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Poupart ligament refers to the inguinal or groin ligament. Compression bands are also known as pressure bandages; are used to control bleeding and encourage blood clotting without constricting normal blood circulation. Esmarch tourniquet is used to stop bleeding located on the limbs.
Pneumothorax is air in the pleural cavity i.e., accumulation of air between the lungs and chest wall. Accumulation of air will prevent chest excursion on the affected side during respiration, that is why we see no chest movement on that side ( here the right side of the chest lags during respiration).Pneumothorax develops when air enters the pleural space as the result of disease or injury. This leads to a loss of negative pressure between the two pleural membranes, which can result in the partial or complete collapse of the lung. Pneumothorax is classified as spontaneous or traumatic. Spontaneous pneumothorax can be further classified as primary (i.e., no underlying lung disease) or secondary (i.e., due to underlying lung disease). Any type of pneumothorax can progress to tension pneumothorax. Symptoms include; dyspnea, ipsilateral chest pain, diminished breath sounds, and hyper-resonant percussion on the affected side
Hemothorax, hydrothorax will give dull sounds during percussion because of the presence of fluid.
rule of “nines” – area of different areas of the body is proportional: anterior surface of the trunk – 18 %, posterior – 18 %, lower limb – 18 %, external genitals – 1 %);
rule of “palm”. It is used if burns are limited and located on different areas of the body. According to the rule, the palm takes 1 % of the skin surface.
Division of the burns on superficial (I, II, IIIA st.) and deep (IIIB-IV st.)
I stage – hyperemia of the skin
II stage – separation of epidermis with formation of bullas/
III A stage – necrosis of superficial layers of the skin with saving of bulbs hair, sweat glands and sebaceous glands.
IIIB stage – necrosis of all the derma
IV stage – necrosis of the skin and underlying tissues.
Notice that on ultrasound examination, pyelocaliectasis was observed. This refers to the dilation of the renal pelvis and calyces. The most common causes of pyelectasis are:
Ureteropelvic junction obstruction: A blockage of urine between the kidneys and the ureter
Vesicoureteral reflux: An abnormal flow of urine from the bladder to the kidneys.
This Presents with excruciating spasms around the lumbar region ( renal colic).
This patient is said to have a nonspecific ulcerative colitis which is an inflammatory bowel disease characterised by the presence of ulcers and sores in the innermost lining of your large intestine (colon) and rectum. On the other had, corticosteroids possess anti-inflammatory, immunosuppressive and anti-pyretic actions, in patients with inflammatory bowel diseases such as chrohns and ulcerative colitis, these drugs are administered as short term treatment because they quickly reduce inflammation ( within few days to month).
Ulnar Nerve: Sensory innervation to the Fifth and medial half of the fourth digits; Motor innervation: flexion, adduction and abduction of 4th and 5th digits. Injury to this nerve causes Claw hand
Median Nerve: innervates the skin of the palmar side of the index finger, thumb, middle finger, and half the ring finger, and the nail bed; motor innervation: flexion of lateral fingers, thumb opposition, lumbricals of index and middle fingers. Injured in Carpal Tunnel syndrome and leads to ape’s hand.
Radial Nerve: Sensory innervation to the dorsum (back) of the hand except the little finger (supplied by ulnar). Motor innervation to the dorsum of the hand. Injury leads to loss of grip strength, wrist drop ‘drop hand’.
Recall that the complications of ulcers include Bleeding (hemorrhage), penetration, perforation, outlet obstruction and malignization.
Hemorrhage: Hemorrhage is the most common complication of peptic ulcer disease. Symptoms include hematemesis (vomiting of fresh blood or "coffee ground" material); passage of bloody or black tarry stools (hematochezia and melena, respectively); and weakness, orthostasis, syncope, thirst, and sweating caused by blood loss.
Penetration: A peptic ulcer may penetrate the wall of the stomach or duodenum and enter the adjacent confined space (lesser sac) or organ (eg, pancreas, liver). Pain may be intense, persistent, referred to sites other than the abdomen (usually the back when caused by penetration of a posterior duodenal ulcer into the pancreas), and modified by body position.
perforation: perforation usually presents as an acute abdomen. Ulcers that perforate the peritoneal cavity are usually located in the anterior wall of the duodenum or, less commonly, in the stomach. The patient experiences sudden, intense, steady epigastric pain that spreads rapidly throughout the abdomen, often becoming prominent in the right lower quadrant and at times referred to one or both shoulders.
Gastric outlet obstruction: This may be caused by scarring, spasm, or inflammation associated with an ulcer. Symptoms include recurrent large volume vomiting, occurring more frequently at the end of the day and often as late as 6 h after the last meal. Persistent bloating or fullness after eating and loss of appetite also suggest gastric outlet obstruction. Prolonged vomiting may cause weight loss, dehydration, and alkalosis.
Malignization/ Stomach cancer: H. pylori is associated with intestinal-type adenocarcinoma of the gastric body and antrum but not cancer of the gastric cardia. Gastric lymphomas and mucosa-associated lymphoid tissue (MALT) lymphomas have also been linked to this infection.
