomy is the treatment of choice in the following situations: Tumor size ≥7 cm Tumors with a more central location Suspected lymph node involvement Tumor with associated renal vein or inferior vena cava (IVC) thrombus Direct extension into the ipsilateral adrenal gland Even in the presence of the above, patients with any of the following conditions must have partial rather than total nephrectomy: A solitary kidney Multiple, small, and/or bilateral tumors Patients with or at risk for chronic renal disease Active surveillance with regular imaging is for patients not fit for surgery or with a ≤5-year life expectancy. 📈 Renal biopsy's role is controversial for small renal masses; it may be considered if surgery isn't an option, life expectancy is short, or the patient requests it. 🤷

Answer 118

The initial imaging exam to consider for diagnosing colonic volvulus is a plain abdominal x-ray. It reveals a distended loop of colon that may resemble a coffee bean or a dilated U-shaped colon with a cut-off point at the site of obstruction. The most accurate confirmatory diagnostic tool for both cecal and sigmoid volvulus is a contrast-enhanced abdominal CT scan. 📸📊 water-soluble contrast enema can also be used 📸

Answer 119

The preferred confirmatory diagnostic tool for both cecal and sigmoid volvulus is a contrast-enhanced abdominal CT scan. 📊 It excludes perforation and vascular impairment

Answer 120

The most appropriate initial treatment for patients in whom bowel perforation or ischemia has been excluded is rigid or flexible sigmoidoscopy. After endoscopic detorsion, a rectal tube is left in place for 1 to 3 days to maintain reduction. 🩺

Answer 121

The definitive treatment for colonic volvulus is surgery. 📋

Answer 122

Lateral epicondylitis (LE) is characterized by repetitive, forceful overuse of wrist and digit extensors, leading to angiofibroblastic tendinosis of extensor tendons at the lateral epicondyle. [Pathophysiology, Overuse of wrist & digit extensors, Angiofibroblastic tendinosis, Lateral epicondyle 🦴] LE typically presents with insidious pain that develops over weeks to months. The maximal pain and tenderness are typically found approximately 1 cm distal to the lateral epicondyle. [Clinical presentation, Insidious pain, Location of tenderness, Maximal pain, Lateral epicondyle location] Pain in LE is elicited by resisted wrist extension and passive wrist flexion. [Resisted wrist extension, Passive wrist flexion, Pain elicitation] Diagnosis of LE is mainly based on clinical presentation. In doubtful cases, musculoskeletal ultrasound can be used. [Diagnosis, Clinical presentation, Musculoskeletal ultrasound 🩺] The initial management of LE includes activity modification and the use of a counterforce elbow brace (tendinosis strap) or a compression sleeve to reduce the load transmitted to the tendon origin. For refractory symptoms, short-term NSAIDs, corticosteroid injection, or surgery may be considered.

Answer 123

Colonoscopy should be performed one year after sporadic cancer resection, unless a complete post-operative colonoscopy has been done sooner 📆🔍 Recommendations for familial adenomatous polyposis (FAP) and hereditary nonpolyposis colorectal cancers (HNPCC) differ from sporadic cancers 🧬 If a peri-operative colonoscopy at one year reveals advanced adenoma, the next colonoscopy should be performed in 3 years 🩺 If the one-year colonoscopy is normal or identifies no advanced adenomas, the next colonoscopy should be performed in 5 years 🩺🔍 If a patient has not had a colonoscopy in the past 10 years, they should undergo colonoscopy now 📆🔍

Answer 124

Consider periodic examination of the rectum at 6-month intervals for 2-3 years 📆🕵️ Include digital rectal examination, rigid proctoscopy, flexible proctoscopy, and/or rectal endoscopic ultrasound in the examinations 🖐️👀📡 These examinations are independent of the colonoscopic examination schedule 📆🚫🩺

Answer 125

Clinical findings: Facial nerve dysfunction on the left side and a painless firm, mobile mass on the same side 🧏‍♂️💡 Primary concern: Excluding a malignant parotid tumor that has invaded the facial nerve 🦠🦷

Answer 126

Imaging studies: CT/MRI of the head and neck 📸🧠📊 Role: Differentiate neoplastic from benign disease, define intra- versus extra-glandular location, assess local extension and invasion, and detect nodal and systemic metastases 📈📡🔍 For CT scan: Both pre- and post-contrast studies are performed to detect calcifications (pre-contrast) and assess enhancement pattern (post-contrast) 📸🔍 Biopsy (FNA or core biopsy) is the definitive means of diagnosing a parotid malignancy, typically performed after imaging studies and before surgical treatment 🧬🔍🏥

Answer 127

TURP Syndrome: A rare but potentially life-threatening complication of TURP. Occurs due to fluid absorption during bladder irrigation into prostatic venous sinuses. Clinical features are varied and unpredictable, often resulting from fluid overload and electrolyte imbalance, particularly hyponatremia. Severity of TURP Syndrome varies from mild to severe. The type of irrigant used during the procedure may influence the presentation of the syndrome.

