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SLIDESHOW PRACTICE Slide 2 What is this? What condition it associated with? What are the most common causes of this condition? What oesophageal condition is it associated with? Name 3 important investigations Slide 3 ANSWERS Iron deficiency anaemia Caused by blood loss (gi bleed, menorrhagia; hookworm in tropics, malabsorption (coeliac disease) Plummer Vinson syndrom (post cricoid web) FBC, serum iron, ferritin, TIBC, FOB, sigmoidoscopy, colonoscopy, barium enema Tx oral iron Slide 4 A 52 year old diabetic man presented to A and E feeling sick. 1 week previously his GP had treated him for reflux Describe immediate management Slide 5 ANSWER Morphine Oxygen Nitrates (buccal suscard) Aspirin 300mg B-blocker and ACE-I (within 24 hours) Thrombolysis if no contraindications! As presented within 24 hours of ischaemic chest pain with ST elevation of at least 2mm in 2 adjacent chest leads PRIMARY PCI IF IN COOL TEACHING HOSPITAL Slide 6 CONTRAINDICATIONS TO THROMBOLYSIS Internal bleeding Prolonged/traumatic CPR Any prev haemorrhagic stroke Ischaemic stroke within 1 year Recent trauma surgery (2 weeks) Intracerebral neoplasm/recent head trauma Suspected aortic dissection Prev allergic reaction to fibrinolytic Slide 7 Report this Xray Describe 5 changes you should look for on the XRay in this condition What investigations would you do if this was an acute problem? How would you manage? Slide 8 5 changes in L ventricular failure Aalveolar oedema (bat wings) B Kerley B lines (interstitial oedema) CCardiomegaly DDilated upper lobe vesseld EPleural Effusion SIGNS: tachycardia, basal creps, pink frothy sputum, PND, orthopnoea FBC, U+E, cardiac enzymes, ECG (ischaemia, MI, LVH), ABG, BNP (raised in failure) Echo Slide 9 Commonest causes of acute LVF? Post MI myocardial ischaemia Malignant hypertension aortic stenosis or aortic incompetence mitral incompetence arrythmia Slide 10 Management of acute LV failure Sit up Give 100% 02 IV access monitor ECG for arrythmias, MI etc Diamorphine 2.5-5 mg IV slowly Metoclopramide 10mg iv Frusemide 40-80mg IV slowly Give sublingual GTN if systolic BP>100 Monitor urine output (catherterise) Repeat ABG and K+ if condition deteriorates Slide 11 A 58-year-old afebrile woman presented with a 2-day history of pain and red streaks of her right leg following minor trauma. There were palpable cords beneath the erythematous streaks.red streaks of her right leg How would you manage? Slide 12 ANSWER SUPERFICIAL THROMBOPHLEBITIS Treatment includes gentle support by means of a bandage or stocking and elevation of the affected leg. Anti-inflammatory drugs such as ibuprofen 400mg tds. duplex ultrasound scan (DVT risk) Slide 13 This 55year old man has returned from a holiday 2 weeks ago with arthralgia, malaise, lymphadenopathy and peripheral neuropathy He has the following lesion which started as a red macule. What is the diagnosis? How would you treat? Slide 14 Erythema chronicum migrans classical immune-mediated skin lesion which occurs at the site of the bite in Lyme disease some weeks after the bite by the tick. (boriella burgdorferi infection) The tick bite leaves a red macule or papule which approximately later expands to produce a hot, painless annular/target lesion. Tx doxycycline Slide 15 Lyme disease often the first manifestation of Lyme disease = Lyme borreliosis spirochete Borrelia burgdorferi is transmitted by the bite of the deer tick Ixodes scapularis in the northeastern U.S. systemic borreliosis is a potentially serious disease, causing both acute and chronic symptoms such as fever, malaise, arthralgia, carditis, arthritis, meningitis, neuropathy, ataxia Slide 16 TROUSSEAUs SIGN This is a recurring thrombophlebitis characterised by successive crops of tender nodules in affected blood vessels. Different veins may be affected simultaneously or randomly. It denotes a thrombotic state and is associated with visceral malignancy, especially of the pancreas and lung. Thrombophlebitis migrans was first recognised by Trousseau in the diagnosis of his own pancreatic cancer. Slide 17 What is this? What causes it? What other signs would you look for? Slide 18 ANSWER Plummer vinson syndrome (Post cricoid web) Iron deficiency anaemia Koilonychia, pallor, atrophic mucous membranes, tachycardia if marked Tx balloon dilatation and iron supplements Pre-malignant!!! Slide 19 This patient presented with weight loss and this crazy skin condition What is it? Clue: say what you see Slide 203days or previous surgery within 12 weeks requiring regional or general anaesthesia1 Localised tenderness along the distribution of deep venous system1 Swelling of the entire leg1 Calf swelling by more than 3cm compared with asymptomatic leg1 Pitting oedema confined to the symptomatic leg1 Collateral superficial veins1 Previously documented DVT1 Alternate diagnosis as likely or greater than that of DVT-2"> DVT Figure 2: Wells Clinical model for predicting pretest probability. Clinical feature Score Active cancer1 Paralysis, paresis or recent plaster immobilisation of lower extremities1 Recently bedridden > 3days or previous surgery within 12 weeks requiring regional or general anaesthesia1 Localised tenderness along the distribution of deep venous system1 Swelling of the entire leg1 Calf swelling by more than 3cm compared with asymptomatic leg1 Pitting oedema confined to the symptomatic leg1 Collateral superficial veins1 Previously documented DVT1 Alternate diagnosis as likely or greater than that of DVT-2 Slide 45 Wells criteria SCORE >3 HIGH RISK SCORE 1-2 MODERATE RISK SCORE Management of severe hypovolaemia Lie patient flat and raise feet to restore BP IV access - Two large cannulae - brown venflons Give colloid/crytalloid (no evidence either is better) Insert CVP line/arterial line (more accurate assessment of BP) Catheterise and monitor urine output. Monitor Bp, lying and standing, JVP, chest Pulmonary OEDEMA Take blood for group and save, crossmatch. fluid should be run in as fast as possible; patient's response monitored. If the patient remains shocked, group specific or O Negative blood should be given as cross-matching may take up to 45 minutes. If the patient still fails to improve, internal bleeding should be sought. Following stabilisation, fluid infusion may be moderated according to urine production. Give blood to maintain Hb>8g/dl Slide 61 Hypovolaemia Haemorrhage aortic dissection, leaking AAA, splenic rupture Fluid loss - Diarrhoea, vomiting, polyuria,burns 3 rd space losses- acute pancreatitis, ascites Adrenal failure Slide 62 What is this x ray showing? what condition is this person likely to have? What are the complications of this condition? Slide 63 arachnodactyly MARFANS SYNDROME (AD) diff diagnosis homocystinuria -disorder of methionine metabolism OCULAR upward lens dislocation retinal detachment SKELETAL and MUSCLES arachnodactyly tall with disproportionately long legs and arms - the span of the arms is greater than the height pectus excavatum spinal abnormalities - spondylolisthesis, scoliosis SUFE generalised joint laxity with predisposition to flat feet or dislocation of patella or shoulder CARDIOVASCULAR dilatation of the aorta may aortic regurg, mitral regurg dissecting aneurysm of the aorta Mental development is normal. The average lifespan of an affected individual is 40 to 50 years. Slide 64 What is this and with what conditions is it associated? Slide 65 Dupuytrens contracture Liver disease Epilepsy/ treatment with phenobarbitone or phenytoin Peyronie's disease - penile fibrosis Family history trauma myxoedema diabetes mellitus hypercholesterolaemia AIDS Slide 66 What is this called? What conditions is it associated with?? Slide 67 Alopecia areata localised, round bald patches developing suddenly over one or two weeks, without any preceding symptoms. At the edge of the patch, there may be small, broken hairs with a tapering shaft - 'exclamation mark' hairs. autoimmune phenomenon Asssociations: thyroid disorders, vitiligo, diabetes. Slide 68 A diabetic patient developed this eruptionwhat is it? These are small rounded plaques with raised borders lying in a linear fashion over the shins. In late diabetic dermopathy these may present as pigmented scars. Slide 69 Diabetic dermopathy These are small rounded plaques with raised borders lying in a linear fashion over the shins. In late diabetic dermopathy these may present as pigmented scars. Slide 70 What is wrong with these chaps? Slide 71 Peyronies disease the penis becomes curved due to