A positive Kulenkampff’s symptom refers to an acute pain during palpation of the stomach and an absent tension of muscles of the anterior abdominal wall. This sign helps in the diagnosis of abdominal bleeding. The main symptom of a ruptured spleen is pain located around the left costal arch. A kidney related pathology will present with pain in the lumbar region (since the kidney is a retroperitoneal organ) and also have an effect on urine. Pancreatic pathologies will present with belt-like pain. In peritonitis, the pain is dull and poorly localised.
This patient is experiencing multiple hemorrhages; notice that the platelets are very low ( Platelet count 150 − 400 · 109/L- norm) and due to the continuous hemorrhage, the rbc, hemoglobin level and wbc levels are low - this signals the increased production of reticulocytes ( which are immature red blood cells). Recall that the spleen acts as a blood filter, removing damaged or abnormal blood cells. In patients with Immune thrombocytopenia, their immune system treats the blood platelets as foreign bodies, thereby signaling their removal by the spleen leading to thrombocytopenia. Therefore, if the spleen is removed, more platelets can be preserved.
A carbuncle is a collection of boils ( pus filled inflammation) all connected under the skin. This patient presents to the surgeon with carbuncle and edema of the upper lip and eyelids. The surgeon should admit this patient, drain the carbuncle, followed by an antibiotic regime with observation of the patient to see if any complication arises.
Duroziez sign is elicited as an audible systolic murmur heard over the femoral artery when the artery is compressed proximally along with a diastolic murmur when the femoral artery is compressed distally. This patient presents with signs of an occluded left femoral artery, these include; pain while walking, numbness and coldness. Also notice that since this issue began just 3 hours before- it is an acute case. The state of the skin of the left foot and shin; a marbled skin is seen when blood supply is not adequate to that area - in this case due to an occlusion to the left femoral artery.
From anamnesis, there is an abscess ( fluid filled cavity) in the left lung. The development of sudden pain, dyspnea and tachycardia raises a question about the worsening of the patient’s current state. The result from the Ro-gram ( pulmonary function study) shows the presence of air and fluid in the pleural cavity of the left lung thereby indicating that the earlier mentioned abscess has burst open and its content has spread into the pleural space.
This patient is currently having a spontaneous pneumothorax. Spontaneous pneumothorax refers to the sudden collapse of the lungs in the absence of any apparent cause such as trauma or any underlying lung pathology. Notice that the chest radiography shows the collapse of the left lung indicating a spontaneous pneumothorax. This is an emergency procedure that requires a Thoracostomy to be carried out ( a small surgical incision that allows the drainage of air, fluid etc).
The type of drainage selected depends on the cause and type of pleural disease.
Passive drainage relies on the increased intrathoracic pressure generated during exhalation. This will force air from the pleural space. This has been shown to be very effective in treating spontaneous pneumothorax and traumatic pneumothorax. There is no active suction on the lungs, the theory being this will allow small ruptures in the pulmonary parenchyma to heal whereas constant suction could dislodge the fibrin and lead to delayed healing of the tear in the pulmonary tissue.
Active drainage entails suction consistently placed on the thoracostomy tube and works well in the case of marked pleural effusion and pyothorax.
Intestinal obstruction refers to the blockage of food from getting into the small intestine and colon. These blockades can be as a result of strictures ( from an inflammatory condition), medications, fibrotic changes etc. Abdominal cramps, bloating, constipation, inability to pass stool are key findings in this condition. For confirmation of diagnosis of intestinal obstruction, an abdominal X-ray is recommended. Although not all obstructions can be viewed via an abdominal x-ray, additional examinations include abdominal ultrasound and CT.
Bronchiectasis is the abnormal and persistent dilatation of the smaller bronchi and mainly the segmental or subsegmental bronchi due to destruction of elastic tissues and muscles of the bronchial wall.
Social limitations in addition to treatment failure, despite preventive precautions and aggressive medical treatment, are the main indications for surgery in patients with bronchiectasis. For a patient that has lived with this condition for 12 years, we can safely assume that she must have tried conservative management which definitely did not work as we can still see exacerbations of the symptoms.
Cases with long-term treatment lead a life without comfort and with high risk due to life-threatening complications. It is important to perform surgical treatment when indicated to save patients from these risks and to minimize the surgical risks in delayed cases.
The left lower lobe is affected so the surgery will be a resection of the left lower lobe - left lower lobectomy.
Ventricular rupture is a known complication of Myocardial infarction and this patient currently presents with signs and symptoms of cardiac tamponade - extravasation of blood into the pericardial cavity preventing the heart from pumping properly.
We can pick out: muffled heart sounds; low blood pressure (hypotension 60/20mmHg); elevated jugular venous pressure (evidenced by swelling and throbbing of the neck veins). These three signs are known as Beck’s triad. They indicate a Cardiac Tamponade (the impaired pumping ability of the heart due to accumulation of fluid in the pericardium). Note that percussion reveals heart border extension in both directions. The most suitable approach should be a pericardial puncture (pericardiocentesis) to remove the fluid in the pericardium. A thoracotomy can be carried out to gain access to the pleural cavity.
A patient that underwent surgery for diffuse toxic goiter presented with a high metabolic rate (elevated body temperature, tachycardia, tachypnea) 24hrs post-operation. This patient currently has a thyrotoxic crisis.
One of the rarer complications from thyroid surgery is precipitation of a thyroid storm, which can occur intraoperatively or postoperatively. It is thought to occur secondary to thyroid gland manipulation in the operating room in patients with hyperthyroidism.