Answer 128

Radiographic features associated with higher risk for malignancy in pancreatic cysts include: Large size (≥3 cm) 📏 Solid components or calcifications 🧱 Main pancreatic duct involvement (ductal dilation) 📝 Thickened or irregular cyst wall 🧱🧼 The goal of management is to identify lesions at high risk for malignancy. Surgical resection (without prior biopsy) may be considered for very high-risk lesions. Endoscopic ultrasound (EUS)-guided biopsy is a minimally invasive approach to tissue sampling for further evaluation. 🩺🔍

Answer 129

Patients classically present with unilateral lower abdominal pain that becomes increasingly diffuse, often radiating to the shoulder due to phrenic nerve irritation. 🩸👉💪 Peritoneal signs (rigidity, rebound, guarding) and hemodynamic instability (hypotension, tachycardia) develop as blood fills the abdominal cavity. 🏥📈 Diagnosis is confirmed by pelvic ultrasound, which reveals heterogeneous pelvic free fluid and a possible ovarian cyst. 📷🩺 Patients with peritoneal signs and hemodynamic instability require emergency surgery, often in the form of diagnostic laparoscopy. 🚑🔍 Unlike ovarian torsion, ruptured ovarian cysts with hemoperitoneum cause hypotension, acute blood loss anemia, and shoulder pain. 🩸❌📉👉🚫

Answer 130

Injury mechanisms for ACL tears involve rapid deceleration or direction changes and pivoting on the lower extremity with the foot planted. 🏃🔄 Common symptoms include sudden onset severe pain, a popping sensation at the time of injury, significant swelling (effusion/hemarthrosis), and joint instability. 🩺🚑 Examination findings reveal anterior laxity of the tibia relative to the femur, typically tested with the anterior drawer test and Lachman test. 🖐️🦵 Plain x-rays are often normal, but a fracture of the tibial spine or anterolateral tibial plateau may suggest an ACL tear. MRI provides a definitive diagnosis. 📷🩺 Treatment involves RICE (Rest, Ice, Compression, Elevation) measures and may include surgery depending on the patient's age and activity level. 🥶🏥

Answer 131

ACL tears frequently occur in young athletes who rapidly change direction or pivot on the lower extremity, leading to significant twisting forces on the knee. 🏃🩸 Commonly, a popping sensation in the knee is experienced at the time of injury, followed by rapid-onset hemarthrosis and a feeling of joint instability with weight-bearing. 💥🦵🏥

Answer 132

The Lachman and anterior drawer tests are highly sensitive and specific for ACL injuries, but they may be difficult to perform in the first 1-2 weeks due to guarded knee movement. Diagnosis is confirmed with MRI, which is not typically required. 🧩📊 Choice B refers to MCL tears, while Choice C relates to meniscal tears, both of which differ in mechanisms, symptoms, and examination findings compared to ACL injuries. 🦵🤕

Answer 133

MCL tears are commonly caused by severe valgus stress (e.g., blow to the lateral knee) or twisting injury. 🦵💥 Examination findings may include local swelling, ecchymosis, and joint line tenderness at the medial knee. 🩺🟣 Appreciable laxity during the valgus stress test helps with diagnosis but may be obscured by swelling and muscle spasm. 🖐️🤕 Acute effusion/hemarthrosis is rare unless there is concurrent injury to the anterior cruciate ligament. 🚑 MRI is the most sensitive test for diagnosis and is typically reserved for patients considered for surgical intervention. Nonoperative management involves rest, ice, compression, elevation (RICE), and analgesics with a gradual return to activity as tolerated. 📷🩺🚑

Answer 134

MCL injuries result from valgus stress and are characterized by joint line tenderness at the medial knee. Valgus laxity is a key diagnostic feature. 🦵🦵🩺 In contrast, ACL injuries often lead to acute hemarthrosis with an effusion, and the tibia displays anterior rather than valgus laxity. 🩸🚫🤕