asymmetrical fibrosis in the fascia surrounding the corpora cavernosa. Curvature towards the affected side is increased during an erection making intercourse difficult and painful Assoc with dupuytrens contracture and premature atherosclerosis Slide 72 What is wrong with this chap? Slide 73 Winged scapula Long thoracic nerve injury The long thoracic nerve supplies the serratus anterior muscle. It may be injured as a result of pressure on the shoulder, either from a sudden blow or by prolonged carrying of heavy objects. It is often one of the nerves affected in brachial neuritis and may also be damaged in diabetes mellitus. Winging of the scapula results. Slide 74 Slide 75 Henoch schonlein Henoch-Schonlein purpura is a condition characterized by a widespread necrotizing vasculitis of arterioles and small capillaries. children aged 3 to 8 years are affected, boys more than girls, Abdo pain, arthritis (large joints) and glomerulonephritis 70% have haematuria and proteinuria, but the glomerulonephritis is often asymptomatic, conferring a good prognosis. The disease is usually self limiting. Bed rest and simple analgesics may be prescribed for arthropathy Slide 76 What is this? What aggravates this condition? How do you treat? Slide 77 psoriasis Made worse by stress, alcohol, b-blockers, infection Better in sunlight Tx emolients, dithranol, Vitamin D analogues, coal tar, keratolytics PUVA Methotrexate, cyclosporin Infliximab, Etanercept Slide 78 Slide 79 erythrodermic psoriasis Life threatening complication of psoriasis Plaques cover over 90% of the body surface. Problems with thermoregulation, septicaemia, dehydration and high output cardiac failure may occur. Slide 80 This middle aged man is very unwell and has lost weight He developed these slowly evolving itchy lesions What is the diagnosis? Slide 81 Mycosis fungoides Mycosis fungoides is a non-Hodgkin's lymphoma that arises from CD4+ T lymphocytes. It is a cutaneous lymphoma that characteristically affects middle aged males. It usually begins as an eczematous reaction and proceeds to form plaques, tumours and fungating ulcers. Erythroderma may occur which often is highly pruritic. Treatment - topical steroids, topical cytotoxic agents, PUVA or radiotherapy. Prognosis relates to extent and type of skin involvement - average survival in the early stage of this disease is at least 10-15 years (2) Slide 82 What has this young chap developed? Slide 83 Eczema herpeticum widespread HSV infection superimposed on pre-existing (often mild) atopic eczema. Widespread vesicles and erosions, fever, and malaise occur. treat with intravenous and topical acyclyovir broad spectrum antibiotics are added in to treat or prevent superinfection. It is necessary to scrupulously care for the skin and carefully monitor fluid and electrolyte balance. Prophylactic oral aciclovir is indicated for recurrent disease. Slide 84 Eczema herpeticum again Slide 85 What has this 72 year old man developed? What would you advise? Slide 86 Chronic venous insufficiency Wear thick socks Avoid bruising Raise legs up as often as possible Compression bandaging for ulcer Tx dermatitis, infection Slide 87 What is this? What are the main complications? Slide 88 Neurofibromatosis (2 types) von Recklinhausen's disease, peripheral or type I neurofibromatosis (AD) bilateral acoustic neurofibromatosis, central or type II neurofibromatosis Caf au lait spots commonly seen COMPLICATIONS: Nerve entrapment Peripheral nerve tumours neuropathy Slide 89 What is this? Slide 90 pemphigoid autoimmune blistering disorder characterized by large, tense, intradermal (subepidermal) blisters on an erythematous base. BLISTERS REMAIN INTACT. If in eyes- blindness Elderly affected, Women > men. it is more common than pemphigus treatments that aim to suppress the inflammatory process, e.g. corticosteroids, antibiotics (e.g. tetracyclines, sulphones) other immunosuppressive treatments aim to suppress the production of the pathogenic antibodies, e.g. high-dose corticosteroids e.g. prednisolone 30- 60 mg per day, azathioprine, methotrexate, cyclophosphamide and cyclosporin Slide 91 What is this? Slide 92 PEMPHIGUS blisters within the epidermis of both skin and mucous membranes. autoimmune basis? Peak onset is between 60 and 70 years of age. W>M In comparison, bullous pemphigoid is characterised by blister formation at the level of the basement membrane and not within the epidermis. Slide 93 Long standing asymptomatic lump. What is the likely diagnosis? Slide 94 Lipoma Treatment is for cosmesis and consists of local excision. Some individuals have multiple subcutaneous lipomata; a biopsy may be required to exclude neurofibromatosis in such patients. The patient with multiple, tender lipomata may have Dercum's disease. A rare complication of lipomata is a liposarcoma. Slide 95 What is shown at the arrow? Slide 96 Ascending lymphangitis spreading of infection from its focus along regional lymphatic vessels. Commonly, an abscess forms at the regional nodes. commonly due to Streptococcus pyogenes; less often, to Staphylococci. It presents as red blushes and streaks in the skin corresponding to the inflamed lymphatics. Treatment is bed rest with the affected limb elevated. Penicillin V and Flucloxacillin Permanent lymphatic obstruction may develop resulting in a persistent oedema. Repeated attacks cause chronic lymphangitis. Slide 97 What is this? It started life as a red macule. Slide 98 Erythema chronicum migrans Caused by Borrelia burgdorferi, Lyme disease is common in the northeast United States and in Wisconsin and Minnesota. It is carried by Ixodes spp. of ticks. The rash occurs in 2/3 of those infected, with a solitary lesion characteristic of Stage 1 disease, and multiple lesions characteristic of disseminated Stage 2 disease Slide 99 What is this associated with? Slide 100 Vitiligo is associated with Hypothyroidism Addisons disease diabetes mellitus pernicious anaemia Tx camouflage cream Slide 101 What does this 72 year old chap have? Slide 102 Basal cell carcinoma This is a locally invasive carcinoma of the basal layer of the epidermis. It almost never metastasizes but it may kill by local invasion. sunlight exposure the initial lesion is a small pearly-white nodule with visible (telangiectatic) blood vessels; early lesions may bleed and ulcerate and then heal again a red nodule forms which expands to leave a characteristic rolled edge with central ulceration ('rodent ulcer') Tx: surgery, local radiotherapy, cryotherapy, or curretage Slide 103 Think maybe he should have come to the doc sooner about this one Slide 104 What is this? Slide 105 Squamous cell carcinoma Squamous cell carcinoma (SCC) is a malignant tumour of the epidermis in which the cells, if differentiated, show keratin formation. basal cell carcinoma keratocanthoma malignant melanoma solar keratosis pyogenic granuloma infected seborrheic wart rapidly expanding painless, ulcerated nodule rolled indurated margin. Often the lesion may have a cauliflower-like appearance with areas of bleeding, ulceration or serous exudation. Metastatic potential surgery (+radio/chemo if advanced) Slide 106 What is this? What types exist and what features are characteristic in this lesion? Slide 107 Malignant melanoma superficial spreading (48%) nodular (23%) lentigo maligna (15%) acral lentiginous including periungual (6%) amelanotic melanoma Change in SHAPE, SIZE, COLOUR >5mm diameter, inflammation, bleeding, irritation Excision biopsy (1cm margin for every mm thickness) Slide 108 What is happening in this patients arm? They previosly had a simple ulcer there Slide 109 Marjolins ulcer (arm) cancer Slide 110 What is this condition? Slide 111 Peutz Jeghers Peutz-Jegher's syndrome (AD) multiple hamartogenous polyps of the gastrointestinal tract - most often in the small bowel but may occur affect any portion of the GI tract mucocutaneous pigmentation - mainly, of the lips, buccal mucosa, genitalia, hands and feet Patients often present with small bowel intussusception before the age of 10 years. The polyps themselves have a very low malignant potential. About 10-20% of patients develop gastrointestinal carcinoma but this is thought to arise from coexistent adenomas. Patients have an increased risk of developing carcinomas of the pancreas, lung, ovary and breast. Slide 112 What are these lesions? Slide 113 Lichen planus flat-topped shiny violaceous (pink/mauve/purple) typically they are seen on the inner aspects of the elbows, on the wrists, shins and sacral area and genitals Wickhams