Thyroid (or thyrotoxic) storm is an acute, life-threatening syndrome due to an exacerbation of thyrotoxicosis. Classic features of thyroid storm include fever, marked tachycardia, heart failure, tremor, nausea and vomiting, diarrhea, dehydration, restlessness, extreme agitation, delirium or coma.
Hypothyroid crisis will present with bradycardia, low body temperature, low respiratory rate, constipation etc. Postoperative tetany is a possible postoperative complication in thyroid surgery as the parathyroid gland which resides behind the thyroid could be accidentally resected. Postoperative tetany indicates low calcium levels of which it will most likely be associated with bradycardia instead of the 110bpm (tachycardia) seen in this patient.
Extension of a tonsil infection can take place in the surrounding tissue and is referred to as a Peritonsillar abscess or quinsy. The 26 year old man had previously had angina (acute tonsillitis) but didn’t follow medical advice. This complication of tonsillitis is usually caused by a B-hemolytic streptococcal infection and are characterised by an extremely sore throat and high fever (as seen in the patient) .
A peritonsillar abscess forms in the tissues of the throat next to one of the tonsils. An abscess is a collection of pus that forms near an area of infected skin or other soft tissue. The abscess can cause pain, swelling, and, if severe, blockage of the throat. If the throat is blocked, swallowing, speaking, and even breathing become difficult.
The key sign that distinguishes quinsy/peritonsillar abscess from ordinary tonsillitis is the presentation of trismus. Trismus is usually absent in any form of tonsillitis but would be seen in a Peritonsillar abscess.
Benign Prostate Hyperplasia (BPH) is a non carcinogenic pathology that occurs in men usually above 40 years of age. It presents with symptoms similar to Prostate cancer. These include painful urination (dysuria), acute urinary retention, urinary frequency, hesitancy, dribbling, and frequent nighttime urination (nocturia). To differentiate between these two pathologies, an objective examination is carried out - a digital rectal examination or prostate biopsy. In this case, on digital rectal examination, the prostate is dense, enlarged, elastic and well defined with no nodes - these findings support the initial diagnosis of BPH because on digital rectal examination, prostatic carcinoma will not be well defined and will present with nodes. To further prove this diagnosis, the Prostate specific antigen is measured (normal <4). A marginal increase is going to support the diagnosis of BPH while PSA of 10 and above will indicate prostate cancer.
From the vaginal examination, we observe the presence of a very large fibroid mass that causes the enlargement of the uterus and is responsible for the severe pain the woman is experiencing and the mucous discharge. Coupled with the positive symptom of peritoneal irritation, this patient is in need of an urgent surgical procedure.
Uterine fibroids are noncancerous growths that grow in the wall of the uterus. When fibroids cause heavy bleeding or painful symptoms, and other treatments are ineffective, a doctor may recommend surgery. People with asymptomatic fibroids do not require surgery or other treatments. However, other people experience severe abdominal pain, pressure, bloating, pain during sex, frequent urination, and heavy or painful periods. These individuals may require surgery.
Myomectomy is a surgical procedure that removes fibroids. Depending on the location of these growths, a surgeon may also have to remove other tissue in the process. The traditional technique is quite invasive as it uses a relatively large cut (Laparotomy). This incision may go from the bellybutton to the bikini line or run horizontally along the bikini line. Some surgeons also perform laparoscopic surgeries, which use smaller incisions but require more skill. However, in this case, a fibroid as big as 9 weeks gestation will require a big incision and laparoscopic surgery will not be able to get the fibroid out.
The patient in question presents with obstructive/mechanical/post-hepatic jaundice. The gallbladder is enlarged and tense and the patient also presented with general weakness, poor appetite plus progressive jaundice.
Obstructive jaundice is a common clinical manifestation of pancreatic cancers, especially in patients with malignant tumors of the head of the pancreas. Obstructive Jaundice is a common surgical problem that occurs when there is an obstruction to the passage of conjugated bilirubin from liver cells to intestine.
Cancer of the head of the pancreas appears near the common bile duct. From an early stage, they tend to compress this duct leading to an obstruction in bile flow (causing an obstructive jaundice).
Apart from Cancer of the head of pancreas, other causes of obstructive jaundice include: biliary stricture (narrowing of the bile duct); cholangitis (infection or inflammation of the common bile duct); cholelithiasis (gallstones); cysts of the bile duct; parasitic infection etc.
Note that Cholecystitis usually presents with pain in the right upper quadrant and signs of systemic infection (pyrexia, raised leukocyte count, raised C-reactive protein). The above patient presents with none of these symptoms thereby ruling out the options of cholecystitis.
The idea here is to Place the tourniquet between the injured vessel and the heart and the tourniquet should be over a bone, not on a joint. For arterial bleeding, the tourniquet should be above the wound which usually falls between the wound and the heart. And venous bleeding is usually below the wound.
Understanding the anatomy will help you to understand this better. Arteries take blood away from the heart, so for arterial bleeding, the blood is flowing from the heart to the wound, so you tie above it to stop the flow.
For Venous bleeding, Veins take blood to the heart, so you tie below the wound to stop the flow towards the wound (heart).
