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Itmainlyaffectsthosebetween324
months,althoughitcanoccurinolderchildrenwithriskfactorssuchasHenochSchnleinpurpura
(HSP),tumoursetc.
Symptomsincludeabdominalpainwhichissuddenandcolickyinnature.Vomitingisalsoapresenting
complaintaswellascirculatorycollapseandshock.Thepassageofbloodperrectumisalateand
seriousfeature.
Physicalexaminationmayrevealasausageshapedmassintherightupperquadrant.Clinicalsuspicion
isusuallyconfirmedbyultrasonography.
Reductionisusuallyachievedbyhydrostaticenema,andifunsuccessfulsurgicalinterventionmustbe
performed.
Morphinedoesnotcausesdirectmyocardialdepression,althoughitmaycauseabradycardia.
Thehypotensionassociatedwithitsuseisduetothedecreaseinthesystemicvascularresistance
(SVR)whichisdue,inpart,tohistaminerelease.Thehistaminereleasemayalsocausebronchospasm.
Theproductionofantidiuretichormone(ADH)isalsoincreasedbymorphine.
Diamorphinehasalmostnoaffinityfortheopioidreceptor,andisaprodrugofmorphine.
Phenylpiperidinesincludepethidineandfentanyl,whereasmorphineisaphenanthrene.
KnowledgeoftheECGwithregardtothecoronaryanatomyprovidesabetterunderstandingofthe
severityofischaemiaaswellasaguidetoappropriatetreatment.
STelevationinleadsII,IIIandaVFsuggestsinferiormyocardialinfarction(MI)andisusuallydueto
occlusionoftherightcoronaryartery.
V14elevationindicatesananteriorMIandisusuallyaconsequenceofleftanteriordecendingartery
occlusion.
Aposteriorinfarct(STelevationinV 68withreciprocalchangesanteriorlySTdepressioninV 13)is
duetoocclusionofthecircumflexartery.
Infectivecausesplusinflammatoryboweldiseaseshouldbeconsideredinthedifferentialdiagnosisof
ayoungmanwithbloodydiarrhoea.Shigellosisisapossiblecause.MostcasesofShigellainfection
are related to foreign travel. Unrelated to foreign travel, there has been an increase in sexually
transmittedShigellainfectioninmenwhohavesexwithmen.
Amoebic trophozoites (the active form) may be seen in fresh stool in acute dysentery. However,
amoebiccystsseenonmicroscopyforE.Histolyticahaveasensitivityof<60%andaspecificityof10
50%inthediagnosisofpossibleamoebicdysentery.Therearemanynonpathologicalamoebae(e.g.
E.dispar)andmanyasymptomaticpatientshave Entamoebahistolytica intheirstool.Stoolantigen
(ELISA)forEntamoebahistolyticahassensitivityandspecificityof>95%.
Waterydiarrhoeawouldbeexpectedwithcholeraandgiardiasis.
Alteplase(tissuetypeplasminogenactivator)isathrombolyticandactsbyactivatingplasminogento
formplasmin,whichdegradesfibrinandsobreaksupthrombi.Itisusedinthetreatmentofmyocardial
infarctionandlifethreateningvenousthrombosis.
Aprotininisanenzymeinhibitoractingonplasminandkallikreinandisclassedasanantifibrinolytic,
thusinhibitingfibrinolysis.Itisindicatedinpatientsathighriskofbloodloss.
WarfarinisanoralanticoagulantanditinhibitsthesynthesisofvitaminKdependantfactorsII,VII,IX
andX.Hepaticenzymeinducingagents,forexample,carbamazepineandphenobarbitonereduceits
effect.Enzymeinhibitors,suchasvalproate,enhancetheeffectofwarfarin.Iftheenzymeinducing
drugiswithdrawnwithoutreducingthedoseofwarfarin,haemorrhagemayoccur.
Factor VIIa(recombinant) isapurified coagulation factor usedtotreat patientswithinhibitors to
factors VIII and IX. It has been used successfully in patients with serious trauma in whom
haemorrhagehasbeendifficulttocontrolsurgically.Thusitcanbeclassedasaprocoagulant.
Heparin is an anticoagulant and its effects are monitored by measuring the activated partial
thromboplastintime(APTT),althoughthrombinandclottingtimesarealsoprolonged.Itaccelerates
theactionofantithrombinIII,whichinhibitsactivatedfactorsXII,XI,X,IXandthrombin.
Exercisetherapy.Thismanneedstoaddresshisriskfactorsandstopsmokingforimprovementinhis
cardiovascular profile, but his walking is a quality of life problem since he covered 180 metres.
Althoughonecouldperformanangioplastyorsurgeryitisnotcurrentlyindicated;heshouldgaingood
symptomatic improvement from an exercise programme and in addition to improving his general
healththishasnoiatrogenicrisksassociatedwithit.bypass
Poplitealpedalbypass.Thismanhastissuelosswithsevereinfrageniculardisease.A"suckitandsee"
amputationofhishalluxmaywork,buthastherealriskofacceleratingthetissuedestructioninhis
footandultimatelyleadingtolimbloss.Apoplitealpedalbypasswilltakebloodfromanareaofgood
flowtothepointwhereitisrequiredandalthoughatechnicallydifficultoperationgivesthismanthe
bestchanceoflimbsalvage.
Intussusceptionoccurswhenasegmentofbowelinvaginatesintoitsadjoininglowersegment.
Itismorecommoninboys.About60%areunder1yearoldand80%90%under2yearsold.Itisrare
aftertheageof6.
Intussusceptionisassociatedwith:
Haemophilia
HenochSchnleinpurpura
Haemangiomas,and
GIlymphomas.
Clinicalfeaturesincludeseverecolickyabdominalpainandvomiting.Betweenattackstheinfantmay
appearingoodhealth.
Theinfant maypass'redcurrant jelly'stoolsandasausageshapedmassispalpableonabdominal
examination.
Rectal examination may reveal blood in the majority of cases and occasionally the apex of the
intussusceptionispalpable.
InadditiontotheABOandrhesussystems,anothereightbloodgroupsystemshavebeenidentified.
TheKell,DuffyandKiddsystemscancausebothhaemolytictransfusionreactionsandthehaemolytic
diseaseofthenewborn.
ThePandMNsystemscanalsocausebothofthesereactions,buttheyarerareevents.
TheLutheran,Lewis,SciannaandLisystemsareclinicallyoflessimportancebecausetheydonot
cause the haemolytic disease of the newborn, and are unlikely to (or rarely) cause haemolytic
transfusionreactions.
ThereareanumberofcriteriausedintheRanson'sscoringsystemwhichreflectprognosisassociated
withacutepancreatitis.
