A PULSATILE MASS IN THE ABDOMEN

History A 68-year-old man presents to the emergency department with a 1h history of pain in the left side of his abdomen. The pain started suddenly while he was getting up from a chair.It became constant and radiated through to his back. His past medical history includes hypertension and stable angina. He lives with his wife and is normally independent. Examination The patient is pale, sweaty and clammy. His pulse is 100/min and the blood pressure is 90/50 mmHg. Heart sounds are normal and the chest is clear. Examination of the abdomen reveals a large tender mass in the epigastrium. The mass is both pulsatile and expansile. The peripheral pulses are present and equal on both sides. There is no neurological deficit. Questions • What is the most likely diagnosis? • What is required in the immediate management of this patient? • What is the prognosis? ANSWER The most likely diagnosis is a ruptured abdominal aortic aneurysm. An aortic aneurysm is defined as an increase in aortic diameter by greater than 50 per cent of normal (3 cm).The aneurysm diameter increases exponentially by approximately 10 per cent per year. As the aneurysm expands, so does the risk of rupture: Aneurysm size: • 5.0–5.9 cm,
25 per cent 5-year risk of rupture • 6.0–6.9 cm,
35 per cent 5-year risk of rupture • more than 7 cm,
75 per cent 5-year risk of rupture. Aneurysm rupture can present with abdominal pain radiating to the back, groin or iliac fossae. An expansile mass is not always detectable and other conditions, such as acute pancreatitis or mesenteric infarction, should always be considered. Intravenous access should be established quickly with two large-bore cannulae. Ten units of crossmatched blood, fresh-frozen plasma and platelets should be requested. The bladder should be catheterized and an electrocardiogram (ECG) obtained. It is important not to resuscitate the patient aggressively as a high blood pressure may cause a second fatal bleed. The patient should be taken immediately to theatre and prepared for surgery. A vascular clamp is placed onto the aorta above the leak and a graft used to replace the aneurysmal segment. Some centres now practise endovascular stenting of ruptured aneurysms in a patient stable enough to undergo computerized tomography (CT) scanning. The mortality from a ruptured aneurysm is high, with haemorrhage, multi-organ failure,myocardial infarction and cerebrovascular accidents accounting for most deaths.

General Medicine • General Surgery + 2 more

ABDOMINAL PAIN AND METABOLIC ACIDOSIS

History A 65-year-old man presents to the emergency department with an 8 h history of severe generalized abdominal pain. Earlier in the day he passed fresh blood mixed in with his stool.His past medical history includes diabetes, hypertension and atrial fibrillation. He is not currently taking any anticoagulation therapy for his atrial fibrillation. He smokes 20 cigarettes per day. Examination He has difficulty lying still on the bed. He has a temperature of 37.5°C with an irregularly irregular pulse of 110/min. His blood pressure is 90/50mmHg. Abdominal examination shows generalized tenderness with absent bowel sounds. Rectal examination confirms loose stool mixed with some fresh blood. Questions • What does the arterial blood gas show? • What is the most likely diagnosis? • What are the differential diagnoses? • What other investigations can you suggest? • What is the treatment and prognosis for this condition? ANSWER The arterial blood gas shows a metabolic acidosis (low pH, negative base excess and high lactate) with partial respiratory compensation (low pCO2). The most likely diagnosis is mesenteric ischaemia secondary to superior mesenteric artery thrombosis or embolism. Atrial fibrillation is a risk factor for embolism. Differential Diagnosis • Pancreatitis • Ruptured abdominal aortic aneurysm • Perforated viscus Investigation should include: • routine bloods and serum amylase to exclude pancreatitis • electrocardiogram • chest X-ray: may show free air under the diaphragm • abdominal X-ray: typically ‘gasless’ • computerized tomography of the abdomen: not always diagnostic with ischaemic bowel but would help to exclude an abdominal aortic aneurysm. The prognosis associated with this condition is poor, with less than 20 per cent survival.The patient should be resuscitated with intravenous fluids and broad-spectrum antibiotics given. The patient should then be taken for urgent laparotomy where any dead bowel isresected. Revascularization by embolectomy or bypass may improve doubtfully viable bowel and allow primary anastamosis. Otherwise, both ends of the bowel should be exteriorized. KEY POINTS • Atrial fibrillation increases the risk of arterial embolization. • A re-look laparotomy at 24 h may be required to check for further intestinal ischaemia.