Definitive treatment for Acute Appendicitis is Surgical. Conservative management with medications to relieve pain or stop inflammatory processes will only produce temporary relief.
ESR is elevated which is a sign of an inflammatory process. Right iliac fossa tenderness and right iliac fossa pain (Rebound tenderness, blumberg sign) are pointers to Acute Appendicitis.
Diagnosis of Appendicitis is made clinically, Ultrasound or abdominal X-ray will not give a definite diagnosis. When we say a diagnosis is clinical, it means the diagnosis is based on signs and symptoms elicited clinically. In this case, positive signs of appendicitis will give a better diagnosis than report of X-ray or Ultrasound.
Appendiceal signs: Pain elicited in any of these signs indicates a positive test
Rebound tenderness: To elicit the sign, gentle pressure is placed on the right iliac fossa of the abdomen and then the hand is lifted suddenly. A sudden increase in abdominal pain occurs when the examiner's hand is lifted.
Rovsing's sign is elicited by pushing on the abdomen in the left lower quadrant as in most people the appendix is in the right lower quadrant. While this maneuver stretches the entire peritoneal lining, it only causes pain in any location where the peritoneum is irritating the muscle. In the case of appendicitis, the pain is felt in the right lower quadrant despite pressure being placed elsewhere.
Obturator sign: First the patient lies on his back with the right hip flexed at 90 degrees. The examiner then holds the patient's right ankle in his right hand. With his left hand, the examiner rotates the hip by pulling the right knee to and away from the patient's body.
Fibroadenomas are typically present as firm, mobile, painless, and frequently multiple breast nodules. These tumors are common, benign breast tumors that usually affect women in second and third decades of life. Fibroadenomas are usually small and can be managed conservatively; however, a good percentage of these lesions will grow rapidly.
During pregnancy, fibroadenomas increase in size and may show lactational histologic changes. High concentrations of estrogen, progesterone, and prolactin promote the ductal growth and formation of tubuloalveolar structures. This may be a reason for the significant enlargement in this period.
Hence, it is recommended that it be removed prior to pregnancy.
A filling defect was observed in the imaging technique used, which is a well defined oval mass indicating a tumor. Notice that mucosal walls are intact and wall peristalsis and elasticity are not affected- these rule out the options of achalasia cardia, Esophageal burns and barrett's esophagus ( because in these pathologies, one or more of the above listed is/are affected). The result from the x-ray shows a mass with clear oval borders thereby indicating a tumour.
Achalasia Cardia is a rare neurodegenerative disorder of esophagus resulting in defective peristalsis and impaired relaxation of lower esophageal sphincter. In Barrett's esophagus, the mucosal lining transforms from normal stratified squamous epithelium to simple columnar epithelium.
Intravenous or Excretory Urography is an X-ray procedure that involves the intravenous administration of contrast material inorder to verify and localize upper urinary tract diseases. Retrograde pyelogram also uses a contrast agent for better visualization of the ureters and kidneys but note that: In intravenous pyelogram, the contrast dye is injected into a vein while in retrograde pyelogram, it is injected directly into the ureters. Retrograde pyelogram is mostly done in cases where excretory urography does not give a clear image of the pathological area.
Many patients with penetrating thoracic injuries do not survive to the Emergency Department (ED), and those that do survive to the ED often require immediate interventions such as tube thoracostomy, intubation, and thoracotomy.
Thus, the emergency clinician must be able to rapidly diagnose and treat injuries that are immediately life-threatening as in this case that presented with a Gunshot injury.
The above patient presents with a major trauma to the right side of the chest which is confirmed by a hemothorax (Hemothorax).
Thoracotomy is a surgical procedure carried out inorder to have access to thoracic organs such as the lungs, heart or esophagus. This procedure is the first step in gaining access to the thoracic cavity and thus is indicated in cases of a lobectomy, major trauma of the chest, pneumonectomy. In the case of this patient, an emergency thoracotomy should be carried out in order to drain the blood and prevent compression and eventual collapse of the lungs.
Thoracentesis or Pleural puncture is a procedure in which a needle is inserted into the pleural space between the lungs and the chest wall. This procedure is done to remove excess fluid, known as a pleural effusion, from the pleural space to help you breathe easier. In this case, it’s not just fluid, there are blood clots. So, an incision (thoracotomy) should be made and arrest the bleeding, then drain. This patient needs this to be done as soon as possible, that’s why the best answer choice is the Emergency Thoracotomy.
It’s not enough to use hemostatic therapy, the clots must be removed and blood drained. Thoracoscopy is an imaging technique and the X-ray has given enough information at this point.
Abdominal adhesions refer to bands of scar tissues that form between abdominal tissues and organs causing them to stick together; These are one of the major causes of intestinal obstructions. Notice that this patient underwent an operation for acute destructive appendicitis and since then has had complaints of bloating and abdominal pains; fibrous bands of scar tissue that formed after this procedure are the most likely cause of the intestinal obstruction.
Ileal diverticulum (meckel's diverticulum) refers to the bulging out of the lower part of the small intestine. It can be a major cause of intestinal obstruction, but not in this case.
Having hypertension, increases the risk of the surgery - for this patient, the blood pressure should be corrected before the surgery can be carried out.