Ranson'scriteriaonadmissionthatsignifyaworseprognosisinclude:
Criteriapresentat0hours:
Age>55yearsold1point
WBC>161091point
Glucose>11.1mmol/L1point
LDH>350U/L1point
AST>250U/L1point
Criteriapresentat48hours:
Hematocritfallof10%orgreater1point
Ureariseof1.8mmol/Lormoredespitefluids1point
SerumCalcium<2mmol/L1point
pO2<60mmHg1point
Basedeficit>4meq/L1point
Fluidsequestration>6000mL1point
Theinternaljugularveinoriginatesatthejugularforamen.
Itinitiallyliesposteriortothecarotidartery,asitdescendsinthecarotidsheathitlieslateralfirsttothe
internalthenthecommoncarotidarterywithinthecarotidsheath.
Itpassesanteriortothesubclavianarterytojointhesubclavianveinandthenformthebrachiocephalic
vein;theleftandrightbrachiocephalicveinsunitetoformthesuperiorvenacava.
Theinternaljugularveinreceivesalymphatictrunkatitsunionwiththesubclavianvein.
Theexternaljugularveindrainsintothesubclavianvein.
Tensionpneumothoraxisalifethreateningsurgicalemergency,sincefailuretorelievethetensionmay
resultinacardiorespiratoryarrest.Itusuallyoccursfollowingpenetratingorbluntinjuriestothe
chest,andfrequentlyfollowingmajortraumas.
Intensionpneumothorax,theairisdrawnintothepleuralspacewitheachinspiration,buthasnoroute
toescape;thusactingasaonewayvalve.
Patientspresentwith:
Respiratorydistress
Tachycardia
Hypotension
Distendedneckveins
Decreasedairentryintheaffectedlung,and
Deviationoftracheaandmediastinumtotheoppositeside.
However,notallthesesignsandsymptomsarealwayspresent.
The classical history of Boerhaave's syndrome is of severe vomiting and retching followed by
extremelysevereretrosternalandupperabdominalpain.Shockdevelopsrapidly.
Thereisahistoryofalcoholismorheavydrinkingin40%ofpatients.Thesiteofruptureisusuallyin
theleftposterolateral distaloesophagusandisseveral centimetreslong.Subcutaneousemphysema
(crepitus)isonlypresentin27%ofpatientsandisarelativelylatesign.
An initial chest x ray will show mediastinal or free peritoneal gas. After hours or days, pleural
effusion(s), often with a pneumothorax, and a widened mediastinum develops. The diagnosis is
confirmedwithaCTscanfollowedbyagastrografinswallowtoassesstheextentoftheoesophageal
leak.
Themaintreatmentissurgery,whichshouldbewithin24hours.Mortalityis2050%andisincreased
with delay in treatment. The oesophagus is repaired or resected and the mediastinum drained.
Occasionallycontainedleaksmaybemanagedconservatively.Endoscopiccoveredstentshavebeen
used.Surgeryistheonlyeffectiveoptionwhenthereisextensivemediastinalcontaminationordelayin
diagnosis.
MalloryWeiss syndrome is the cause of bleeding in 5% of patients with upper gastrointestinal
haemorrhage.Longitudinalmucosallacerationsinthedistaloesophagusandproximalstomachcause
bleedingfromsubmucosalarteries.Mosttearsaresingle.Theconditionwasoriginallydescribedin
1929,relatedtovomitinginalcoholicpatients.
Otherassociationsinclude:
Coughing
Epilepticconvulsions
Closedchestmassage
Bluntabdominalinjury,and
Hiccupsunderanaesthesia.
Hiatusherniaappearstobeapredisposingfactor(40100%).Somepatientshaveepigastricorback
pain.Thebloodlossisusuallysmallandselflimiting.
Transfusionsmaybe needed andendoscopichaemostatictreatment maybe required.Rarely,with
protractedvomiting,perforationmayoccur.
Inthisprocedureallthediseasedtissueisremovedbutthepatientavoidsapermanentstoma.The
patienthastobewellmotivatedtodealwiththepossiblecomplications(anastomoticleak,adhesional
obstruction,poorfunction,pouchitis).
Aloopileostomyisconstructednearthepouchintherightiliacfossatoallowtheanastomosistoheal.
Theloopileostomyisclosedateightto10weeks.
Carcinomaisthecommonestoflargebowelobstructions.Theoperationofchoiceforanobstructing
sigmoid tumour is a Hartmann's procedure. The tumour is removed (sigmoid colectomy) and a
colostomyformed.(Sometimestheremaybeenoughdistalsigmoidtobringoutasamucousfistula
ratherthandoaHartmann'sprocedure.Thiswouldbeeasiertoclosesubsequently.)
Primaryanastomosisshouldusuallybeavoided,asthereisahigherriskofanastomoticleakinpatients
presentingwithobstruction.
Iftheproximalcolonisgrosslydilatedandischaemicthenasubtotalcolectomyandileostomyshould
beperformed.
Theoperationofchoiceisarighthemicolectomy,thusremovingthetumour.Ifthereisnoevidenceof
perforationthenaprimaryanastomosiswouldbeperformed.However,thereisamuchhigherriskof
anastomoticbreakdowninacontaminatedfield.Thereforeanendileostomyisformed.Amucusfistula
isalsorequired,toallowmucustodrainfromtheremainingcolon.
Dysphagiaisdefinedasdifficultyinswallowing,incontrasttoodynophagiawhichreferstopainful
deglutition.
Dysphagiacouldbeduetointraluminal,mural(includingmusculardisorders),extrinsicorfunctional
causes.Thesymptommaybedescribedbysomeasstickingsensation.
Thesiteisusuallywelllocalised,especiallyintheuppertwothirdsoftheoesophagus,duetoits
innervationpattern(somaticasopposedtovisceral).
RetrosternalburningismostcharacteristicofGORD.Itmaybeaggravatedbyfoodanddrinks.The
factthatthisisassociatedwithstickinessoffoodinthiselderlywoman,probablysuggeststhatshehas
astrictureprobablybenignassheisotherwisewell.
The70yearoldmanclearlyhasamalignantstrictureorcarcinomaoftheoesophagus.Difficultyin
initiation of swallowing is usually a pharyngeal problem; in view of his age and of the choices
provided,heismostlikelytosufferfromcarcinomaofthepharynx.
Globushystericus(syndrome)mainlyaffectspeoplebetween30to60.Thepredominantsymptomisa
feelingoflumpandisnotatruedysphagia.Itismostpronouncedfordryswallow(swallowingown
saliva)thanwheneatingordrinking.