striae mouth lesion This is a condition of unknown aetiology characterized by intensely pruritic flat topped papules that are usually seen on the inner aspect of the elbows and wrists. The mucous membranes are often affected. Slide 114 What does this chap have? What complications is it associated with? Slide 115 Ehlers danlos Ehlers-Danlos syndrome (EDS) is a condition where abnormalities of collagen production result in bruising, wide scars, laxity of joints and hyperelasticity of the skin. Hernia MR/AR Aortic dissection pneumothoraces GI bleeds Slide 116 This 34 year old wool factory worker presented with thiswhat is it? Slide 117 Cutaneous anthrax Anthrax sheep wool Slide 118 What is this? Slide 119 tylosis Tylosis is a congenital hyperkeratosis with pitting of the palms - tylosis palmaris - and of the soles - tylosis plantaris. It is inherited as an autosomal dominant trait. In some cases, it is associated with oesophageal carcinoma. Treatment measures include the use of a keratolytic. Systemic treatment with retinoids may be used Slide 120 What is wrong with this chap? How would you diagnose it? Slide 121 Kaposis sarcoma Kaposi's sarcoma is a multicentric, malignant neoplastic vascular proliferation, characterised by the development of bluish-red nodules on the skin. Sometimes there may be widespread visceral involvement. It may metastasize to lymph nodes. occurs in immunocompromised patients (e.g. HIV positive patients, transplant patients) Diagnosis: skin biopsy Slide 122 What is this? Slide 123 keratoacanthoma Difficult to distinguish from SCC rapidly growing epidermal tumour that resembles squamous cell carcinoma both clinically and histologically. It is believed to arise from hair follicles. There is little evidence that keratocanthoma has malignant potential Trauma, viral infection, sun exposure, and chronic exposure to tar, pitch and petroleum have all been implicated as aetiologic agents. Surgical excision is thought to produce less scarring than leaving the lesion to resolve spontaneously. Slide 124 What are these? What are they associated with? Slide 125 Gottrons papules Gottron's papules are scaly, erythematous lesions affecting the dorsum of the hands, knuckles, and extensor surfaces of other small joints. They are characteristic of dermatomyositis. Slide 126 What does this patient have? With what is it associated? Slide 127 Heliotrope rash Polymyositis and dermatomyositis are systemic connective tissue diseases which are characterised by acute and chronic inflammation of striated muscle. In dermatomyositis there is an accompanying dermatitis. The limb girdle or proximal muscles are most severely affected but their bulk is preserved beyond that expected from their weakness: this is an important sign distinguishing this condition from a limb girdle dystrophy. The aetiology is unknown but there is an association with HLA-B8 and HLA-DR3. Dermatomyositis in males over the age of 60 years may be suggestive of an underlying systemic malignancy. Slide 128 This 33 year old woman presented with fever, tachycardia, chills, malaise and this hot tender lesion on her face. What is it? What is tx? Slide 129 erysipelas Erysipelas is a rapidly spreading Streptococcal infection of the skin and subcutaneous tissue characterized by cellulitis and lymphangitis. Streptococcus pyogenes fever, tachycardia, chills, malaise the infected area is red, hot, and tender e.g. red shiny plaque on face local oedema which produces a raised border that is clinically diagnostic the cellulitis spreads rapidly to involve uninfected skin careful examination may reveal an abrasion through which the streptococcus organism gained entry an incision within the infected area exudes a thin pus Tx: amoxicillin Slide 130 What is wrong with this chap? What could have caused it? Slide 131 Left CN III palsy TUMOUR, INFECTION, VASCULITIS, DEMYELINATION SAFE ANSWER FOR ALL NERVE LESIONS central lesions: tumours: due to direct invasion of the third nerve nucleus due to raised intracranial pressure vascular: caused by a brainstem lesion demyelination peripheral causes include: compressive lesions: tumour aneurysm, often the posterior communicating artery basal meningitis nasopharyngeal carcinoma orbital lesions e.g. Tolosa-Hunt syndrome infarction: often spares the pupillary reflex, when the condition is termed a "medical third nerve palsy" often caused by diabetes mellitus Slide 132 This xray and CT are showing the same sign what is it? Slide 133 Porcelain gallbladder Porcelain gallbladder is a calcification of the gallbladder believed to be brought on by excessive gallstones but more studies are necessary to determine the exact cause.calcification gallbladdergallstones Porcelain gallbladder often results in a diagnosis of gallbladder cancer. The association with the two is uncertain; gallbladder cancer is rare, but is almost always found with porcelain gallbladder. The prognosis is poor, in that the gallbladder is usually asymptomatic until the cancer has spread.gallbladder cancer Slide 134 A 53-year-old man presented with low-grade fever and abdominal pain. A tender, erythematous umbilical 3-cm mass is shown. Slide 135 Strangulated umbilical hernia In a strangulated hernia, the blood supply of the contents of the hernia, e.g. bowel or omentum, is cut off. It is commonest at the neck of the sac. The region becomes ischaemic and subsequently gangrenous. Gangrene can lead to perforation of the bowel with ensuing peritonitis. When a loop of gut is strangulated, there will also be intestinal obstruction. Slide 136 This 23 year old woman is complaining of rectal pain. She denies any other symptoms Slide 137 What is this xray showing? Patient presented with an acute abdomen with the sudden onset of severe upper abdominal pain, nausea and vomiting. Slide 138 Gallstone pancreatitis Slide 139 A 50-year-old man presented with a 2-day history of atraumatic right middle finger swelling, redness, and pain. There was tenderness and swelling of the proximal interphalangeal joint. ESR was elevated. The leukocyte count normal. Describe how you would investigate and manage this patient Slide 140 Septic arthritis URGENT ADMISSION!!! ASPIRATE!!!! blood cultures full blood count for leucocytosis erythrocyte sedimentation rate C-reactive protein aspiration of synovial fluid - usually purulent with a neutrophil count above 50,000 per mm3, and low glucose concentration anti-streptolysin O titre Tx flucloxacillin and amoxicillin empirically! Slide 141 A 65-year-old woman presented to the emergency department because a friend was concerned that the patient was having a stroke. The patient was asymptomatic other than complaints of a pestering nonproductive cough. What is wrong? Slide 142 Subconjuntival haemorrhage This presents as a bright red patch under the conjunctiva following rupture of a small conjunctival vessel. It may arise spontaneously, following slight trauma, or as a result of local congestion due to coughing or sneezing. In head injury, blood from a fracture at the base of the skull may travel through the floor of the orbit and into the subconjunctival space. The condition is usually unilateral. Recurrent or bilateral subconjunctival haemorrhage suggests hypertension or blood dyscrasias. Slide 143 A 28-year-old woman complained of a foreign-body sensation, pain and redness of the outer lower quadrant of her left eye of 2-day's duration. Slide 144 episcleritis unilateral in two-thirds of cases. It is benign and self-limited. 