In hypothyroidism, there is reduced production of thyroid hormones ( T3 and T4) leading to findings such as; reduced metabolic rate, fatigue, cold intolerance, weight gain, and periorbital edema. Notice that this patient underwent a thyroid surgery due to thyrotoxicosis (clinical manifestation of hyperthyroidism); she currently presents with signs of hypothyroidism ( post surgery).
The 43 year old female patient with signs of edema (swelling of legs), dyspnea, ascites (abdomen enlargement), pricking heart pain, bulging neck veins (increased pressure in jugular veins), muffled heart sounds with history of Tuberculous bronchadenitis most likely has Tuberculous pericarditis.
Tuberculous pericarditis is an important complication of tuberculosis (TB); the diagnosis can be difficult to establish and is often delayed or missed, resulting in late complications such as constrictive pericarditis as seen in this patient with bulging neck veins and pricking heart pain.
The management is therefore aimed at anti tuberculosis medications for six months, drain fluid from the pericardium if the patient has heart failure, and sometimes remove the pericardium if it is thick and making the patient ill (this will require the skill of a cardiac surgeon); and sometimes give corticosteroids to reduce the effects of the inflammation.
The major complaints here that necessitated presentation to the hospital are the symptoms of heart failure and management of this patient’s cardiac condition will require the expertise of a cardiac surgeon.
Lung abscess is a type of liquefactive necrosis of the lung tissue and formation of cavities (more than 2 cm) containing necrotic debris or fluid caused by microbial infection. It can also be caused by aspiration, which may occur during altered consciousness and it usually causes a pus-filled cavity.
Recall that An abscess is a cavity filled with Purulent content found within body tissue. This patient presents with an acute abscess of the left lung and can be easily identified on X-ray fluid as a cavity with air-fluid level.
One major complication of an abscess is the rupture and release of its content into surrounding tissues. This is a serious medical concern. Potential complications following rupture of an abscess could lead to Empyema - this is a large collection of infected fluid around the lung that occurs where the abscess is. As seen in this patient with air and horizontal fluid level in the pleural cavity.
A person who has frostbite should be covered with a warm blanket ( a warm bandage on the affected area). The frostbitten area should be warmed slowly and should not be warmed in front of a fire nor rubbed with snow. A vasodilatory injection such as Reserpine can be administered to improve blood flow to the affected area. Antibiotic therapy can also be given.
An abscess is a purulent filled cavity found within the body tissue. A wound abscess occurred in this process mainly due to an infection before or during the closure of the wound. This is confirmed by the presence of edema and purulent content from the wound gap 4 days after the closure. The sutures of this wound should be removed and the purulent content should be drained followed by an antibiotic therapy.
This patient who is 20 days postpartum most likely has Postpartum or Puerperal Mastitis. It is an inflammation of breast tissue that sometimes involves an infection. The inflammation results in breast pain, swelling, warmth and redness. You might also have fever and chills. Mastitis most commonly affects women who are breast-feeding (lactation mastitis). Milk that is trapped in the breast is the main cause of mastitis. Also, Bacteria from your skin's surface and baby's mouth can enter the milk ducts through a crack in the skin of your nipple or through a milk duct opening. Stagnant milk in a breast that isn't emptied provides a breeding ground for the bacteria.
From the question stem, In the upper quadrant of the left breast, there is an infiltrate sized 10 X 15cm with a softening inside. This case will require an incision and drainage which will be done by the surgical team followed by antibiotic treatment.
Normal Rbc level in the blood ranges from about Male: 4.3 − 5.9 · 1012/L Female: 3.5 − 5.5 · 1012/L and hemoglobin level: Male: 135-175 g/L; Female: 120-160 g/L. A reduction in these values in the blood test indicates Anemia. Red blood cells are produced in the bone marrow of large bones and a bone marrow biopsy is needed for diagnosis. Platelets and White Blood Cells are also markedly decreased in this case. We are actually looking at a case of Pancytopenia.
Pancytopenia occurs when a person has a decrease in all three blood cell types. This happens when something is wrong with the bone marrow, where blood cells are formed. Pancytopenia has many possible causes: Diseases such as cancer, lupus or bone marrow disorders. Sternal puncture which is a type of bone marrow biopsy is indicated to verify the diagnosis.
Many patients with penetrating thoracic injuries do not survive to the Emergency Department (ED), and those that do survive to the ED often require immediate interventions such as tube thoracostomy, intubation, and thoracotomy. Thus, the emergency clinician must be able to rapidly diagnose and treat injuries that are immediately life-threatening as in this case that presented with a Gunshot injury.
The above patient presents with a major trauma to the right side of the chest which is confirmed by a hemothorax and pneumothorax (Hemopneumothorax). Thoracotomy is a surgical procedure carried out in order to have access to thoracic organs such as the lungs, heart or esophagus. This procedure is the first step in gaining access to the thoracic cavity and thus is indicated in cases of a lobectomy, major trauma of the chest, pneumonectomy. In the case of this patient, an urgent thoracotomy should be carried out in order to take out the bullet and prevent eventual collapse of the lungs.
Blumberg sign refers to the presence of pain upon removal of pressure on the abdomen. It is a clinical sign that indicates Peritonitis ( inflammation of the peritoneum).
A laparotomy is a surgical incision into the abdominal cavity done to examine the abdominal organs and aid diagnosis. From the listed options, an urgent diagnostic laparotomy procedure should be carried out to confirm the incidence of Peritonitis.