Elderlypatientswithperrectalbleeding,changeinbowelhabits,andweightlossshouldbeconsidered
tohavecoloniccancerunlessprovenotherwise.Increaseinageisariskfactorfordevelopingcolonic
cancer.
Theotherriskfactorsinclude:
afamilyhistoryofcoloncancer
familialadenomatouspolyposis
dietrichinredmeat,and
longstandingulcerativecolitisorCrohn'sdisease.
Theclinicalpresentationofpatientswithcolonicmalignancydependsonthesiteofthetumour.
Rightsidedcoloniccarcinomacommonlypresentswith:
anaemia
tiredness
malaise
pallor,and
lossofweight.
Theleftsidedcoloniccarcinomapresentswith:
changeinthebowelhabits
bleedingperrectum,and
intestinalobstruction.
Rectalcarcinoma,inadditiontothefeaturesseeninleftsidedcoloniccarcinoma,isassociatedwitha
sense of incomplete evacuation of the bowel (tenesmus). Tumours of the caecum affecting the
ileocaecalvalvecanalsopresentwithsymptomsoflowersmallbowelobstruction.
Investigationsforsuspectedcolonicmalignancyinclude:
fullbloodcellcount
renalfunctionandelectrolytes
liverfunctiontests(toruleouthepaticinvolvement)
plainxrayoftheabdomen,and
ultrasoundandCTscans.
Carcinoembryonic antigen (CEA) is the commonly used tumour marker to diagnose colonic
malignancyandsubsequentlytoassesstheprogress,includingrecurrence.
Surgeryremainsthemainstayofmanagementofcolonictumoursthoughacolonicstentmaybeplaced
inleftsidedobstructionasabridgetosurgery.Radiotherapyandchemotherapyhavetheirrolesin
selectedpatients.Atemporaryorapermanentcolostomyisfrequentlyrequiredfollowingthesurgical
treatmentofleftsidedcolonictumours.
ThechangesinhyperkalaemiabeginwithpeakedTwaves,particularlyintheprecordialleads.Thena
widenedQRScomplex(>120msec)whenthepotassiumis>6.5.Theremayalsobedecreasedpwave
amplitudeandanincreasedPRinterval.Withapotassium>7.0theremaybeabradycardiaandAV
block.Eventuallypwavesarelostandasinewavemaydevelop.Thisisoftenafatalarrhythmia.
WPWisassociatedwithanaccessorybundle,whichcausesadeltawave(notch)precedingtheQRS
complex,givingtheimpressionofashorterPRinterval.However,thedeltawaveischaracteristic.
OthercausesofprolongedQTinclude:
CongenitalprolongedQT(LownGanongLevinesyndrome)
Hypocalcaemia
Drugtherapy(Amiodarone,Sotalol)
Pericarditis is associated with concave upward ST segment elevation on the ECG, versus convex
upwardSTsegmentelevationinMI.
Regardingcannulationforcardiopulmonarybypass,pleasechoosethemostappropriateanswerfrom
thelist.
In which structure is the venous cannula placed when a patient is undergoing a tricuspid valve
replacement?
IncorrectThecorrectanswerisVenacava
Whentherightsideofthehearthastobeopened,separatecannulaeareinsertedintothesuperiorand
inferior venae cava. Pursestring sutures are snared around the incisions to produce a blood and
airtightseal.
Inwhichstructureisthearterialcannulafromthecardiopulmonarybypasscircuitplaced?
IncorrectThecorrectanswerisAscendingaorta
Theblooddrainedfromtheheartispassedthroughtheoxygenatorinwhichitisseparatedfromagas
mixturebyasystemofmembranes.Thebloodisthenreturnedtothepatientunderpressurethrougha
rollerpumpviaanarterialfilterandairbubbledetector.Thearterialcannulaisusuallypositionedin
theascendingaorta.
In which structure is the venous cannula placed when a patient is undergoing a mitral valve
replacement?
IncorrectThecorrectanswerisRightatrium
Cardiopulmonarybypassallowswholebodyperfusioninwhichthepumpingactionoftheheartand
oxygenationofbloodbythelungsarereplacedbyanextracorporealcircuit.Thereturningvenous
bloodisdivertedfromtheheartusingalargeborecannulainsertedintherightatrialappendage.
Malignantmelanomamaybesubungual,buccal,anal,andpresentonanymucosalsurface,notmerely
inthedermis/epidermis.
Theincidenceofmalignantmelanomaoftheskinhasbeenrisingrapidlyinthewhitepopulations
aroundtheworldforseveraldecades. Incidencerates inGreatBritainincreasedfromaround2per
100,000populationformalesand3per100,000populationforfemalesin1971to7and9per100,000
populationformenandwomenrespectivelyin1996,athreefoldincrease.
Amelanoticmalignantmelanomamostcommonlyoccursinthesettingofmelanomametastasistothe
skin, presumably because of the inability of these poorly differentiated cancer cells to synthesise
melaninpigment.
Morethan50%ofcasesarebelievedtoarisedenovowithoutapreexistingpigmentedlesion.
TumoursizeisonlyoneofthecriteriausedintheAJCC2009RevisedMelanomaStaging.Tumour
thicknessandmitoticrate(mitoses/mm2)arethemost important prognosticfactorsintheprimary
tumour.
The ventral branches of the aorta include the coeliac artery and superior and inferior mesenteric
arteries.
Theseventralbranchesgiveriseto:
Left gastric artery branches with the aortic oesophageal branches around the lower
oesophagus.
Anteriorandposteriorsuperiorpancreaticoduodenalarteries(coeliactrunk)withtheinferior
pancreaticoduodenal(superiormesentericbranch)aroundtheheadofthepancreasandsecond
partoftheduodenum.
Themarginalarteryanastomosisbetweenthemiddlecolicandtheleftcolic.
Thesuperiorrectalartery(inferiormesenteric)withthemiddlerectal(internaliliac)and/orthe
inferiorrectal(internalpudendalfrominternaliliac).
Therightgastricarterymostfrequentlyoriginatesfromtheproperhepaticartery(~53%).Itcanalso
originate:
fromtheregionwherecommonhepaticarterydividesintoitsbranches(~20%)
fromthelefthepaticbranch(~15%)
asabranchofthegastroduodenalartery(~8%),or
asbranchofthecommonhepaticartery(~4%).
Theincidenceofcleftlipandpalateisonein600livebirths,and1:1000livebirthsforisolatedcleft
palate.
TheincidenceincreasesintheOrientalgroups(1:500)anddecreasesintheblackpopulation(1:2000).
The highest incidence reported for cleft lip and palate occurs in the Native American tribes of
Montana,USA(1:276).
Thetypicaldistributionofclefttypesis:
Cleftlipalone15%
Cleftlipandpalate45%
Isolatedcleftpalate40%.