30% are associated with general medical conditions such as collagen disease, herpes zoster, gout and syphilis. There are two types - simple and nodular. Simple episcleritis is characterized by a very acute onset. It is mild, sectoral, recurrent and resolves rapidly. The nodular form presents as a localised, raised mobile area of inflammation near the limbus. The nodules may be single or multiple and usually recur. About 15% of patients develop a mild iritis. Episcleritis is distinguished from conjunctivitis by the localised response and the lack of palpebral conjunctival involvement. oral non-steroidal anti-inflammatory drug (NSAID). Slide 145 A 2- year-old girl presented with fever, erythema, and swelling of the left upper eyelid. There were no visual symptoms or proptosis. Slide 146 periorbital cellulitis The findings shown are suggestive of acute periorbital cellulitis, or more accurately, preseptal cellulitis, an infection confined to the soft tissues of the eyelid. Bacteriology of preseptal cellulitis includes those bacteria that cause sinusitis (Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis, S pyogenes); skin flora from trauma (Staphylococcus aureus and group A Streptococcus); and idiopathic (H influenzae type B, S pneumoniae). (L.S.) Slide 147 A 20-year-old man presented with a brief loss of consciousness following a fall from standing height. He had a brief lucid interval then became progressively less responsive. This is his CT scan Slide 148 Extradural haematoma The characteristic appearance of a CT of an extradural haemorrhage is of a biconvex, lozenge shaped area of increased density. Spread is limited by the adhesion of the dura to the skull. A midline shift with compression of the ipsilateral ventricle may be apparent. Slide 149 A 25-year-old man was brought to the emergency department after having been hit in the left lateral chest with a jet ski. He was short of breath and hypotensive. Slide 150 Tension pneumothorax Should not have obtained an Xray emergency situation Slide 151 A 37-year-old homeless man presented to the emergency department with a 3-week history of neck pain that had started after a motor vehicle accident Slide 152 Subluxation of c1 on c2 Cervical subluxation is a flexion injury. There is no bony damage but the soft tissues are extensively damaged and the posterior ligaments torn. The affected vertebra hinges forward on the one below, opening up the interspinous space posteriorly then falls back again. Radiologically there may be an increased gap between the spines of affected vertebra, but the film often appears normal - flexion radiology may be required to demonstrate the instability. Treatment is usually a collar for six weeks. However, if there is persistent instability a posterior spinal fusion may be required. Slide 153 What is wrong with this girlbe specific! Slide 154 Bells palsy It is a lower motor neurone palsy usually diagnosed by exclusion. Typically, presentation is with facial distortion, loss of taste, hyperacusis and a watery eye. Bell's palsy was previously considered as an idiopthic lower motor neurone nerve palsy but there has been increasing evidence to suggest that the main cause of Bell's palsy is latent herpes viruses (herpes simplex virus type 1 and herpes zoster virus), which are reactivated from cranial nerve ganglia Slide 155 Patient is asked to look left Slide 156 Right VI nerve palsy Tumour Trauma Demyelination Ischaemia (stroke) Raised intracranial pressure FALSE LOCALISING SIGN Slide 157 Slide 158 Left CN 9 palsy Uvula deviates away from the affected side Slide 159 Slide 160 Left CN 12 palsy Tongue deviates towards side of lesion Slide 161 What is wrong with this lil lady? Slide 162 Trochlear CN IV palsy Diplopia abnormal head posture - head tilted towards the normal side, face rotated towards the normal side, and the chin is depressed. The affected eye is higher than its fellow. positive head tilt test - affected eye moves higher when the head is tilted towards the affected side CNIV is thinnest and has the longest intracranial course damaged easily by stroke and trauma Slide 163 What is wrong with these miserable looking folk? Slide 164 Myasthenia gravis Myasthenia gravis is an acquired autoimmune disorder characterised by weakness, typically of the periocular, facial, bulbar, and girdle muscles. Associated with serum IgG antibodies to acetylcholine receptors in the postsynaptic membrane of the neuromuscular junction. Classically, the muscles are easily fatigued. It affects 5 people in every 100 000. Non-thymoma cases have a peak incidence at 10-30 years and again, at 60-70 years of age; those associated with thymoma have a peak incidence at 40-50 years of age. Slide 165 Diff diagnosis Lambert-Eaton syndrome - muscles are not fatiguable - contraction leads to increased strength - reflexes are diminished congenital myasthenia botulism motor neurone disease (MND) - note that eye is very rarely involved in MND Slide 166 Myasthenia gravis Exacerbated by: exercise, barbituates, steroids improvement in strength after administering a short-acting anticholinesterase drug, for example, edrophonium chloride. acetylcholine receptor antibodies Management oral anticholinesterase medication, e.g. pyridostigmine or neostigmine (symptomatic improvement). if there is life-threatening or respiratory weakness developing in treated patients, then this usually requires immediate control of the airway, treatment of any underlying infection, and a course of plasma exchange thymectomy - required if there is a thymoma because of the risk of local infiltration. Also occasionally undertaken in other non-thymoma patients with myasthenia immunosuppression with corticosteroids +/- cytotoxic agents is also highly effective in inducing remission of disease and may be necessary preliminary to surgery in patients with severe disease. plasma exchange Slide 167 Lambert eaton Lambert-Eaton myasthenia is a presynaptic myasthenic syndrome characterised by impaired release of acetycholine from nerve terminals. 60% of patients have small cell lung carcinoma. Electromyography shows increased evoked potentials after repeated galvanic stimulation (the opposite occurs in myasthenia gravis). Symptoms improve with exercise Slide 168 Slide 169 Right sided horners syndrome slight ptosis pupillary miosis: due to paralysis of the sympathetically innervated Muller's muscle which normally dilates the pupil anhydrosis over the forehead Pancoasts tumour, carotid body tumour infection, vasculitis, demyelinating disease MS Slide 170 What is wrong with this chap? Ignore the white thing I dont know what that is Slide 171 hydrocephalus Communicating hydrocephalus obstruction to CSF flow from outside the ventricular system, usually in the subarachnoid space. All the ventricles show a generalised dilatation on a CT scan. It is safe to perform a lumbar puncture Non-communicating hydrocephalus obstruction to CSF flow within the ventricular system. Fluid accumulates proximal to the site of the blockage causing dilation. Slide 172 Management of hydrocephalus The cause of hydrocephalus should be eliminated if possible - e.g. colloid cysts of the 3rd ventricle, intraventricular meningioma, other obstructive causes. Otherwise, relieve pressure by shunting, or if the patient is rapidly deteriorating, by draining the ventricle directly. Endoscopic third ventriculostomy has become a more recent, and important, treatment option for occlusive hydrocephalus associated with aqueductal stenosis or space-occupying lesions of or around the posterior third ventricle and upper brainstem (1,2): this procedure appears to be more successful in adults than in young children it is efficacious in both previously shunted and non shunted patient complication and mortality rates compare favorably with those for shunts has also been increasingly used as an alternative treatment option for shunt complications Lumbar puncture may be used to relieve pressure in an acute communicating hydrocephalus. Slide 173 NPH Normal pressure hydrocephalus is a form of communicating hydrocephalus in which the intracranial pressure, as measured by lumbar puncture, is normal or intermittently raised. Failure to reabsorb CSF is compensated by reduced production. gait apraxia progressive dementia with memory loss sphincter disturbance resulting in incontinence Slide 174 What has happened here? What are the risk factors for this? Slide 175 L Middle cerebral artery ischaemic stroke Hypodense (dark) area on CT No midline shift Modifiable Risk factors for stroke smoking diabetes mellitus diet: high salt intake high fat intake low potassium intake low vitamin intake excess alcohol intake morbid obesity low physical exercise low body temperature cholesterol Non-modifiable risk factors increasing age male gender Afro-Caribbean descent positive family history of stroke Slide 176 Slide 177 Haemorrhagic stroke Note the high-density haemorrhage within the low density of the oedematous, infarcted region in the right hemisphere. Haemorrhage is evident from its onset on CT scanning. Slide 178 What is this?? What factors predispose to this condition? How would you manage? Slide 179 Subdural haemorrhage The characteristic picture of a CT scan of a subdural haemorrhage is one of a biconcave, concentric shaped, area of increased density spreading around the surface of the cerebral hemisphere. The contralateral ventricle may dilate owing to obstruction at the foramen of Munro. After 10-20 days, the subdural haematoma becomes isodense with brain. Later it becomes relatively