Many babies born with a small ventricular septal defect (VSD) won't need surgery to close the hole. After birth, the doctor may want to observe the baby and treat symptoms while waiting to see if the defect closes on its own.
Babies who need surgical repair often have the procedure in their first year. Children and adults who have a medium or large ventricular septal defect or one that's causing significant symptoms may need surgery to close the defect.
With this 5 year old boy already having exertional dyspnea, fatigability and in the sub compensation stage, it is an indication for Surgery in order to close the defect. Surgical treatment for ventricular septal defects involves plugging or patching the abnormal opening between the ventricles.
In the sub compensation stage and with the child already showing symptoms of dyspnea, conservative treatment is no longer indicated. Indomethacin is used in the case of patent ductus arteriosus due to its inhibitory effect on Prostaglandin E2 which helps in closing the ductus arteriosus immediately after birth.
Lobectomy has been generally recommended as an optimal surgical approach for symptomatic unilateral goiter, toxic adenoma, and low-risk differentiated thyroid cancer. Although patients are expected to maintain normal thyroid function after lobectomy or subtotal resection since not all the thyroid tissue was resected, some patients develop hypothyroidism that requires thyroid-hormone replacement. Routine levothyroxine (L-Thyroxine) supplementation is commonly prescribed for prophylaxis of postoperative hypothyroidism.
Merkazolil and Iodomarin can be used in case of Hyperthyroidism. They are anti-thyroid medications. Lithium is commonly used in Psychiatry cases for Bipolar conditions but it is commonly associated with Hypothyroidism and will not be useful in this case.
Embryocardia is a symptom of heart disease in which the heart sounds resemble that of the fetal heart. In this condition, S1 and S2 sound cannot be distinguished and are equally spaced. This condition is usually seen in myocarditis. This patient presents with a tension Pneumothorax of the right lung indicated by the absence of breath sound on the right.
A tension Pneumothorax is a medical emergency in which air is drawn into the pleural space during inspiration and has no route of escape during expiration. Respiratory distress, tachycardia, hypotension, distended neck veins and deviation of trachea from the affected side are key findings. Unless the air is rapidly removed, cardiorespiratory arrest will occur.To evacuate the air, a pleural puncture ( Pleural tap, thoracocentesis) is carried out.
From anamnesis, we observe that this patient had an open fracture (trauma) of the lower third of the femur 2 years ago. The healing process was slow and accompanied by purulent inflammation. Osteomyelitis is a serious bone inflammation that can result from a previous trauma, puncture wound, surgery, bone fracture, abscessed tooth, or infection of soft tissue, the ear or sinus. Chronic osteomyelitis usually occurs after an acute episode of osteomyelitis when the infection has not been totally cured. Purulent discharge, bone pain, redness, swelling and elevation of temperature in the affected area are key findings.
Hematogenous Osteomyelitis usually occurs in Children and takes place on the background of a spreading infection via the blood.
Multiple myeloma is a cancer of the plasma cells and is characterised by the presence of bence jones proteins.
A positive Homan’s sign ( calf pain at the dorsiflexion of the foot ) indicates a case of Deep Vein Thrombosis (blood clot within a deep vein). Patients with DVT are mostly predisposed by
Stasis - due to post operation (as in this case), long drive/flight.
Hypercoagulability- can be due to a defect in coagulation cascade proteins eg factor V Leiden; oral contraceptive use.
One major complication of DVT is pulmonary embolism.
Unfractionated heparin or LMWH are used for prophylaxis or acute management.
Note that the color of blood and the rate of its flow helps us detect the type of bleeding. Arterial bleeding is characterized by bright red color with a pulsating stream (flow) while dark red blood is found in venous bleeding with the rate of flow being less.
Aure-rozanov sign is commonly seen in cases of retrocecal appendix; it refers to the presence of pain in the right petit triangle when palpated. The location of pain in the lower abdomen and right lumbar area rules out the option of cholecystitis ( right hypochondrium). The results from deep palpation of the abdomen helps put the provisional diagnosis of acute appendicitis.
From anamnesis, this patient had a trauma to the head which led to the results from palpation “ tense neck muscles and protruding spinous process of C4 vertebra. These findings help us put a provisional diagnosis of an Uncomplicated cervical fracture.
A thyroid fine needle aspiration biopsy is a procedure that removes a small sample of tissue from your thyroid gland. Cells are removed through a small, hollow needle. The sample is sent to the lab for analysis. In some cases, hard nodules form inside the gland. Most times, the nodules are not dangerous. But in some cases they can be thyroid cancer. A thyroid fine needle aspiration biopsy can take a sample from the nodule to test for cancer.
Thyroid scan (thyroid scintigraphy) is a nuclear medicine examination used to evaluate thyroid tissue. Clinical indications include; functional status of a thyroid nodule, thyrotoxicosis: differential diagnosis and thyroid cancer. Note that an ultrasound procedure has already been carried out therefore, carrying out a thyroid scintigraphy will just be a repetitive test.
Of all the listed injuries sustained, the brain concussion should be addressed first. Recall that brain concussion refers to a mild traumatic brain injury that affects your brain function. Effects are usually temporary but can include headaches and problems with concentration, memory, balance and coordination.