Geneticinfluenceismoresignificantincombinedcleftlipandpalatethancleftpalatealonewhere
environmental factors such as maternal epilepsy and drugs (for example, steroids, diazepam,
phenytoin)exertagreaterinfluence.
Althoughmostcleftsofthelipandpalateoccurasanisolateddeformity,thePierreRobinsequence
remainsthemostcommonsyndrome.Thissyndromecomprisesisolatedcleftpalate,retrognathiaanda
posteriorly displaced tongue (glossoptosis), which is associated with respiratory and feeding
difficulties.
Facialnervepalsiesmaybecausedbylesionsaffectinganypartofitscourse.Itarisesinthemedulla
andemergesbetweenponsandmedulla,passesthroughtheposteriorfossaincloseproximitytothe
middleearbeforeemergingfromthestylomastoidforamentopassunderneaththeparotidgland.
Causescanbedividedinto:
Intracranialbrainstemtumours,stroke,multiplesclerosis,acousticneuroma
Intratemporalotitismedia,RamsayHuntsyndrome,cholesteatoma
Infratemporalparotidtumours,trauma
Otherssarcoid,GuillainBarrsyndrome,diabetes,Bell'spalsy.
Thispatientpresentwithsymptomssuggestingamaurosisfugax.
InthiscaseNICEguidelinessuggestthatthemostappropriatetherapywouldbeClopidogrel75mgod
oraspirin75mgodplusdipyridamolemodifiedrelease200mgbd(notachoiceinthislistasyoucan
onlyhaveonecorrectanswer).Thereislittleevidencethatoneorotheroftheseregimensissuperior.
Clopidogrelhastheadvantageofbeingonetabletadaysocomplianceislikelytobebetter.
Inthiscase,hehasatrialfibrillation(AF),andthemostappropriatetreatmentwouldbewarfarin.AF
withamaurosisfugax wouldsuggest avery highfuture riskofcompleted stroke,and thisriskis
minimisedmostwithwarfarin.
NICEguidelinesonVasculardiseaseclopidogrelanddipyridamole(TA210)liststhebesttreatment
as clopidogrel for occlusive events, aspirin and dipyridamole for TIAs, moving down the list if
intoleranttothefirstlinetreatment.
Withanyacuteswollenscrotumthefearisoftorsionoftestis.Thisisuncommonintheneonate,andis
muchcommoneraroundpuberty.Presentationiswithahard,tendertestis,andspermaticcord/+ared
scrotum.
Torsionoftheappendageoftestishasapeakincidenceofbetween4and8yearsofage,asdoesacute
idiopathicscrotaloedema.Intheformer,thereisatenderupperpoleoftestiswithabluespoton
transillumination.Inthelattertheerythemaextendsbeyondthescrotumandthetestisisminimally
tender.
Epididymitisisrarebeforepuberty,andpresentswithatenderepididymus(urologicalinvestigations
areneeded,asitisassociatedwithrefluxofinfectedurineviathevasdeferens).
Inguinalherniaewhichareirreducible,haveapeakincidencebelow2yearsofage.Afirmimmobile
tender swelling is found in the scrotum, which becomes inflamed as the strangulation occurs.
Occasionally,acutehydrocelescanalsopresentwithamobilebluetransilluminatingswellingat13
yearsofage.
Differentialdiagnosesofsolitarypainfululcerintherectumat60yearsofageare:
cancer
solitaryrectalulcersyndrome(otherwiseknownasulcerativeproctocolitis),and
rarelyinfections,suchasamoebiasisorbilharziosis.
Thebestresponseamongstthosegivenhereisulcerativeproctocolitis.
Theposteriortriangleoftheneckcontains:
Nerves:
Spinalaccessorynerve(Xi)
CervicalPlexus(lesseroccipital,greaterauricular,transversecervicalandsupraclavicular)
Arteries:
3rdpartoftheSubclavianArtery
TransverseCervicalandSuprascapularArteries(bothbranchesoftheThyrocervicalTrunk)
OccipitalArtery
Veins:
ExternalJugularVein
LymphNodes:
Theinferiorbellyofomohyoid
10
Thebrachialplexusliesdeeptotheprevertebralfascia.
Therearenumerousindicationsfortheformationofatracheostomy.
Theseinclude:
Theupperairwayobstruction
Tofacilitateairwaysuction,and
Todecreasetheworkofbreathingandtoallowweaningfrommechanicalventilation.
Oncethedecisionhasbeenmadetogoahead,atracheostomymaybeperformedpercutaneouslyor
openly.
Whenusingtheopenmethod,amidlineincisionismadeandthethyroidisthmusdividedandligated,
andaverticalincisionmadebetweenthesecond,thirdandfourthtrachealrings(astheformationof
windowsandflapsincreasestheriskofstenosis),andthecuffisinflated.
However,inchildren,cuffedtubesshouldbeavoidedduetotheriskoftrachealstenosisandmucosal
ulceration.
Bleeding from the tracheotomy wound is also a recognised complication, and best treated by not
deflatingthecufforremovingthetube(astheyhelptotamponadethebleeding)butbygivingoxygen,
ventilatingthepatient,andgainingIVaccess,whilstcallingforhelp.
Criterionfortheremovaloftracheostomytubes:thepatientisabletomaintaintheirownairwayand
ventilateadequately.
Indicators of this are: a low inspired oxygen concentration, adequate carbon dioxide elimination,
minimalsputumproductionandthatthepatientisnotheavilysedatedandabletocooperate!
Nonfunctioningpituitarytumour(NFPT)causingendocrinedisturbance.
IncorrectThecorrectanswerisFreeT48.2nmol/L,TSH2.1mU/L
ANFPTmaybeassociatedwithhypopituitarismandsecondaryhypothyroidism,withalowthyroxine
(T4),plusnormalorlowthyroidstimulatinghormone(TSH)levels.IftheT4islowyettheTSHis
normal,thenthiswouldsuggestthattheTSHisabnormallylowfortheT4,suggestingthatthepituitary
hypothalamicaxisisdysfunctional.Itisalsopossibleforanonfunctioningpituitarytumourtonot
causehypothyroidismandthepatienttobeeuthyroid.
Subclinicalhypothyroidism.
FreeT412.1nmol/L,TSH7.9mU/L
Correct
SubclinicalhypothyroidismisassociatedwithanormalT4,butanelevatedTSHlevel.Thissuggestsa
developing thyroid failure. The raised TSH signals a reacting pituitary, with the elevated TSH
endeavouringtoincreaseT4secretionfromthethyroid.
Subclinicalhyperthyroidism.