hypodense. Slide 180 Subdural haematoma Subdural haemorrhages result from rupture of cortical bridging veins. These connect the venous system of the brain to the large intradural venous sinuses and lie relatively unprotected in the subdural space. any factor that stretches the bridging veins: cerebral atrophy, e.g. elderly low CSF pressure after shunting, for example for long- standing hydrocephalus or a fistula alcoholism coagulation disorder or anticoagulation therapy patients in whom conscious level is depressed: evacuate haematoma through 2-3 burr holes, and irrigate cavity with saline nursing in the head down position is recommended to prevent recollection patients in whom conscious level is not depressed: consider conservative measures - steroid treatment over several weeks Slide 181 How do you diagnose and treat this condition? Slide 182 Multiple myeloma a malignant neoplasm of plasma cells that arises in the bone marrow. Presentation is with anaemia, bone pain, skeletal destruction, pathologic fractures, or Bence Jones proteinuria. M (monoclonal) band on serum electrophoresis Tx- cytotoxic chemo and supportive,measures Slide 183 What is wrong with these chaps? What features are common? Slide 184 Parkinsons disease tremor bradykinesia rigidity impaired postural reflexes shuffling gait expressionless, unblinking face Pill-rolling tremor slurred monotonous speech small handwriting increased salivation and dribbling Ali actually has parkonsonsim due to dopamine depletion within the basal ganglia (boxing knocked it all out) Slide 185 What is wrong with this chap? Slide 186 Myotonic dystrophy characterised by myotonia and muscular atrophy. Inheritance is AD. The incidence is 5 per 100 000 with onset between 15 and 40 years, although it may present as early as birth. The causal gene is on chromosome 19. The disease is slowly progressive and is characterised by cataract formation, hypogonadism, frontal balding and cardiac disorders. There is weakness, wasting and myotonia of involved muscles. Wasting of the stenocleidomastoids produces the classical swan-necked appearance Slide 187 Loss of lower limb refelxes and extensor plantar response noted in this 15 year old boy Slide 188 Friedreich's ataxia most common inherited ataxia. prevalence of 1 in 50000. inheritance is ar progressive gait and limb ataxia, loss of proprioception, pyramidal weakness and dysarthria. Extra-neurological involvement includes: hypertrophic cardiomyopathy in most patients diabetes mellitus in 10% pes cavus and kyphoscoliosis Onset is usually during adolescence. Slide 189 What is wrong with this 14 yr old boy ? He has foot drop and reduced reflexes Slide 190 Charcot marie tooth AD condition characterised by slowly progressive sensorimotor neuropathy. It is the most commonly inherited peripheral neuropathy in the UK. type I: a demyelinating sensorimotor neuropathy early onset, typically in the first decade presentation with walking difficulties and pes cavus associated deformities include eqinovarus foot and kyphoscoliosis wasting occurs: distally before proximally in the legs before the arms distal wasting may produce the classical inverted champagne bottle deformity there is generalised areflexia there may be cerebellar ataxia of the arms respiratory muscles may be weak nerve conduction is slowed to less than 38 m/sec peripheral nerves may be palpably thickened Slide 191 This girls leg is wasted, weak, with absent knee and ankle reflexes What is your differential diagnosis? Slide 192 polio Poliomyelitis is a notifiable infectious viral illness affecting the central nervous system. Poliomyelitis is an acute illness that follows invasion through the gastrointestinal tract by one of the three serotypes of polio virus (serotypes 1, 2 and 3) LMN lesion Sensation is unaffected by this condition. When a badly- paralysed limb is picked up it has a floppy feel which, in the presence of normal sensation, is characteristic of the residual paralysis from poliomyelitis. Slide 193 differential Polio Trauma Botulism paraneoplastic Slide 194 What is this? What conditions is it associated with? Slide 195 Berry aneurysm adult polycystic kidney disease Ehlers-Danlos syndrome coarctation of the aorta mostly remain asymptomatic throughout life vary in size, most symptomatic aneurysms are >1 cm often occur at vessel bifurcations cause 80% of subarachnoid haemorrhages If >1cm clip them prophylactically If risk of bleed) Slide 196 Slide 197 Optic atrophy Full moon Featureless disc retinal lesions: central retinal artery or vein occlusion retinitis pigmentosa tobacco / nutritional - end result of tobacco amblyopia optic nerve: chronic glaucoma - most common of all causes ischaemic optic neuropathy secondary to papilloedema or papillitis secondary to optic neuritis or retrobulbar neuritis trauma - severing, avulsion, contusion, surgery familial - Leber's disease, Friedreich's ataxia pressure on optic nerve: tumour - glioma, meningioma Paget's disease aneurysm of the anterior circle of Willis chiasmal compression: pituitary tumour, craniopharyngioma, suprasellar meningioma, aneurysm, stroke Slide 198 Slide 199 Acute glaucoma cupping Tx of acute closed angle glaucoma reduction of intra-ocular pressure by reducing aqueous secretion acetazolamide pupillary constriction - topical pilocarpine or thymoxamine, an alpha receptor antagonist surgical or laser iridectomy - once the attack has been controlled - rarely surgery may be undertaken as an emergency procedure if medical management fails Slide 200 Slide 201 papilloedema intracranial space-occupying lesions tumours, cerebral abscesses; subdural haematoma hydrocephalus e.g. subarachnoid haemorrhage, meningitis, head injury venous sinus thrombosis benign intracranial hypertension malignant hypertension central retinal venous occlusion, ischaemic optic neuropathy, optic neuritis chronic carbon dioxide retention Slide 202 Slide 203 Pan retinal photocoagulation Treatment of diabetic nephropathy Slide 204 Slide 205 maculopathy Reduced vision Slide 206 What would this patient complain of? Slide 207 Retinitis pigmentosa Night blindness peripheral visual loss pigmentary retinopathy Seen in Laurence-Moon-Biedl syndrome Slide 208 Slide 209 Tuberous sclerosis congenital disease characterised by hamartomatous lesions in the skin, nervous system and internal organs, principally heart and kidney. Triad of adenoma sebaceum: actually an angiofibroma with passive involvement of sebaceous glands epilepsy mental retardation Slide 210 What is this? With what is it associated? Slide 211 Same again Slide 212 Osler weber rendu Hereditary haemorrhagic telangiectasia is a rare AD condition where multiple small telangiectases occur on the skin and mucous membranes, most commonly on the lips and the tongue. Lesions are also often scattered over the pulps of fingers. Epistaxis is the most common complaint. When telangiectases are present in the gastrointestinal tract they may cause chronic blood loss with iron deficiency anaemia. Occasionally there may be torrential bleeding. Arteriovenous malformations may occur in the: liver lungs, causing: clubbing murmurs paradoxical emboli Slide 213 Slide 214 Scurvy Gingival haemorrhage Vitamin C deficiency anaemia, spongy gums, a tendency to mucocutaneous haemorrhages, and brawny induration of calf and leg muscles, poor wound healing Tx Vitamin C - 100-200 mg/day orally. Slide 215 What is this? What causes it? Slide 216 Gingival hyperplasia acute leukaemia typically AML Drugs: phenytoin nifedipine cyclosporin scurvy pregnancy gingivitis Slide 217 What is wrong with this patient and what is your immediate management 55yr old man was started on ACE-I for his hypertension 2 weeks ago. His blood pressure is now higher than 2 weeks ago and his creatinine is raised Slide 218 Renal artery stenosis STOP ACE-I ! This condition may result in secondary hypertension and secondary hyperaldosteronism. Other possible features include: coexistant cerebrovascular, cardiovascular or peripheral vascular disease deterioration of renal function following treatment with ACE inhibitor abdominal bruit; signs of coexistant vascular disease e.g. carotid or femoral bruit; absent peripheral pulses Tx - balloon dilatation Slide 219 This patient presented with tiredness and weight loss. ON examination his tongue has this appearance and he has proteinuria, oedema and hepatosplenomegaly Slide 220 Macroglossia in amyloidosis In amyloidosis, there is extracellular deposition of fibrillar protein. This may be in a localized deposition or