Answer 135

Initial imaging for assessing the biliary tree and gallstone disease should be performed with ultrasound. 🩺🔍 In cases of suspected chronic pancreatitis, the first-line investigation of choice is CT, which is moderately accurate for diagnosis. 🖥️🏥 Additional modalities like magnetic resonance cholangiopancreatography (MRCP), secretin-augmented MRCP (sMRCP), and endoscopic ultrasound (EUS) can offer further diagnostic information and help guide interventional management. 🧲📷🩺

Answer 136

For patients 40 or older with no clear cause of pancreatitis after excluding gallstones and alcohol, a CT scan can be considered to investigate for pancreatic malignancy, although it's a rare cause of acute pancreatitis. 📷🧲🩺 In cases of recurrent pancreatitis, regardless of age, further investigation is advised due to the increased risk of morbidity and potential progression to chronic pancreatitis. 🔄📈🩺 Endoscopic ultrasound (EUS) is recommended as the first investigation for patients with pancreatitis of unknown cause and a normal abdominal ultrasound (AFTER CT). 🪶🩺📷 If no cause is identified on EUS, patients may proceed to magnetic resonance cholangiopancreatography (MRCP) or secretin-augmented MRCP (sMRCP). 🧲📷🩺 Diagnostic endoscopic retrograde cholangiopancreatography (ERCP) is now replaced by EUS and MRCP, but it remains an option for therapeutic interventions when necessary. 🩺🪶📷

Answer 137

Femoral hernias are hernias located below the inguinal ligament and medial to the femoral artery. They protrude through the femoral ring and usually present as a nontender, nonpulsatile bulge in the groin. 🩺 This bulge tends to increase in size with increased abdominal pressure. 💥 Due to the narrow hernia orifice, the risk of incarceration (strangulation) with femoral hernias is high. 🚨 As a result, patients with asymptomatic femoral hernias are referred for early elective hernia repair to prevent complications. 🏥

Answer 138

Inguinal hernias are located above the inguinal ligament and have a different anatomical position compared to femoral hernias. 📏 Asymptomatic inguinal hernias can often be managed with watchful waiting. 🕒 This approach is feasible because hernia contents pass through a wider orifice, reducing the risk of incarceration. 🔒 Surgical repair may be considered if the inguinal hernia becomes symptomatic or if there are other compelling reasons for intervention. 🔪

Answer 139

Tibial stress fractures are a type of fracture that most commonly occurs in athletes, such as runners and dancers, or in individuals who increase their activity level without adequate rest. 🏃💃 These fractures result from repeated tension or compression and the absence of recovery periods. They are especially common in women with low caloric intake and functional hypothalamic amenorrhea, which leads to lower bone density, often characterized by a low BMI. 🥗 Additional contributing factors to stress fractures include improper footwear, biomechanical abnormalities (e.g., weak calf muscles, high-arched feet), and inadequate calcium and vitamin D intake. 🥿🦵🥛

Answer 140

These findings are consistent with a varicocele, a tortuous dilation of the pampiniform plexus surrounding the spermatic cord and testis. Varicoceles typically present in adolescent and young adult males and are more common on the left side. They are often asymptomatic but may cause a dull ache after prolonged standing, as in this patient. Clinical examination can help differentiate between varicocele and inguinal hernia, which can also present as a painless, soft scrotal mass that does not transilluminate. Like varicoceles, indirect inguinal hernias (caused by a patent processus vaginalis) also increase in size with Valsalva maneuver. However, unlike varicoceles, hernias are often reducible with manipulation; in addition, palpation reveals a soft-tissue mass, unlike the characteristic "bag of worms" texture of a varicocele. A scrotal ultrasound can be useful if the diagnosis remains unclear after clinical examination. A spermatocele is a fluid-filled cyst of the head of the epididymis that transilluminates. It presents as a painless mass at the superior pole of the testis. A spermatocele does not change in size with positioning or Valsalva maneuvers. Hydroceles are peritoneal fluid collections between the parietal and visceral layers of the tunica vaginalis. Although communicating hydroceles can change size with positioning, the fluid within a hydrocele is easily transilluminated.