Cardiology • General Medicine

BREAST INFECTION

History A 26-year-old woman who is 5 weeks post partum presents with right breast pain and a fever. She is breast-feeding her son. Over the last 3 weeks she has seen her general practitioner (GP) on two occasions with mastitis and has been prescribed antibiotics. However,the pain is now worsening and she is starting to feel more unwell. She is normally fit and healthy. She does not take any regular medications and is allergic to penicillin. Examination She has a temperature of 37.9°C and a pulse rate of 92/min. On examination, there is a localized, tender area, adjacent to the areola of the right breast. There is surrounding erythema and tender lymphadenopathy in the right axilla. Breast and endocrine Questions • What is the likely diagnosis? • What other investigations would you arrange? • What are the treatment options, and what other considerations do you have to make when prescribing? • What other advice would you give regarding her breast-feeding? ANSWER This woman has a puerperal breast abscess. Mastitis occurs frequently in lactating females. Infection is most common in the first 6 weeks post partum. This is the result of organisms entering through traumatized skin and cracked nipples. It is usually treated with antibiotics, and mothers are advised to continue expressing from the breast to aid drainage through the ducts. Occasionally the infection can progress and lead to a breast abscess. The most commonly involved organisms are Staphylococcus aureus and the Streptococcus species. Non-lactating breast abscesses occur most commonly around the age of 30 years and are often associated with duct ectasia. Periareolar abscesses are found to be associated with smoking, whereas peripheral abscesses are more common in immunosuppressed women,such as those taking steroids or patients with diabetes. In this case other investigations would include anaerobic and aerobic cultures taken from the abscess. These can usually be obtained by needle aspiration under ultrasound guidance. Treatment is either by recurrent needle aspiration or by incision and drainage. Antibiotics should be continued. Flucloxacillin (or erythromycin if the patient is penicillin allergic) are recommended, but the choice of antibiotic should be guided by the culture results. Co-amoxiclav is prescribed in non-lactating breast abscesses where anaerobes and enterococci may also be causative. Appropriate analgesia should also be prescribed. It is imperative to remember that this patient is breast-feeding and the British National Formulary (BNF – Appendix 4) should be consulted before prescribing to ensure there are no contraindications. KEY POINT • It is important to note that if the inflammation or mass persists after treatment, then the possibility of breast cancer should be ruled out with further imaging and tissue sampling.

General Medicine • Gynaecology and Obstetrics

SUDDEN ARM PAIN

History A 59-year-old woman presents to the emergency department with pain and tingling in the right arm. The pain occurred that morning while she was walking the dog. It was sudden in onset and has improved since arriving in the department. There is no history of trauma and she has had no previous episodes. She is now able to move her fingers, but says they feel numb. Her previous medical history includes intermittent episodes of palpitations for which she is waiting to see a cardiologist. Examination The right hand appears pale and feels cool to touch. The radial and ulnar arterial pulses are absent. There is no muscle tenderness in the forearm and she has a full range of active movement in the hand. Sensation is mildly reduced. An urgent angiogram is performed and an electrocardiogram. Questions • What is the likely diagnosis? • What is the probable aetiology? • What other aetiologies do you know for this condition? • How would you investigate and manage this patient? ANSWER This is an acutely ischemic limb secondary to arterial embolism. The embolus is likely to have originated from the left atrium as the patient has atrial fibrillation (shown on the ECG). Aetiologies include: • cardiac arrhythmias: commonly atrial fibrillation • aneurysmal disease • procoagulant state caused by underlying malignancy • thrombophilias • atrial myxomas. Investigations aim to determine the aetiology of the embolism and to prepare the patient for theatre: • full blood count (polycythaemia) • clotting • group and save • ECG (arrhythmias) • chest X-ray (underlying malignancy). The patient should be given heparin and resuscitated with intravenous fluids and analgesia.Loss of sensation and paralysis in the affected limb (signs of advanced ischaemia) are indications for urgent embolectomy. A postoperative echocardiogram is arranged if preoperative investigations do not reveal an obvious cause for the embolism. This investigation can detect cardiac thrombus or an atrial myxoma KEY POINTS Signs and symptoms of acute limb ischaemia – six Ps: • pain • pulseless • pallor • paraesthesia • perishingly cold • paralysis.