widely distributed throughout the body. Amyloid fibrils stain with Congo red and show apple green birefringence in polarized light. Cytotoxic and immunosuppressive drugs have been used to treat amyloidosis, but often with poor results. Improvement may be attained by treatment of an underlying cause. Slide 221 What is wrong with this patient? Slide 222 HEPATOMEGALY MASSIVE Secondary metastasis HCC alcoholic liver disease with fatty infiltration (more likely to have shriveled liver) myeloproliferative disease malaria MODERATE right heart failure haemochromatosis haematological disease: chronic myeloid leukaemia lymphoma fatty liver - secondary to diabetes, toxins MILD hepatitis biliary obstruction Slide 223 Slide 224 Hepatosplenomegaly infection: acute viral hepatitis infectious mononucleosis cytomegalovirus haematological disease: leukaemia myeloproliferative disease lymphoma pernicious anaemia sickle cell anaemia thalassaemia chronic liver disease and portal hypertension: chronic active hepatitis amyloidosis acromegaly systemic lupus erythematosus Slide 225 What is this condition and how would you treat? Ca and PO4 are normal Alk Phos is raised Slide 226 Pagets It is characterised by excessive and disorganised bone resorption and formation. Analgesia Bisphosphonates Surgery for fractures/ joint replacement Slide 227 What is the likely cause of this boys enlarged abdomen who presented with fever, chills and sweating? Slide 228 Splenomegaly MASSIVE SPLENOMEGALY : chronic myeloid leukaemia myelofibrosis primary lymphoma of the spleen malaria kala-azar (visceral form of leishmaniasis ) MODERATE SPLENOMEGALY portal hypertension: splenic/portal vein thrombosis hepatic cirrhosis Budd-Chiari syndrome lymphocytic leukaemias thalassaemias Slide 229 What emergency surgery was performed here? Slide 230 Liver transplant Possible indications in an adult include: fulminant or subacute liver failure: paracetamol poisoning viral hepatitis end-stage liver cirrhosis: alcoholic liver disease chronic active hepatitis primary biliary cirrhosis Slide 231 Slide 232 caput Medusae It is a sign of severe portal hypertension with portal-systemic shunting through the umbilical veins Slide 233 What is this and how many are we allowed? Slide 234 Spider naevi None are normal for a man Less than 5 in women They are found in the distribution of the superior vena cava i.e. on the arms, neck, and chest wall. cirrhosis - most frequently, alcoholic oestrogen excess - usually in association with chronic liver disease; part of normal hepatic function is the inactivation of oestrogens hyperthyroidism rheumatoid arthritis - rarely Slide 235 87 year old man presented with abdominal pain and a 4 wk history of constipation What features would you expect on examination? How would you treat this man? Slide 236 Sigmoid volvulus - 'bent inner-tube' - inverted U - sign marked abdominal distension sudden onset of colicky pain absolute constipation and no passage flatus for at least 24 hours abdomen is distended and tympanic left ilac fossa tenderness rectal examination reveals a capacious, empty rectum Tx immediate management: sigmoidoscopy and air insufflation there is a gush of liquid faeces and flatus as the obstruction is relieved High fibre diet and review medication Slide 237 Slide 238 Caecal volvulus A caecal volvulus occurs when there is twisting of the bowel at the caecum and resultant intestinal obstruction. Distention of the caecum ensues to the extent that the volvulus can be felt as a palpable mass. The patient may have vomiting, abdominal pain and constipation. The classical radiological appearance is the 'comma' sign - there is a gas-filled ileum and caecum. Treatment is by decompression and resection, or fixing of the caecum to the posterior abdominal wall. Slide 239 What does this xray show? With what conditions is it associated? Slide 240 Ulcerative colitis primary sclerosing cholangitis Cholangiocarcinoma sacro-iliitis and ankylosing spondylitis pyoderma gangrenosum, erythema nodosum anterior uveitis episcleritis Increased risk colon cancer Toxic megacolon Slide 241 What does this colonoscopy show? Slide 242 crohns Slide 243 What is this close up of a barium enema showing? What disease has caused this? Slide 244 String Sign Crohns disease Small-bowel follow- through study demonstrates the string sign in the terminal ileum. pseudodiverticula of the antimesenteric wall of the terminal ileum, secondary to greater distensibility of this less-involved segment of the wall Slide 245 What is this? How would you treat? Slide 246 Small bowel obstruction with fluid levels Drip and suck Slide 247 Slide 248 pneumoperitoneum Slide 249 What does this xray show? A 23yr old man presented to A and E with fever, abdominal distension and tenderness On examination he was tachycardic and had postural hypotension Slide 250 Toxic megacolon life-threatening complication of inflammatory or infectious colitis. segmental, non-obstructive dilatation of the colon to greater than 6 cm diameter systemic toxicity Xray dilatation of the lumen from 6-15 cm the most common sites of dilatation are the right and transverse colons there is thickening of the colonic wall with disruption of the normal haustral pattern there may be multiple air-fluid levels Slide 251 Slide 252 Diverticular disease Management high fibre diet, antispasmodics, laxatives Complications: peritonitis, fistula formation, persistent haemorrhage, pericolic abscess formation, intestinal obstruction, and repeated episodes of diverticulitis that are resistant to medical therapy. Slide 253 What sign is shown? What is the most likely cause? Slide 254 Apple core sign Stricture most likely due to colon cancer Slide 255 What is wrong with this patient? Slide 256 Dextrocardia/Situs Inverus Kartagener's syndrome bronchiectasis (also seen in Xray) sinusitis dextrocardia It is associated with a defect in cilia function and now is termed as synonymous with primary ciliary dyskinesia. The situs inversus is thought to be a developmental consequence of failure of ciliary action in the formation of the gastrointestinal tract and other stuctures. Slide 257 What is the diagnosis? This patient presented with gradual onset, intermittent dysphagia. He also has had recurrent chest infections Slide 258 Achalasia MANAGEMENT intrasphincteric injection of botulinum toxin endoscopic hydrostatic or pneumatic dilatation Heller's operation - cardiomyotomy - success rate of about 90% in those who do not respond to dilatation neuromuscular failure of relaxation at the lower end of the oesophagus with progressive dilatation, tortuosity, incoordination of peristalsis and often hypertrophy of the oesophagus above. Slide 259 What is this upper GI endoscopy showing? What appearance would it have on barium swallow? Slide 260 Oesophageal candidiasis Furry oesophagus on swallow Slide 261 This patient presented with retrosternal chest pain What is the diagnosis? Slide 262 Corkscrew Oesophagus Altered motility of the oesophagus (sometimes loosely referred to as "spasm") can be a cause of chest pain. The rare condition of diffuse oesophageal spasm (seen radiologically as a "corkscrew oesophagus") is associated with pain, Slide 263 What is wrong with this 55 yr old publican who has long standing recurrent abdominal pain and weight loss Slide 264 Chronic pancreatitis Plain film with extensive calcification in duct system of a patient with chronic pancreatitis secondary to alcohol Plain film with extensive calcification in duct system of a patient with chronic pancreatitis secondary to alcohol Slide 265 Slide 266 Apparently this is a leather bottle stomach This is it out of the Body Caused by gastric cancer Slide 267 Slide 268 Oesophageal varices Slide 269 Slide 270 Peutz jeghers multiple hamartogenous polyps of the gastrointestinal tract - most often in the small bowel but may occur affect any portion of the GI tract mucocutaneous pigmentation - mainly, of the lips, buccal mucosa, genitalia, hands and feet Slide 271 Slide 272 Oral hairy leukoplakia This is a lesion on the tongue that may be seen in immunocompromised patients.It appears to be the result of a proliferation of Epstein-Barr virus, possibly associated with Papilloma virus in the superficial layers of the squamous epithelium of the tongue. Slide 273 What is this upper GI endoscopy of dueodenum showing? How else would you investigate this? Slide 274 Coeliac disease Endoscopic still of duodenum of patient with coeliac disease showing scalloping of foldsEndoscopicduodenum ENDOMYSIAL ANTIBODIES