FreeT418.6nmol/L,TSH0.07
11
Correct
Theconverseappliesforsubclinicalhyperthyroidism,wherepituitarysecretionisbeinginhibitedby
theexcessivefortheindividual(althoughstillinnormalrange)T4.
Thyroid function tests are some of the most frequently requested blood tests, and their accurate
interpretationisessential.
Congenitaldiaphragmaticherniasoccurinapproximately1in4,000livebirths.
NinetypercentoccurintheposteriorportionofthediaphragmthroughtheforamenofBochdalekof
which90%areontheleft(theliverisontherightsidesomaybethereasonthemajoritypassthrough
theleftsideofthediaphragm).
Thecommonestclinicalpresentationiswithrespiratorydistressintheneonatalperiodanddueto
pulmonaryhypoplasiaandcompression.Theabdomenoftenhasascaphoidappearance.
About40%ofpatientshaveassociatedcongenitalanomalies.
Thediagnosiscanbeconfirmedradiologicallywithbowelloopsseeninthechest.
Neonatesusuallyrequiresedation,ventilationandintestinaldecompressionpriortosurgerybetween36
and72hoursafterbirth.
12
Theme:HearingLoss
A
B
C
D
E
F
Foreachscenariodescribedbelow,choosethesinglemostlikelycorrespondingtypeofhearingloss
fromthegivenlistofoptions.
Eachoptionmaybeusedonce,morethanonceornotatall.
Amotherbringsher7yearoldgirltoseeyou.Shehashadamoderatehearinglossandhascopedwell
withhearingaidsforthelastthreeyears,butshehasbeenrecentlynotedbyherteachertobemore
withdrawntowardsherpeersinclass.Inspiteofherbeingteasedforbeinga"teacher'spet"andnow
sittingatthefrontoftheclassroomconstantly,heracademicperformancehasdeteriorated.
Correct
Hearinglossshouldbeconsideredinchildrenifthereisanysuspicionfromparentsorteachersbased
onbehaviouralchanges.Accurateelectrophysiologicaltestingcanbeeasilyandnoninvasivelycarried
outinchildrenofanyage.
Eveninthosepatientsknowntohaveahearingloss,vigilanceisimportantasprogressivechanges
oftenoccur.Aschoolagechildmayfindincreasingdifficultyhearingtheteacherandneedtositatthe
frontoftheroomtohearbetterandlipread.Thisindicatesalossofspeechdiscriminationability.
Thislosscanalsooccurinadultswithaprogressiveloss,includingthosealreadyusinghearingaids.
Somegoontoreceiveacochlearimplantwhichcangivethemtheabilitytohearspeechclearlyagain.
A22yearoldmancomestoseeyou.Hewasrecentlyonholidayandlearnedtowaterski.Ontheday
beforereturninghome,hefellwhilewaterskiingatspeedandsustainedablowtotherightsideofhis
head.Onotoscopyyouseeasmallholeinthetympanicmembrane.Youreferhimforaudiological
assessment.Hehasamildhearinglossontherightwithnormalboneconduction.
Correct
Hearinglossisbroadlycategorisedintotwoaetiologicaltypes:conductiveandsensorineural.
Conductivelossesaffectouterand/ormiddleearfunction(forexample,tympanicmembranerupture)
andwillleadtoimpairedairconductionwithnormalboneconduction.
Sensorineurallossesresultfromhaircelllossesinthecochlea(innerear)andbothairandbone
conductionareaffected.
An18montholdbabyisbroughttoyoubyhismother.HewasbornintheUKinahospitalwith
universalhearingscreeningandwasfoundtohavenormalhearingatbirth.Whenthechildwas5
monthsoldthefamilymovedtoChinaforasixmonthperiodafterwhichtheyreturnedtotheUK.
WhileinChinathebabycontractedpneumoniaandwashospitalisedinthelocalregionalhospitalfor
IVantibiotictherapy.
Correct
Anypatientofanyagewithabilateralseveretoprofoundhearinglossshouldbeconsideredapotential
cochlearimplantcandidate.
13
Thecausesofsensorineuralhearinglossesincludeotoxicity(duetoagentssuchasgentamicin,
cisplatinandotherchemotherapeuticagents),bacterialmeningitis,skullfracture,noiseexposure,
presbycusis,geneticsyndromesandhereditarydeafnessandmanyofthe"unknown"causesofhearing
loss.
Gentamicinisstillusedinsomecountrieswithouttherecommendedstrictmonitoringofcirculating
levels,andhaircelltoxicityresults.
A65yearoldmancomestoseeyoucomplainingthathehasbeenmisunderstandingsomewordsin
conversationeveninquietenvironmentssuchasathomewithhiswife.Hehasnopriorhistoryof
hearingloss.Yousendhimforanaudiogramwhichshowsadipinthe68kHzrange.
IncorrectThecorrectanswerisHighfrequencyhearingloss
Highfrequencyhearinglossisknownasthe"invisibledisability"asitspresenceisoftennotobvious
fromhistoryandbasicclinicalexamination.Earlystagesofsomehearinglossescanbeassubtleasan
adulthavingtroubleunderstandingafewwordsofconversationinagerelatedhearinglossesthehigh
frequencysoundsofsomeconsonants(forexample,"sss"or"fff")arelostfirst.
Achildborninahospitalwithauniversalneonatalscreeningprogrammedoesnotpassthefirstand
secondscreeningproceduresandgoesonforfulldiagnosticassessment.Thechildhasaprofound
bilateralhearingloss.Theoutcomeofthethoroughinvestigationsisthatthechildreceivesacochlear
implant.
Correct
Hearinglossisbroadlycategorisedintotwoaetiologicaltypes:conductiveandsensorineural.
Conductivelossesaffectouterand/ormiddleearfunction(forexample,tympanicmembranerupture)
andwillleadtoimpairedairconductionwithnormalboneconduction.
Sensorineurallossesresultfromhaircelllossesinthecochlea(innerear)andbothairandbone
conductionareaffected.
Hearinglossisalsoclassifiedaccordingtodegreeofloss.Itisexpressedasthenumberofdecibelsof
hearinglossthatispresentcomparedtosomeonewithnormalhearing.
Mild
Moderate
Severe
Profound
25-40 dB loss
40-70 dB loss
70-90 dB loss
>90 dB loss
14
Thelongsaphenousveincanbedividedintosixanatomicalregions:
1.
Femoraltriangle
2.
Anteriorfemoralregion
3.
Patellarregion
4.
Posteromediallowerleg
5.
Anteromediallowerleg,and
6.
Foot.
Ithasalinearcourseintheleg.Itascendsvertically,posteriortothemedialborderofthetibia.