Answer 141

Leydig cells are the primary source of testicular testosterone but can also generate estrogen. Leydig cell tumors often present with endocrine manifestations due to excessive estrogen (e.g., gynecomastia, loss of libido, erectile dysfunction) or testosterone (e.g., acne, hirsutism). 🚹🚺 A testicular mass is frequently observed upon examination, which is typically confirmed by bilateral scrotal ultrasound. 🩺 Unlike many germ cell tumors, Leydig cells do not generally produce serum tumor markers such as β-hCG or alpha-fetoprotein (AFP). However, the generation of estrogen or testosterone often leads to FSH and LH suppression. 📈🧪 Choriocarcinoma, teratoma, and yolk sac tumors are nonseminomatous germ cell tumors. They typically present with a painless, firm testicular mass. However, they often produce β-hCG (particularly choriocarcinoma) or AFP (particularly yolk sac tumors); in addition, estrogen production is rare, so feminization is uncommon. Seminoma is a germ cell tumor that does not usually produce β-hCG, AFP, or estrogen. Therefore, feminization would be atypical. Most seminomas present with a painless, unilateral testicular mass or swelling.

Answer 142

The quadriceps muscle, composed of the rectus femoris, vastus lateralis, vastus medialis, and vastus intermedius, generates extreme force across the knee joint at full activation. 💪 Sudden, forceful contraction, as can occur during deceleration from a fall or in certain athletic activities, can cause rupture of the quadriceps-patellar tendon complex. 🏃‍♂️ Tendon injuries involving the quadriceps-patellar complex can be categorized in relation to the patella as follows: Quadriceps tendon tears (proximal to the patella in the rectus femoris tendon): the patella rides low, indicating an intact connection to the tibia, with a palpable defect above the patella. 🦴 Patellar tendon tears (distal to the patella): the patella rides high, often with a palpable defect below the patella. 🦵

Answer 143

Anterior cruciate ligament (ACL) tears are common in middle-aged athletes and can cause rapid-onset hemarthrosis (bleeding into the joint). 🩸 Extensive swelling may mask ligamentous instability in the acute phase, but knee extension against gravity remains intact. 👟🦵

Answer 144

Obscure GI bleeding is defined as bleeding from the GI tract that persists or recurs without an obvious etiology found on upper endoscopy, colonoscopy, and radiologic evaluation of the small bowel. 🩺 Obscure bleeding can be subdivided into two categories based on clinical presentation: Obscure occult (inactive) bleeding, which is manifested as iron deficiency anemia or recurrent positive Fecal Occult Blood Test (FOBT) results. 🩸 Obscure overt (active) bleeding, which is manifested as recurrent episodes of clinically evident bleeding (e.g., melena or hematochezia) or persistent blood loss, which may necessitate transfusion and is considered life-threatening. 💉

Answer 145

In patients with active bleeding, radiological investigations are the mainstay of the diagnostic approach due to their high sensitivity and non-invasiveness. CT Angiography (CTA) is commonly used. 📷 A negative CTA suggests that catheter angiography is not indicated, as it is less sensitive and requires a higher rate of blood loss (greater than 0.5 ml/min) to detect the bleeding source. 🚫 With a negative CTA and ongoing bleeding, technetium 99m-labeled RBC nuclear scan is used as a second-line investigation at some institutions, as it is highly sensitive for active GI bleeding and can detect bleeding rates as low as 0.1 mL/min. 💉 Life-threatening hemorrhage should prompt catheter angiography as the first-line management, as it is very likely to identify and control the source of bleeding. 🩸

Answer 146

For patients with inactive obscure GI bleeding, capsule endoscopy is the preferred option. 📸 However, a negative test demands further assessment through CT angiography or other radiologic modalities (radionuclide scan, etc.). 📊

Answer 147

In patients with acute closed-angle glaucoma, the cornea is hazy and the pupil is partially or fully dilated and unresponsive to light. The red reflex is lost. Other accompanying features include hardness of the orbit, ipsilateral headache and nausea and vomiting. Chronic closed-angle glaucoma does not cause a red eye.

Answer 148

Inguinal hernias are located above the inguinal ligament and are more common in men. 👨‍⚕️ The inferior epigastric vessels serve as a landmark during laparoscopic hernia repair to distinguish between types.

Answer 149

Indirect inguinal hernias occur due to the failure of the processus vaginalis to obliterate. They allow abdominal contents to protrude lateral to the inferior epigastric vessels, following the inguinal canal path. 🏥 Direct inguinal hernias result from weakness in the transversalis fascia. Compared to indirect inguinal hernias, direct hernias have a wide neck, making them less prone to incarceration and less likely to descend into the scrotum. 👖🩺

Answer 150

The femoral vein runs directly lateral to femoral hernias. These hernias protrude below the inguinal ligament into the femoral canal. 👖🩺

Answer 151

The pectineal ligament (inguinal ligament of Cooper) forms the posterior border of the femoral ring and would be located behind a femoral hernia that protrudes through the ring. The rectus abdominis muscle sheath forms the most medial aspect of the Hesselbach triangle, the site of protrusion for direct inguinal hernias. It is not useful for distinguishing between direct and indirect hernias as both are lateral to the rectus abdominis muscle sheath.