ENDOSCOPY AND JEJUNAL BIOPSY Bloods anaemia, iron, folate, PT prolonged DEXA- looking for damage due to low Ca Tx gluten free diet, vit + calcium + iron supplements, pneumococcus vaccine Slide 275 Slide 276 Biopsy of small bowel showing coeliac disease manifested by blunting of villi, crypt hyperplasia, and lymphocyte infiltration of crypts,small bowelcoeliac diseasevillilymphocyte Slide 277 This man has a 2 month history of weight loss. He is itchy, has no pain and has a palpable gall bladder Slide 278 Head of pancreas Ca Presents with painless obstructive jaundice, weight loss and anorexia Gallbladder is palpable (Courvoisiers Law) painless jaundice + palpable gallbladder is not gallstones!!!! US/CT for diagnosis (CT for staging) Tx Whipples (pancreatoduodenectomy) Chemo Most present with metastatic disease with crap prognosis (6months mean survival) Slide 279 Slide 280 Sclerosing cholangitis Beads on a string Associated with UC Slide 281 Slide 282 Acute otitis media common causes are URTI (viral or bacterial) clinical features ear pain ear rubbing cloudy white/yellow eardrum (pus in middle ear) bulging eardrum distinctly immobile eardrum distinctly red eardrum 80% recover in around three days without antibiotics complications are rare Tx paracetamol and Inbuprofen (watchful waiting) Slide 283 Slide 284 Glue ear Secretory otitis media, or `glue ear', is the most frequent cause of hearing problems in children. accumulation of serous or viscous fluid within the middle ear pain conductive hearing loss dull / dark blue/ grey appearance of tympanic membrane Rinne's test negative; Weber's test - sound heard loudest in the deafer ear. Slide 285 Slide 286 Grommets The function of a grommet is to ventilate the middle ear, rather than drain it. Grommets thus replace the function of the blocked eustachian tube in glue ear and improve hearing. use of grommets in glue ear (otitis media with effusion) offer only small benefits potentially adverse effects on the tympanic membrane are common after grommet insertion ears treated with grommets had an additional risk for tympanosclerosis one to five years later Slide 287 This 5 year old boy presented with fever, malaise, sore throat and otalgia What is the differential diagnosis? How would you manage this condition? Slide 288 Acute tonsilitis Differential rest soluble paracetamol held in the mouth and then swallowed eases the discomfort (1) the patient must be encouraged to drink to prevent dehydration antibiotics are unnecessary for most patients with sore throat as it is a self-limiting condition, which resolves by one week in 85% of people, whether it is due to streptococcal infection or not Slide 289 The Centor criteria tonsillar exudate tender anterior cervical lymph nodes absence of cough history of fever Then treat with antibiotics as it could be Group A beta-haemolytic streptococcus infection (erythromycin as amoxicillin will cause rash in infectious mononucleosis) Slide 290 Slide 291 Slide 292 Torsion of testis Slide 293 The patient is a five year old boy who presented with a febrile urinary tract infection (UTI). His CT and US are shown. What is diagnosis? Slide 294 Acute pyelonephritis On CT, an edematous left kidney is seen with multiple large areas of decreased enhancement in the periphery Ultrasound images reveal an enlarged left kidney with heterogeneous echo texture as well as several discrete areas of hyopechogenicity Slide 295 Slide 296 Staghorn calculi Slide 297 Slide 298 nephrocalcinosis Slide 299 Slide 300 Right hydronephrosis Slide 301 Slide 302 Chronic pancreatitis Slide 303 Slide 304 gallstones Note that no contrast was necessary to acquire this image; sequence depicts fluid which is either stagnant or flowing slowly. Slide 305 Slide 306 What sign is being shown? What other features are likely to be present? would you treat this problem? Slide 307 Trousseaus sign Paraesthesia, tetany, psychosis, convulsions, long QT interval Chvosteks sign (tapping on facial nerve causes twitch mild tetany - oral calcium supplements severe tetany - intravenous calcium gluconate, 10 ml (2.32 mmol) calcium gluconate 10% IV over 10 minutes. vitamin D - either if primary disease is due to vitamin D or, to ensure adequate absorption of calcium. calciferol for simple vitamin D deficiency alfacalcidol or calcitriol if in renal failure - offer no advantage over calciferol for simple deficiency Slide 308 This 38 yr old woman with asthma has presented with a purpuric rash and haematuria, proteinuria and raised BP What is the diagnosis ? Slide 309 Churg Strauss The six classification criteria asthma peripheral blood eosinophilia neuropathy pulmonary infiltrates paranasal sinus involvement biopsy showing vasculitis with extravascular eosinophils Laboratory diagnosis is based on tissue biopsy and the antineutrophil cytoplasmic antibody (ANCA) test. About 25% of patients have cANCA and about 50% have pANCA This syndrome is also characterised by elevated levels of IgE. Glomerulonephritis is a result of the vascultits Tx high dose corticoteroids Slide 310 This 50 year old man who enjoys a drink and smokes 10 cigs per day presents with epigastric pain and weight loss. What is being shown here and how would you investigate? Slide 311 Virchows node Gastric cancer endoscopy and biopsy: investigation of choice barium meal; suspicious findings: space occupying mass rigidity of adjacent gastric wall greater curve ulcer an ulcer with irregular borders and disruption of normal mucosal folds contracted, non-distensible stomach - linitis plastica fundic tumours are difficult to evaluate because of poor filling chest x-ray, liver enzymes, and liver ultrasound for evidence of metastases anaemia in as much as 50% of all cases faecal occult blood test positive in the vast majority of subjects Slide 312 This 70 year old man presented with a few weeks history of difficulty swallowing and weight loss What other investigations would you perform? What is his prognosis? What would you do for him in terms of swallowing difficulty? Slide 313 Oesophageal carcinoma Adenocarcinoma (lower 1/3) Apple core sign CT staging should be performed 5 year survival 10% (asymptomatic until late stage) Oesophageal stenting (palliative) Slide 314 Risk factors for Oe cancer AGE Diet (far eastern diet) Smoking Acid reflux Barrets oesophagus (30-40X) Achalasia Tylosis Plummer-vinson (fe deficiency oesophageal web) also called paterson-kelly-brown Slide 315 What is this upper GI endoscopy showing? What symptoms will this 70 yr old man be experiencing? Slide 316 Oesophageal Ca Dysphagia Vomiting/ food regurg Chest pain Odynophagia Wt loss/ anorexia Haematemesis Hoarse voice/ coughing/ aspiration of saliva into lung Slide 317 What is being shown here? Slide 318 Hiatus hernia with pneumoperitoneum SLIDING Sphincter at bottom of oesophagus and top of stomach slides through hiatus in diaphragm. May slide up and down ROLLING Part of stomach protrudes up through a hole in the diaphragm next to the oesohagus can become strangulate. Less common Slide 319 This 34 yr old male patient presented with malaise, weight loss, apthous ulcers and this intensely itchy skin rash Slide 320 Dermatitis herpetiformis Dermatitis herpetiformis is an intensely itching subepidermal vesicular blistering condition that usually develops in the 3rd or 4th decade. Men>women. intensely pruritic, vesicular rash chiefly affecting the extensor surfaces of shoulders, buttocks, knees, forehead and scalp, sparing the mucosae. Small blisters are rarely seen since they are rapidly excoriated, leaving raw papules. Vesicles are frequently grouped, as those of the true herpes virus, hence the name 'herpetiformis. About 90% of patients with dermatitis herpetiformis will have coeliac disease Tx - dapsone, in doses of 25-100 mg/day for itching Gluten free diet Topical steroids Slide 321 How would you exanine this patient? Slide 322 Determining if indirect or direct inguinal hernia Only true way to know is at surgery Reduce hernia Place finger over internal ring with 2 fingers When standing if no protrusion hernia is likely indirect. If protrusion present is direct. Slide 323 How would you examine this patient? Slide 324 DO NOT EXAMINE ANAL FISSURES ARE EXTREMELY PAINFUL!!! There is a prominent skin tag present also in this photo Slide 325 What is the diangosis? How would you treat? Slide 326 Prolapsed internal haemorrhoids CONSERVATIVE TX ensuring the perineum is dried and washed after defaecation: digital replacement of prolapsed haemorrhoids: local anaesthetic