Itisaccompaniedbythelegbranchofthesaphenousnerve.Thisanatomicalrelationobviouslycarries
ariskofsensorydisordersfollowingstripping.
Atthekneethelongsaphenousveintravelsposteriorlytothemedialfemoralcondyle(secondconstant
anatomicallandmark).
Itthentravelssuperficiallyoverthemedialregionofthethigh,remainingparalleltothemedialedgeof
thesartoriusmuscle.
Inthefemoraltriangle,thelongsaphenousveinformsanarchasitpenetratesintothedepthofthe
thigh.ItperforatesthecribriformfasciaimmediatelyaboveAllanBurn'sligament,whichactually
correspondstoareinforcementorfoldofthecribriformfascia.
Thearchofthelongsaphenousveinthenopensontotheanteriorsurfaceofthefemoralvein4
centimetresbelowtheinguinalligament.Itentersthefemoralveinatthisjunctionwhichthenpasses
throughthefemoralcanal.
Theexternalpudendalveinsdraintotheiliacveins.Thelongsaphenousmaydrainintotheposterior
tibialveins.
Thevalvesoftheperforatingveinsshouldpreventbackflowofbloodfromthedeeptothesuperficial
system.
In75%ofoccasionsthelongsaphenousreceivesbloodfromthesuperficialexternalpudendalveins.
Score
6
5
4
3
2
1
EyeOpening
Eyesopenspontaneously
Eyesopentoverbalcommand
Eyesopentopain
None
VerbalResponse
Orientated
Confused
Inappropriatewords
Incomprehensiblesounds
None
MotorResponse
Obeyscommands
Localisingpain
Withdrawingfrompain
Flexiontopain
Extensiontopain
None
15
Myastheniagravisisanautoimmunediseasecharacterisedbyskeletalmuscleweaknessandincreased
fatigability.
Ninetypercentofpatientshaveantibodiesagainstthepostsynapticacetylcholinereceptorsatthe
neuromuscularjunction.Sixtyfivepercentofpatientswithmyastheniagravishavehyperplasiaofthe
thymusand12%haveathymoma.
Treatmentiswithacetylcholinesteraseinhibitors,forexample,pyridostigmine,whichmaycausea
cholinergiccrisisinoverdosage.Sideeffectsoftreatmentinclude:
Diarrhoea
Urinaryfrequency
Meiosis
Excessivesalivation,and
Lacrimation.
Amyastheniccrisis(suddenworseningandspreadingweakness)maybeprovokedbydrugomission,
infectionandstress.
Preoperativeassessmentofrespiratoryfunctionisimportant.Pyridostigmineisusuallywithheldon
themorningofsurgeryandthenrestartedinreduceddosagepostoperatively.
Atracheostomydoesimproveweaningfromventilatorysupport,butitisnotperformedroutinelyafter
athymectomy.Thesepatientsareoftenextubatablewithin24hoursontheICUifnotimmediately
afterthesurgery.
Thesehistologicalfeaturesaretypicalofcoeliacdiseasewith:
Villousatrophy
Crypthyperplasia/hypertrophy
Inflammatoryinfiltrateofthelaminapropria,and
Intraepitheliallymphocytes.
UsefulserologyincludesantiTTGantibodieswhichwouldbeexpectedinover90%ofcases.
Treatmentofthiscasewouldthereforeentailglutenfreediet.
16
A4yearoldboyborninNorthAfricahaspresentedwithrecurrentchestinfectionandwheezesince
birth.Onauscultationhehasanejectionsystolicmurmurandarumblingmiddiastolicmurmur.Heis
alsonotedtohaveafixedandwidelysplitsecondheartsound.
IncorrectThecorrectanswerisAtrialseptaldefect
Therearetwomaintypesofatrialseptaldefect:
Ostiumsecundumdeficencyoftheforamenovaleandatrialseptum,and
Ostiumprimiumdefectoftheatrioventricularseptum.
Bothpresentwithsimilarsymptoms.
Allsymptomaticchildrenshouldbeofferedsurgery,whichconsistsofclosingthedefectprimarilywith
suturesorwithapatch.
A6weekoldboyisnotedtohavealoudsystolicmurmurathissixweekcheck.Themotherreports
thathefeedswellandisheisonthe50thcentileforweightandheight.
IncorrectThecorrectanswerisVentricularseptaldefect
Ventricularseptaldefects(VSDs)arecommonandareoftwomaintypes:
Perimembranousclosetothetricuspidvalve,and
Muscularcompletelysurroundedbymuscle.
MostchildrenareasymptomaticwithmostVSDsclosingspontaneouslywithinthefirstfewyearsof
life.
Symptomsincludefailuretothrive,recurrentchestinfectionsandheartfailure.Surgeryisindicatedif
thereareseveresymptomswithfailuretothriveorpulmonaryhypertension.Untreatedpulmonary
hypertensionwillprogresstoirreversibledamageofthepulmonarycapillaryvascularbed.
A6weekoldboyisnotedtohaveacontinuousmurmur.Themotherreportsthathefeedswellandis
heisonthe50thcentileforweightandheight.
IncorrectThecorrectanswerisPatentductusarteriosus
Theductusarteriosusconnectsthepulmonaryarterytothedescendingaorta.Failuretocloseshortly
afterbirthfrequentlyoccursinpretermorsickinfants.Inotherchildrenitisduetoadefectinthe
muscleoftheduct.Childrenareusuallyasymptomaticbutmaydevelopsignsofheartfailure.Ifthe
PDAfailstoclosethensurgical/transvenousclosureisadvisedtoabolishthelifelongriskofbacterial
endocarditis.
17
Peripheralarteriovenousaccessisrequiredifapatientrequireslongtermhaemodialysis.Mostare
formedunderlocalanaestheticinadaycasesetting.Mostfistulaeareformedasdistallyonthearmas
possible,byanendtosidetechniqueontothearterytoreducetheriskofvenoushypertensionandsteal
syndrome.Priortocreatingafistulaitisnecessarytobeabletopalpateadistalpulse.
TheNationalKidneyFoundationKidneyDiseaseOutcomesQualityInitiative(NKFKDOQI)advocate
routineduplexingofthearteryandveintoidentifyanatomicalabnormalitiesordisease.
Fistulafailureisassociatedwith:
Smallvesselsize
Lowfistulaflowratefollowingconstruction
Anastomosismethod(clipsarebetterthansuturing)
Accessposition(moredistalisbetter)
Gender(betterpatencyratesinmen)
Age(pooreroutcomesintheelderly)
Obesity,and
Smoking.
ComplicationsofAVfistulaareinfection,haemorrhageandstealsyndrome.
Apatientwithrecurrentrightupperquadrantpainwithnormalultrasound,gastroscopyandMRCP.