Answer 152

Developmental Dysplasia of the Hip (DDH) is an abnormal development of the femoral head and acetabulum. Infants with no risk factors should have serial hip examinations from birth until age 1. The Barlow and Ortolani maneuvers assess joint stability, and a palpable "clunk" should prompt referral to an orthopedic surgeon. Additional signs such as leg-length discrepancy (e.g., Galeazzi test) or asymmetric inguinal skin folds can also be indicators of DDH. 👩‍⚕️🔍 Infants with abnormal examination should undergo bilateral hip ultrasonography. After age 4 months, x-rays are preferred to evaluate acetabular development and positioning. Confirmed DDH is treated with a Pavlik harness, a splint that holds the hip in flexion and abduction while preventing extension and adduction. 📷🏥

Answer 153

A pseudocyst larger than 5 cm is suitable for endoscopic drainage 📏 Endoscopic drainage can be achieved through either endoscopic transmural or transpapillary drainage 🚰 Transpapillary drainage has the lowest complication rate and is preferred if the pseudocyst communicates with the pancreatic duct, which is the case in approximately 80% of pseudocysts 🧪📊

Answer 154

Endoscopic cystgastrostomy (ECG) or duodenostomy (ECD) are the methods of choice for pseudocysts that do not communicate with the pancreatic duct 🍽️ Percutaneous catheter drainage is not recommended for the treatment of a pancreatic pseudocyst due to its low success rate and high recurrence rates. However, it is the preferred procedure for sampling and examining the material in infected pseudocysts 🧪📉

Answer 155

Respiratory compromise in trauma patients is often a result of underlying pulmonary contusion 🫁 In alert, otherwise uncompromised patients, continuous positive airway pressure (CPAP) may spare them from the need for intubation and mechanical ventilation 🌬️

Answer 156

Intubation and mechanical ventilation are required in the following situations: Patients with severe injuries 💥 Patients with respiratory distress 🌬️ Patients with progressively worsening respiratory functions 📉 Patients with respiratory suppression due to excessive narcotic pain control 💊

Answer 157

Intubation and mechanical ventilation should be followed by prophylactic chest tube insertion, often bilateral. This is because the ragged edges of broken ribs may lead to pneumothorax, and chest tubes are needed to prevent this complication 🩹🫁

Answer 158

The primary goal in the management of achalasia is to reduce the pressure in the lower esophageal sphincter to improve the passage of food 🍽️ Two main treatment options are myotomy (either laparoscopic or peroral endoscopic) and pneumatic balloon dilatation, both equally effective in relieving dysphagia 🫁💨 Peroral endoscopic myotomy (POEM) is a treatment option for achalasia 🫁 POEM is associated with a higher rate of postprocedural gastroesophageal reflux, which can be managed with acid suppression medication 🌡️

Answer 159

Injection of botulinum toxin type A into four quadrants of the lower esophageal sphincter can improve symptoms in achalasia 🩸 This approach may need to be repeated at intervals of 3 to 12 months and is generally used when other therapies are not suitable 🔄 Drugs that relax the lower esophageal sphincter (e.g., nitrates, calcium channel blockers) may be trialed in achalasia management 🩹 However, they are of limited benefit in this condition and may have better outcomes in distal esophageal spasm, following suitable regimens 🌡️📊

Answer 160

Thoracotomy is the procedure of choice for surgical exploration in the following situations: An immediate bloody drainage of ≥20 mL/kg (approximately 1500 mL) 🩸 Persistent bleeding (generally >3 mL/kg/hour) 💧 Shock despite initial treatment 🚨

Answer 161

Vitamin D deficiency has been associated with an increased risk of cancer 🌞🔬 Specific types of cancer linked to vitamin D deficiency include colon cancer, prostate cancer, ovarian cancer, and breast cancer, such as ductal carcinoma 🩺🦠

Answer 162

Femoral hernias most commonly present inferior to the inguinal ligament and medial to the femoral artery 🩸 They present with a swelling below and lateral to the pubic tubercle, which is in contrast to inguinal hernias that present as a swelling medial to the pubic tubercle 📌

Surgery, Ortho and Emergency Flashcards

(193 cards)