Cardiology

LOWER URINARY TRACT SYMPTOMS

History A 71-year-old man has been referred to the urology outpatient clinic with a history of urinary frequency, nocturia and some post-micturition dribbling. He has occasional urgency. He suffers with osteoarthritis of his left hip and uses a walking stick. He has angina, hypertension and hypercholesteraemia. He is an ex-smoker and lives with his wife. His younger brother had prostate cancer and underwent a radical prostatectomy at the age of 65 years. He is anxious to get his prostate-specific antigen (PSA) tested as he is concerned about prostate cancer. Examination Abdominal examination is unremarkable. The bladder is not palpable and the genitalia are normal with no evidence of stenosis of the urethral meatus or phimosis. Digital rectal examination confirms a moderately enlarged smooth prostate gland. Questions • What are the causes of an elevated PSA? • How would you classify this patient’s symptoms? • What is the likely diagnosis in this patient? • What treatment would you recommend? ANSWER Prostate-specific antigen is a glycoprotein enzyme produced by the prostate gland. Its function is to liquefy the ejaculate and to aid sperm motility. In symptomless men appropriate counselling is required prior to performing a PSA blood test. A raised PSA may be caused by benign prostatic hyperplasia (BPH), prostatitis, urinary tract infection, urinary retention, instrumentation (e.g. catheterization), biopsy, a transurethral resection of the prostate (TURP) or by prostate cancer. Prostate cancer screening is not currently of proven benefit,although several trials are investigating its value at present. PSA values vary with age,reflecting the effect of BPH on the prostate gland. Normal ranges are outlined. This patient has lower urinary tract symptoms (LUTS) which are classically divided into two groups: • obstructive: weakness of urinary stream, hesitancy, terminal dribbling, intermittency,feeling of incomplete bladder emptying • irritative: urinary urgency, frequency, nocturia and incontinence. Patients with bladder outflow obstruction may present with obstructive symptoms alone or in conjunction with irritative symptoms. The irritative symptoms are secondary to the obstruction which leads to changes in the bladder causing bladder overactivity. In this case the patient has LUTS secondary to BPH. Organizing a PSA for LUTS alone is reasonable, but in this case the patient has other risk factors – family history and his age. Other indications to organize a PSA blood test include an abnormal digital rectal examination,progressive back pain, unexplained weight loss and prostate cancer monitoring. Baseline LUTS can be measured using the International Prostate Symptom Score (IPSS;range 0–35), a symptom index questionnaire. This is useful in monitoring the response to treatment. In this case he has moderate symptoms. Other factors that point to the diagnosis of BPH include his low maximal flow rate (normal in males 30 mL/s; females40 mL/s) and his elevated post-micturition residual volume, which indicates incomplete bladder emptying (another feature of significant bladder outflow obstruction). Treatment options include watchful waiting (periodic monitoring, lifestyle advice), medical therapy (alpha-blockers and/or 5-alpha reductase inhibitors) and surgery (TURP) KEY POINTS • The serum PSA may be raised in benign disease. • Patients should be counselled prior to PSA testing.

General Medicine • Nephrology

TRANSIENT ARM WEAKNESS

History A 71-year-old man presents to the emergency department with weakness and numbness in his left arm. The symptoms came on suddenly while he was in the garden 2 h ago. His vision was not affected and he thinks the weakness in his arm has now resolved. He has had no previous episodes and has no history of trauma to his head or neck. He is currently on medication for hypertension and is a lifelong smoker. Examination The blood pressure is 130/90 mmHg and the pulse rate is regular at 90/min. Heart sounds are normal and the chest is clear. Abdominal examination is normal. Neurological examination does not show any neurological deficit. A right-sided carotid bruit is heard. Questions • What is the diagnosis? • What are the risk factors? • How should this patient be investigated? • What are the complications of surgery? ANSWER A transient ischaemic attack (TIA) refers to a focal neurological deficit which lasts less than 24 h. A stroke is a deficit lasting more than 24 h. Eighty per cent of cerebrovascular incidents are caused by emboli, with the majority of infarctions in the carotid territory. Risk factors ! • Hypertension • Smoking • Diabetes mellitus • Atrial fibrillation • Raised cholesterol Patients should undergo the following investigations: • full blood count, erythrocyte sedimentation rate • electrocardiogram • imaging of the carotid, which can be done by: • duplex ultrasonography: this technique combines B mode ultrasound and colour Doppler flow to assess the site and degree of stenosis. This is now the investigation of choice in most centres • angiography: intra-arterial angiography is the gold standard but is invasive and is associated with a 1–2 per cent risk of stroke. Intravenous digital subtraction angiography is used in some centres • magnetic resonance angiography • spiral computerized tomography (CT) angiography • CT head scan: to delineate areas of infarction and exclude haemorrhage in an acute presentation with stroke. A stenosis of more than 70 per cent in the internal carotid artery is an indication for carotid endarterectomy in a patient with TIAs . Neck haematoma (5 per cent) • Cervical and cranial nerve injury (7 per cent): hypoglossal, vagus, recurrent laryngeal, marginal mandibular and transverse cervical nerves • Stroke (2 per cent) • Myocardial infarction • False aneurysm: rare • Infection of prosthetic patch: rare • Death (1 per cent) KEY POINTS • Symptoms in a transient ischaemic attack last less than 24 h. • Symptomatic carotid stenosis of 70 per cent should be considered for carotid endarterectomy.