Correct
AHIDA(HepatobiliaryIminodiaceticAcid)scanisanuclearimagingprocedureusedtoevaluatethe
functionofthegallbladder.Aradioactivetracer,usuallya99Tciminodiaceticacidchelatecomplex,is
injectedperipherallythenallowedtocirculatetotheliverwhereitisexcretedintothebiliarysystem
andstoredbythegallbladderandbiliarysystem.Ahealthyfunctioninggallbladdershouldoutlinefully
withinonehour.
Axillarysentinellymphnodebiopsy.
Correct
Toassessaxillarylymphnodearadiocolloidissuperficiallyinjectedoverlyingthetumouror
superficiallyattheperiareolarmargin.Thisisbecauselymphdrainsfromthedeepbreastparenchyma
superficiallytothesubdermallymphatics.Subdermallymphaticsdraintotheaxillaviathesubareolar
plexusthroughoneormorefinalcommonlymphaticchannels.
Radiocolloidinjectionallowspreoperativesentinelnodeimagingusingagammacamera.Thecolloids
areefficientlytrappedinthesentinelnode(whereasbluedyestypicallypassintosecondechelon
nodes).TheuniversalradioactivetracerusedisTechnetium99m.Technetiumhasseveraladvantages,
asitisapuregammaradiationemitter,henceoffersexcellenttissuepenetration.
18
19
Theme:Antibioticregimesinabdominal/pelvicinfections
A Ciprofloxcinfor1week
B Doxycyclinefor1week
C Doxycyclinefor2weeks
D Meropenam
E Metronidrazoleanddoxcyclinefor2weeks
F Piperacillin
G Vancomycin
Foreachofthescenariosbelow,choosethesinglebesttreatmentfromthoselisted.
Eachoptionmaybeusedonce,morethanonceornotatall
Ayoungwomanwithanonspecificgenitalinfection.
IncorrectThecorrectanswerisDoxycyclinefor1week
Nonspecificgenitalinfectionisaninfectionoftheurethraorcervix,whereacausecannotbe
demonstratedonroutineinvestigations.FurtherinvestigationsdemonstrateChlamydiatrachomatisin
3050%andUreaplasmaurealyticumin1040%ofcases.TreatmentiswithDoxycyclineor
Azithromycinfor7days.
A22yearoldwomanpresentswithpyrexiaandlowerabdominalpain.Pelvicultrasoundconfirms
salpingitis.
Correct
Pelvicinflammatorydiseaseisusuallytheresultofinfectionascendingfromtheendocervixcausing:
endometritis
salpingitis
parametritis
oophoritis
tuboovarianabscess,and/or
pelvicperitonitis.
NeisseriagonorrhoeaeandChlamydiatrachomatisaccountforaquarterofcases.Gardnerella
vaginalis,anaerobesandotherorganismscommonlyfoundinthevaginamayalsobeimplicated.
A51yearoldleukaemiapatientwithtyphlitisonCT.
IncorrectThecorrectanswerisMeropenam
Typhlitis(neutropenicenterocolitis)isalifethreatening,necrotizingenterocolitisoccurringprimarily
inneutropenicpatients.Typhlitisoccursmostcommonlyinindividualswithhaematologic
malignancieswhoareneutropenicandhavebreakdownofgutmucosalintegrityasaresultofcytotoxic
20
chemotherapy.Treatmentinvolvesbowelrest,NGTandintravenousfluids.Closemonitoringwith
serialabdominalexaminationsinanintensivecaresettingisrequired.
Intravenousantibioticsshouldincludecoverforgramnegativeandanaerobicorganisms,including
Clostridiumspecies.Metronidazolemayalsobeconsideredifpseudomembranouscolitiscannot
immediatelybeexcluded.Laparotomyisindicatedifperitonitisdevelops.
A75yearoldretiredbuilderhasapigmentedlesiononhisforeheadwithadarkerpatchinonearea.
Correct
Lentigomaligna(Hutchinson'smelanoticfreckle)istheleastmalignantvariety(carcinomainsitu).Itis
morecommonlyseenintheelderly.Itpresentsasanirregularbrownpatchcommonlyoverthecheek.
Malignantchangesarerecognisedbythickening,darkeningandthedevelopmentofdiscretetumour
nodule(s).Thisindicatesdermalinvasionbymalignantmelanocytesandthelesionisthenalentigo
malignamelanoma.
A46yearoldmanpresentswithapainlessfirmlumponhisarm.Thislumphasbeenpresentformany
years.
IncorrectThecorrectanswerisSebaceouscyst
Sebaceouscystsareintradermallesionscontainingkeratinanditsbreakdownproducts.Itissurrounded
byawallofstratifiedsquamouskeratinisingepithelium.Theycommonlyoccurovertheface,chest
andshoulders.Theyhaveacharacteristicpunctum,usuallyinthecentreofthelesion,whichblocksthe
sebaceousoutflow.
A40yearoldNigerianmanpresentswithapigmentedlesiondeeptothelefthalluxnailplate.
IncorrectThecorrectanswerisAcralmalignantmelanoma
Acrallentiginousmelanomasariseonthepalms/solesoraroundthetoenailsandaremorecommonin
darkskinnedpeoples.
A32weekpregnantwomanwithrightsidedabdominalpain.
IncorrectThecorrectanswerisAppendicitis
Acuteappendicitisisthemostcommonsurgicalemergencyinpregnancy.Appendicitisinpregnancyshould
besuspectedwhenapregnantwomancomplainsofnewonsetofcentralorrightsidedabdominalpain.One
studyfoundconsiderablefoetallossafterappendicetomyduringpregnancyinthefirstandsecond
trimester.
Reference:
AndersenB,NielsenTF.Appendicitisinpregnancy:diagnosis,managementandcomplications.ActaObstet
GynecolScand.1999;78:75862.
A7yearoldgirlpresentswithhaematuriaandsuprapubicpain.
IncorrectThecorrectanswerisUrinarytractinfection
21
Ina7yearoldgirlthemostlikelycauseofhaematuriaandsuprapubicpainisurinarytractinfection.
Haematuriamaybeattributabletourinarystonesorunderlyinganatomicalconditionssuchas
vesicoureteralreflux,renalvascularabnormalities,PUJobstruction,VUJobstructionandtumours.
Awomanwhois18weekspregnantpresentswithsuprapubicpainandhistoryofrecentcough.
IncorrectThecorrectanswerisIgAnephropathy
IgAnephropathy(Berger'sdisease)isthemostcommonglomerulonephritisworldwide,and
characteristicallyaffectsyoungmales,presentingwithfrankhaematuriaafteranepisodeofpharyngitis.