For the temporary stop of hemorrhage; - the imposition of a pressure
- the elevated position of the limb;
- digital pressure of the artery
- maximum limb flexion in the joint;
- stop bleeding with a tourniquet;
- stop bleeding from the carotid
artery according to the method of Mikulich. This patient is bleeding from the carotid artery ( bright red blood from the neck) therefore, the highlighted procedures should be followed.
The key finding here is ‘ the right part of the thorax is distended and takes no part in respiration’ this is an indicator for Tension Pneumothorax ( of the right side). Pneumothorax is the collapse of the lung when air accumulates between the parietal and visceral pleura inside the chest. A tension pneumothorax is a severe condition that results when air is trapped in the pleural space under positive pressure, displacing mediastinal structures, and compromising cardiopulmonary function i.e., (distended neck veins, tracheal deviation, and hemodynamic instability)
A peritonsillar abscess is a bacterial infection that usually begins as a complication of untreated strep throat or tonsillitis (4 days ago, the patient had a case of tonsillitis). also known as quinsy, it leads to the accumulation of pus due to an infection behind the tonsil. Key symptoms include; throat pain, difficulty swallowing , drooling , swelling of the face or neck, fever and chills. Notice that this patient presents with signs affecting the TONSILS; in a case of Pharyngitis, the posterior pharyngeal wall will be affected. In a case of infectious mononucleosis, Atypical lymphocytes will be present on analysis.
Notice that this patient had a trauma to the head from which he developed the signs of bradycardia, anisocoria, hemi-hyperreflexia, hemihyperesthesia and a convulsive disorder; a CT scan (computed tomography) should be immediately carried out to get a clear image of the internal structures of the head to find possible damages.
Pneumothorax is air in the pleural cavity ie, accumulation of air between the lungs and chest wall. A spontaneous pneumothorax is a form of pneumothorax without any underlying lung issue (just happens suddenly). N/B Tympanic resonance sound during chest percussion indicates the presence of air. Accumulation of air will prevent chest excursion on the affected side during respiration, that is why we see no chest movement on that side
Frostbite is an injury of the skin and underlying tissues that occur due to exposure to cold ( low temperature). There are 4 degrees of frostbite:
I Degree: lasts for about 5-7 days; after warming, paleness changes to hyperemia (redness). Edema of tissues progresses for about 2 days and then it decreases to 6-7 days when shelling (peeling) of epidermis appears. Tactile and pain sensitiveness (sensation) are preserved but sometimes with disorders. Pain in injured areas could be severe, itching also could be.
II Degree: characterised by the spreading of edema, appearance of bullaes. The bottom of the opened bullaes are covered with fibrin. Cyanotic skin and difficulty of movement of phalanges. Necrosis of keratic and granular layers. N/B growth layer of the skin is not lost and regeneration appears after 2 weeks. Scars are not formed.
III Degree: Necrosis of all skin layers or even fatty tissue appears. Inflammation develops: firstly aseptic and then on 5th- 7th day purulent . Bullas contain blood . Decrease of tactile and temperature sensation. Edema of tissues spreads on the proximal areas. Firstly skin has cyanotic color then dark brown and black crusts are formed.
IV Degree: Necrosis of all skin, fat tissue and even bones and joints. Results in amputation of the affected area.
Normal Rbc level in the blood ranges from about Male: 4.3 − 5.9 · 1012/L Female: 3.5 − 5.5 · 1012/L and hemoglobin levelMale: 135-175 g/L Female: 120-160 g/L. A reduction in these values in the blood test indicates Anemia. Red blood cells are produced in the bone marrow of large bones and a bone marrow biopsy is needed for diagnosis.
Renal calculus is simply kidney stones. These stones may be composed of calcium, fats, uric acid etc). These stones can cause a blockade in the ureter causing a very severe pain (as seen in the patient). An x-ray (KUB- kidney, urather,bladder film) can be used for diagnosis. N/B Radiolucent stones cannot be detected by an x-ray; this is why the plain abdominal x-ray did not produce a result in the patient in review. Other diagnostic methods such as ultrasound will be effective.
A cyst is a fluid filled cavity. Both cysts and tumors can be seen on x-rays and can be differentiated by the level of contrast on the film.
Surgically, lung cancer is divided into 3: Central, Peripheral and atypical. Central cancer includes the tumors of the first to third order bronchi ( main bronchi, secondary/lobar bronchi and tertiary/segmented bronchi). Peripheral cancer includes rounded tumour, pneumonia like tumor and pancoast’s cancer. Atypical forms include miliary carcinomatosis etc.
Basic complaints and signs of a central lung cancer include: Constant cough accompanied by hemoptysis, dyspnea, rales and prolonged or obstructive pneumonia.
On physical examination, asymmetry of the chest and delayed breathing movements on the affected side are observed.
On percussion; dull sound on the side of the lesion.
On auscultation, bronchial breathing or moist rales are observed
From the question stem, the patient presents with symptoms indicating a gallbladder related issue (cholelithiasis, cholecystitis, cholangitis etc); these symptoms include: pain in the right subcostal area especially after eating food rich in fat, bitter taste in her mouth in the morning, constipations, and flatulence.