General Medicine • Cardiology

LEFT KNEE INJURY

History A 22-year-old woman is brought to the emergency department by ambulance. Her friend says that they had been out drinking and that she had fallen off a 4-foot wall landing directly on her left knee. Her knee swelled up immediately and she has not attempted to walk since the injury. She is normally fit and healthy. She takes the combined oral contraceptive pill, smokes 10–20 cigarettes a day and works in a supermarket. Examination Her observations are normal. There is no evidence of a head injury. Her left knee is diffusely swollen and there is evidence of bruising. The skin is intact. The medial and lateral joint lines are not tender. The patient is unable to actively extend the knee. The knee feels otherwise stable. The hip and ankle joints are unremarkable, and the pedal pulses and foot sensation are normal. This type of fracture typically occurs with direct trauma to the knee. It is possible, however, to sustain a similar injury by an indirect mechanism, such as by vigorous jumping which leads to rapid flexion of the knee against a fully contracted quadriceps muscle. An indirect injury tends to result in less displacement and comminution of the fracture. The patella is a large sesamoid bone. The upper border is connected to the quadriceps tendon and the lower pole is connected to the patella tendon, which inserts into the tibial tuberosity. In order to actively extend the knee, the whole unit must remain in continuity.It is, therefore, very important when examining knee injuries to ensure the extensor mechanism is intact by feeling for any palpable gap and by getting the patient to actively extend the knee. Patella fractures can be managed conservatively or operatively. If the extensor mechanism is disrupted and/or there is a greater than 3 mm gap in the fracture site, surgical fixation is necessary. If the extensor mechanism is intact and there is a small gap in the fracture site, more common with the indirect injuries, then a cylinder plaster of Paris cast is more appropriate.It is worth noting that a bipartite patella occurs in 1 per cent of the population, and it is not uncommon for patients to be misdiagnosed with a patella fracture. The diagnosis of a patella fracture is supported if there is a plausible mechanism of injury and the appropriate examination findings are present. KEY POINTS • Bipartite patella occurs in 1 per cent of the population, and can be mistaken for a patella fracture

General Medicine • General Medicine + 2 more

LOWER LIMB ULCERATION

History A 50-year-old man presents to the vascular clinic with an ulcer on the lower aspect of the left leg. It appeared 3 months ago following minor trauma to the leg and has grown in size steadily. There is no other past medical history of note. Examination There is an ulcer, shown in Figure, with slough and exudate at the base. There is surrounding dark pigmentation. Examination of the rest of the leg shows varicose veins in the long saphenous distribution. Questions • What is the definition of an ulcer? • What are the causes of ulceration? • What else should be included in the examination and investigation for lower limb ulceration? • What does the management of a venous ulcer involve? • How should the patient be managed once the ulcer has healed? ANSWER An ulcer is the dissolution of an epithelial surface. This patient has venous ulceration.The ulcer is situated in the medial gaiter region. The edges slope and the base has healthy tissue. The surrounding skin changes support a venous aetiology. Causes of leg ulceration ! • Venous • Arterial • Mixed venous/arterial • Diabetic: underlying aetiology neuropathic/arterial or mixture of both • Rheumatoid • Scleroderma • Sickle cell • Syphilitic • Pyoderma gangrenosum During examination, peripheral pulses should be palpated and Doppler pressures obtained.Investigations include full blood count and erythrocyte sedimentation rate, autoantibodies(if there is a possibility of rheumatoid vasculitis) and blood glucose levels. The mainstay of treatment for venous ulcers is calf pump compression using multi-layered bandages applied to the lower leg. The ulcer is inspected weekly to ensure that it is healing,and bandages are re-applied. An ulcer that fails to heal with these measures may benefit from surgical debridement and the application of a mesh skin graft. Malignant transformation (Marjolin’s ulcer) can develop in a long-standing, non-healing venous ulcer. Once the ulcer has healed the superficial and deep veins of the leg should be assessed using a duplex Doppler scan. Saphenous vein surgery should be considered if there is evidence of sapheno-femoral or sapheno-popliteal reflux with patent deep veins. This can prevent recurrences. Patients who do not undergo surgery should wear graduated elastic support stockings to prevent recurrence. KEY POINTS • Venous ulceration should be treated with compression bandaging. • Caution should be taken in patients with peripheral arterial disease.