Howeveritmayalsopresentwithproteinuria,microscopichaematuria,renalfailureorhypertension.Itis
probablypartofaspectrumofdiseasewithHenochSchoenleinPurpura,whichpresentswitharthritis,
rash,abdominalpainandnephritis.InboththerearemesangialIgAdepositsinthekidney
Fortwoyearsa38yearoldwomanhashadintermittentshootingpainalongtherightfifthfinger.
IncorrectThecorrectanswerisThoracicoutletsyndrome
Thoracicoutletsyndrome(TOS)iscausedbycompressionofthebrachialplexus,subclavianarteryor
subclavianveininthethoracicoutlet.Almostallpatients(95%)presentwithneurologicalsymptoms.
handpainisoftenmostsevereinthefourthandfifthfingers.
Therearemanynonanatomicalcauses,including:
repetitivepressure
sports(e.g.weightlifting,archery,swimming,andtennis)
occupationsinvolvingrepeatedoverheadwork(e.g.plastering,painting,shelfstacking)
obesity,and
poorposture.
Trauma,suchasfracturedclavicle,maycauseTOS.
Thecommonestanatomicalcauseofarterialsymptomsisacervicalrib,whichoccursin0.4%ofthe
population.Although70%ofcervicalribsarebilateral,symptomstendtobeunilateral.
Neurologicalsymptomsandsignsinclude:
pain
paraesthesia
weakness,and
musclewasting.
Vascularsymptomsandsignsinclude:
distendedarmveinswhichdonotcollapseevenonlimbelevation
22
venousthrombosis
cyanosis
oedema
arterialthrombosis(acuteischaemiaorclaudication)andembolisation(digitalischaemia),and
poststenoticdilatationandaneurysmformation
A68yearoldwomanhasdevelopedintermittentpaininthethenareminence.Thesymptomsare
exacerbatedwhenliftingheavyobjects.
IncorrectThecorrectanswerisOsteoarthritisinjoint
Osteoarthritisofthefirstcarpometacarpaljointisextremelycommonandina65yearoldladyisthe
mostlikelydiagnosis.Swellingisusuallybonyhardandduetoosteophyteformationwhichcanleadto
theappearanceofsquaringofthehand.
A28yearoldfemalesecretarycomplainsofpaininherdominantindexfinger.Thesymptomsworsen
throughtheday.
IncorrectThecorrectanswerisCarpaltunnelsyndrome
Themediannerveentersthehandthroughthecarpaltunnel,deeptotheflexorretinaculum,alongwith
theninetendonsoftheflexorsdigitorumsuperficialisandprofundusandtheflexorpollicislongus.
Thecarpaltunnelisthechanneldeeptotheflexorretinaculumbetweenthetuberclesofthescaphoid
andtrapezoidbonesonthelateralsideandthepisiformandhookofhamateonthemedialside.
Distaltothecarpaltunnel,themediannervesuppliesthethreethenarmusclesandthefirstandsecond
lumbricals.Italsosendssensoryfibrestotheskinoftheentirepalmarsurface,thesidesofthefirst
threedigits,thelateralhalfofthefourthdigitandthedorsumofthedistalhalvesofthesedigits.
Howeverthepalmarbranch,whichsuppliesthecentralpalm,arisesproximaltothecarpaltunneland
doesnottraversethetunnel,itrunssuperficialtotheflexorreticulumthereforethereisnolossof
sensationintheskinincarpaltunnelsyndrome.
Carpaltunnelsyndromeisduetoinflammationofsynovialsheathsthatsignificantlyreducesthesizeof
thecarpaltunnel.Fluidretention,infection,andexcessiveexerciseofthefingersmaycauseswellingof
thetendonsortheirsynovialsheaths.
Themediannerveisthemostsensitivestructureinthecarpaltunnelandthereforeismostaffected.
Progressivelossofcoordinationandstrengthinthethumbisduetoweaknessoftheabductorpollicis.
Astheconditionprogresses,sensorychangesradiateintotheforearmandaxilla.
23
A59yearoldmanisundergoingafemorodistalbypassgraftforcriticalischaemia.Avenousconduit
isused.Thevascularsurgeonwantstoavoidasizemismatchbetweentheendsoftheconduittobe
anastomosed.Avalvulotomecuttingknifeispulledbackthroughthegrafttodisruptthevalvesinthe
veinlumem.
IncorrectThecorrectanswerisInsitu
Insitugraftingisthemethodofchoiceforvesselsaroundthekneeornearthefoot.Theveintributaries
areligatedandtheupperendisthenfreedandmobilisedfromthefemoralveinwhichisoversewen.
Theveinisthenanastomosedtotheartery.Theclampsarethendividedandtheveinisallowedto
distendproximaltothefirstcompetentvalve.Thevalvulotomeisthenpasseduptheveintothe
distendedsegmentandisthengentlywithdrawndisruptingthevalvesonebyone.Thedistalendis
thenanastomosedtotheartery.
A67yearoldmanpresentstothevascularoutpatientsclinicwithrightfootrestpainandbilateralshort
distanceclaudication.Heunderwentacoronaryarterybypassgraftingtwoyearsbeforeinwhichthe
longsaphenousveinwasharvestedfromtherightleg.Heunfortunatelydevelopedanextensive
iliofemoralDVTintheleftleginthepostoperativeperiodfollowingtheCABG.Avascularprocedure
isplannedonhisrightleg.
Correct
Thismanhasnolegveinsavailabletoactasaconduit.MostcommonlyaPTFEgraftisused.
However,thereisalowerpatencyrateatoneyearwithsyntheticgraftscomparedtovenousgrafts.
Somevascularsurgeonsrecommendharvestofarmveinswhenlegveinsarenotavailable.
A63yearoldmanpresentstothephysiciansfollowingatransientischaemicattack,onexaminationhe
hasafever.InitialbloodculturesgrewStreptococcus.AnabdominalCTscanshoweda5.7cminfra
renalabdominalaorticaneurysm,therearesignstheaneurysmmaybemycotic.
IncorrectThecorrectanswerisImpregnated
Thediagnosisofamycoticorganismcanonlybedefinitelymadewhenorganismsareculturedfrom
theaneurysmwall.Astheaneurysmisgreaterthan5.5cm,itrequiresrepair.Ifasyntheticgraftisto
beuseditshouldbeimpregnatedwithantibiotics.Thepatientwillrequireaprolongedcourseofiv
antibioticsbasedonculturespreoperativelyandforatleasttwoweekspostoperatively.Some
surgeonsstilladvocateatwostageapproachwithanaxillobifemoralgraftbeingformedfirstandthen
ligationoftheabdominalaortaanumberofweekslater.
24