creams and ointments treatment aimed at reducing spasm of the internal anal sphincter: nitroglycerine ointments: glyceryl trinitrate 0.2-0.3% (unlicensed) botulinum toxin injection SURGICAL TX sclerotherapy rubber band ligation photocoagulation cryotherapy HAEMORRHOIDECTOMY LORDS STRETCH!!!! ANAL DILATATION UNDER GA Slide 327 HOW WOULD YOU TREAT THIS? Slide 328 HYDROCOELE Tx childhood hydrocoeles only if they persist after 1 yrs old. The procedure is as for an inguinal hernia - open the sac, inspect the testis for abnormalities, ligate and divide the patent processus vaginalis. In adults, primary hydrocoeles may be treated: conservatively - reassure the patient and provide a scrotal support. by aspiration - use a sterile needle and syringe. Clear, pale yellow fluid should be drained; fluid that is bloodstained suggests trauma or other underlying pathology. Following aspiration, the testis should be palpable. A sclerosant such as phenol may then be injected to stop fluid from reaccumulating, otherwise, periodic aspiration may be necessary. A hydrocoele should not be tapped if there is any suspicion of tumour - in the case of a tumour, aspiration may result in spread of malignant cells. by operation - if the diagnosis is in doubt, the hydrocoele is large, or fluid repeatedly reaccumulates after drainage. Once the fluid has been removed, the testis is examined for abnormalities. Slide 329 Slide 330 Neuropathic ulcer (diabetes pt) Slide 331 What is this? How would the patient who has had this removed have been investigated initially? Slide 332 Ruptured appendix Acute appendicitis is usually a clinical diagnosis full blood count - leukocytosis is generally present urea and electrolytes - assessment of dehydration pregnancy test serum amylase - if pancreatitis suspected abdominal radiology - helpful to distinguish: volvulus intussusception renal stones (90%) gallstones (10%) localised ileus Generally, urine analysis is unhelpful in differentiating appendicitis from a urinary tract infection. There is no place for barium enema in the diagnosis of appendicitis. Occasionally, ultrasound and CT scanning are used to investigate suspected appendicitis where the story is atypical. US exclude gynae pathology (ovarian cyst) Slide 333 Diff diagnosis of acute appendicitis Ectopic pregnancy Salpingitis Period pains Cystitis Cholecystitis Diverticulitis Perforated ulcer Meckels diverticulum Crohns disease Slide 334 What is this a sign of? Slide 335 Duodenal atresia investigated by: electrolyte and acid-base status measures, e.g. U&E's, blood gases, with subsequent correction of abnormalities plain abdominal X-ray: this may show a 'double bubble' sign of duodenal obstruction barium study may show stenosis Treatment involves surgical correction via a duodenojejunostomy with resection of the atretic section. Slide 336 A 34 year old vagrant is treated following a second variceal bleed what is shown here? Slide 337 TIPS TRANSJUGULAR INTRAHEPATIC PORTO-SYSTEMIC SHUNT the treatment of acute oesophageal variceal bleeds which fail to respond to drugs or sclerotherapy the prevention of variceal bleeds angioplasty balloons and metallic stents are used to enlarge and maintain the porto-systemic shunt Slide 338 What is wrong with this chap? How would you investigate? What are common causes? Slide 339 ASCITES NOTE DRAIN SITES!!! Shifting dullness ultrasound diagnostic paracentesis in which 30 to 50 ml of fluid is withdrawn. This will enable identification of: protein content: albumin and total protein malignant cells bacteria white blood cells Glucose TB culture amylase Slide 340 CAUSES OF ASCITES TRANSUDATE Protein3g/100ml Malignancy Pyogenic Infection Tb Pancreatitis Lymphoma Myxoedmea Slide 341 MANAGEMENT OF ASCITES TENSE ASCITES therapeutic paracentesis of 4-6 litres plasma volume expansion with albumin (6g/litre of ascitic fluid removed) NON-TENSE ASCITES bed-rest, reduced salt intake, and spironolactone (50-100 mg per day). A fall in weight of approximately 0.5 kg per day should be aimed for. spironolactone is gradually increased to 300 mg per day and then, if necessary, frusemide is added, but only once the spironolactone has reached its maximum dose. loop diuretics may precipitate the hepatorenal syndrome If a patient has malignant ascites then large doses of frusemide may be required to control ascites. A Le Veen shunt (peritoneo-venous) may be useful in refractory cases. Slide 342 What is wrong with this baby? How would you treat? Slide 343 kwashiokor Classically hair colour change, hepatomegaly, pitting oedema, bleating cry when picked up Tx electrolyte imbalance, hypoglycaemia, vitamin deficiency. May need warming if hypothermic. 80-100kcal/kg/day care not to overload pt Slide 344 What is wrong with this baby? Slide 345 Marasmus Marasmus is failure to grow associated with emaciation and fair appetite. It may be defined in terms of weight, for example less than 60% of that expected for age. Marasmus generally occurs in infants up to one year. In the developed world it is found in infants who are born undernourished or are recovering from a severe chronic illness, especially those affecting the bowel. In developing countries this condition commonly is associated with failure of lactation due to poor nutrition of the mother. Note that marasmus is an adaptive response to poor nutrition. Slide 346 A 77 year old man presents with his 4 th episode of rectal bleeding. The blood is a mixture of fresh blood and clots. The bleeding was severe enough to require a 4 unit blood transfusion. Barium enema was normal. Colonscopy showed this lesion Slide 347 Angiodysplasia Colonic angiodysplasia is a common cause of acute or chronic rectal bleeding and iron deficiency anaemia. Angiodysplasias are tiny - 1-5 mm in diameter - hamartomatous capillary lesions in the colonic wall which produce bleeding out of proportion to their size. They are believed to be acquired, possibly as a result of tension on the veins where they pass through the muscularis. colonscopy: may visualise lesion Treatment: electrical coagulation via the colonoscope resection of segment of colon if the above is unsuccessful Slide 348 This baby presented with severe diarrhoea, alopecia, FTT and a rash over the mucocutaneous junction. This started soon after he stopped breastfeeding. Slide 349 acrodermatitis enteropathica autosomal recessive disorder characterized by periorificial and acral dermatitis, alopecia, and diarrhoea Sharply demarcated, brightly erythematous periorificial plaque Caused by Zinc deficiency Tx zinc Slide 350 This boy presented with this rash, diarrhoea and confusion What is wrong? Slide 351 Pellagra caused by deficiency of niacin classically characterised by four D's: photosensitive dermatitis diarrhoea dementia Death monotonous maize diet (maize is low in tryptophan) a very low protein diet conditions producing considerable loss of protein e.g. nephrotic syndrome Slide 352 What is wrong with this man with wrist drop and marked wasting of the lower extremities? Slide 353 Beriberi severe prolonged deficiency of vitamin B1 (thiamine) Beriberi was discovered in the seventeenth century in Java by the Dutch physician Jacobius Bonitus. The name means "sheep" in the local language; this describes the characteristic gait of patients. Today, beriberi is confined to the poorest parts of Asia where little else is eaten except polished rice. Prevention of beriberi requires: a more varied diet, including legumes and pulses thiamine supplementation of rice Slide 354 Slide 355 Scoliosis Image in a 27-year-old tennis player with a history of cystic fibrosis and only minimal symptoms exhibits bronchial wall thickening, bilateral small nodular opacities, and scoliosis. Slide 356 Slide 357 bronchiectasis Slide 358 Slide 359 Barrel chest Emphysema Sorry I think that man might actually be dead Slide 360 What is this? What is it showing? Slide 361 Flow volume loop Showing severe airflow limitation This is a normal one Slide 362 Slide 363 Hyperinflated lung COPD Slide 364 Report this xray of a 47-year-old smoker who presented after just a few hours of rigors and productive cough. What other investigations would you carry out and how would you manage? Slide 365 consolidation in the right upper lobe Consistant with a pneumonia Investigate: FBC (WCC raised, particularly neutrophils) U+Es Sputum and blood culture Pulse oximetry and ABG Serology for atypicals RBS diabetes is risk factor for infection Slide 366 Assessing severity CURB-65 Confusion Urea>7mmol/l Resp rate>30 BP systolic