An ultrasound allows sonologists to view images of the organs and soft tissues inside your body. This procedure is used in diagnosing conditions related to the gallbladder. It is fast, accessible, not cumbersome and less expensive, which makes it a first choice in this case.
The patient in question presents with symptoms related to the gastrointestinal system; heartburn, frequent constipations, headaches, irritability, stomach ache. Diseases such as Gastritis, GERD, Ulcers should all be speculated. To confirm one's diagnosis, an Esophagogastroduodenoscopy should be performed. This is a procedure during which a small flexible endoscope is introduced through the mouth (or, with smaller-caliber endoscopes, through the nose) and advanced through the pharynx, esophagus, stomach, and duodenum.
Radial Nerve: Sensory innervation to the dorsum (back) of the hand except the little finger (supplied by ulnar). Motor innervation to the dorsum of the hand. Injury leads to loss of grip strength, wrist drop.
From the question stem, there was no pulse detected over the pedal and popliteal arteries. This is a classic sign of ‘atherosclerosis obliterans’ a peripheral artery disease caused by occlusion of a major, medium or small sized artery (in this case of the lower left extremity).
Obliterating endarteritis is an inflammation that takes place in the inner lining of an artery (intima); it is seen in complications in relation to infections such as tuberculous meningitis, syphilis or in severe radiation poisoning.
Raynaud's disease is a rare disorder of the blood vessels, usually in the fingers and toes. It causes the blood vessels to narrow when you are cold or feeling stressed. When this happens, blood can't get to the surface of the skin and the affected areas turn white and blue.
‘ Meat slops’ sputum is a specific term used by Krok to describe a lung gangrene. A lung gangrene is a diffuse purulent necrosis of the tissue without the tendency of a defined demarcation.
Pleural empyema is a purulent inflammation of its visceral and parietal membranes, which is associated with accumulation of pus in a pleural space.
Lung abscess is defined as necrosis of the pulmonary tissue and formation of cavities containing necrotic debris or fluid caused by microbial infection.
Extension of a tonsil infection can take place in the surrounding tissue and is referred to as a Peritonsillar abscess or quinsy. This complication of tonsillitis is usually caused by a B-hemolytic streptococcal infection and are characterized by an extremely sore throat and high fever ( as seen in the patient) . Note that, Retropharyngeal abscess is also a complication of tonsillitis but is virtually limited to infants in the first two years of life; the characteristic findings are fever, hyperextension of the neck, dysphagia and noisy respiration.
Laparotomy: is a surgical incision of the abdominal cavity performed to examine the abdominal organs and aid diagnosis. Indications include: abdominal hemorrhage or hemoperitoneum, blunt chest trauma, peritonitis, intestinal obstruction etc and is contraindicated in cases of severe sepsis and malignancy.
Laparoscopy: A surgical procedure in which the abdominal organs are observed with the use of a laparoscope (a camera). Unlike a laparotomy, it uses small incisions. It is also known as a keyhole surgery or minimal invasive surgery. Indications include: Cholecystectomy, gastric bypass.
Laparocentesis: is simply the puncture of the peritoneal cavity to obtain its fluid.
Note that the above patient received a blow to the abdomen with the steering wheel- which indicates a blunt trauma; peritoneal irritation signs are positive- and indication for peritonitis.
The Presence of an increased body temperature and pain a days after the wound closure indicates ‘An Infection’ - most likely a bacterial form. To correct this, the sutures/wound dressing should be undone, drained ( if there be any purulent process), an antiseptic should be used in cleaning the affected area coupled with the administration of an antibiotic therapy to the patient.
Aromatic compounds such as benzene and its products (es nitrobenzene, benzidin etc) are major components in factories producing dyes and resins and upon exposure are dangerous to health. One major negative effect is the conversion of hemoglobin to methemoglobin. In recent times, it has been proved that these compounds act as carcinogens and lead to bladder related tumors.
Chronic Prostatitis is ruled out since the patient wasn’t experiencing pain while passing out urine.
In Chronic Cystitis, the patient often observes severe burning sensation in the pelvic region.
Ortner’s sign- tenderness on light percussion on right costal margin by the edge of the palm.
Murphy’s sign- a delay of breathing during palpation of gallbladder on inspiration.
Kehr’s point- acute pain at the tip of the shoulder.
Coupled with the positive result from the above stated signs, the patient also experienced bile vomiting, sharp bitter taste in her mouth, jaundice etc. These are signs specific for pathologies relating to either the gallbladder or liver.Therefore to confirm, the individual should undergo an ultrasound.
A fibrogastrodudenoscopy will be the preferred choice of diagnostic method if it was a Gastrointestinal tract related issue.
Vetebrogenous lumbar ischialgia is one of the clinical forms of reflex syndromes at lumbar – sacral level. Characterised by pain located in the lumbar area and irradiates towards the hips, legs ( as seen in the patient). It has three forms namely;
In Vertebrogenic radicular syndrome of L5-S1, pain is experienced in the external posterior surface of the hip, crus, foot, the 4th and 5th toes; sensory disorders in the same zones, paresis of toe flexors, absent or low achilles tendon reflex.
Poupart ligament refers to the inguinal or groin ligament. Compression bands are also known as pressure bandages; are used to control bleeding and encourage blood clotting without constricting normal blood circulation. Esmarch tourniquet is used to stop bleeding located on the limbs.