Dermatology • Cosmetic Dermatology + 4 more

ABDOMINAL PAIN AND METABOLIC ACIDOSIS

History A 65-year-old man presents to the emergency department with an 8 h history of severe generalized abdominal pain. Earlier in the day he passed fresh blood mixed in with his stool.His past medical history includes diabetes, hypertension and atrial fibrillation. He is not currently taking any anticoagulation therapy for his atrial fibrillation. He smokes 20 cigarettes per day. Examination He has difficulty lying still on the bed. He has a temperature of 37.5°C with an irregularly irregular pulse of 110/min. His blood pressure is 90/50mmHg. Abdominal examination shows generalized tenderness with absent bowel sounds. Rectal examination confirms loose stool mixed with some fresh blood. Questions • What does the arterial blood gas show? • What is the most likely diagnosis? • What are the differential diagnoses? • What other investigations can you suggest? • What is the treatment and prognosis for this condition? ANSWER The arterial blood gas shows a metabolic acidosis (low pH, negative base excess and high lactate) with partial respiratory compensation (low pCO2). The most likely diagnosis is mesenteric ischaemia secondary to superior mesenteric artery thrombosis or embolism. Atrial fibrillation is a risk factor for embolism. Differential diagnoses ! • Pancreatitis • Ruptured abdominal aortic aneurysm • Perforated viscus Investigation should include: • routine bloods and serum amylase to exclude pancreatitis • electrocardiogram • chest X-ray: may show free air under the diaphragm • abdominal X-ray: typically ‘gasless’ • computerized tomography of the abdomen: not always diagnostic with ischaemic bowel but would help to exclude an abdominal aortic aneurysm. The prognosis associated with this condition is poor, with less than 20 per cent survival. The patient should be resuscitated with intravenous fluids and broad-spectrum antibiotics given. The patient should then be taken for urgent laparotomy where any dead bowel is resected. Revascularization by embolectomy or bypass may improve doubtfully viable bowel and allow primary anastamosis. Otherwise, both ends of the bowel should be exteriorized. KEY POINTS • Atrial fibrillation increases the risk of arterial embolization. • A re-look laparotomy at 24 h may be required to check for further intestinal ischemia.

General Surgery • General Medicine + 1 more

PAINFUL FINGERS

History A 30-year-old woman attends the surgical outpatient clinic complaining of painful fingers.She notices the pain particularly during the winter months when it is colder. When she is outside, the fingers firstly become white, then blue and then become red and start to tingle. She smokes ten cigarettes per day and is currently taking atenolol for hypertension. Examination On examination the fingers have a reddish tinge and the skin feels dry. Examination of the neck is normal and all pulses in the upper limbs are present. Questions • What is the most likely diagnosis? • Can you explain the sequence of colour changes? • What are the environmental factors that can exacerbate this condition? • What investigations would you carry out? • What treatments would you suggest? ANSWER This is Raynaud’s phenomenon. When this disorder occurs without any known cause, it is called Raynaud’s disease, or primary Raynaud’s. When the condition has a likely cause,it is known as Raynaud’s phenomenon. The majority of patients are female (up to 90 per cent) and the prevalence of this condition can be as high as 20 per cent in the general population. Raynaud’s can affect the hands,feet and even the tip of the nose. Digital artery spasm results in blanching of the fingers;the accumulation of de-oxygenated blood then gives the fingers a bluish tinge and finally the fingers become red due to reactive hyperaemia. Accumulation of metabolites causes paraesthesia. Causes of Raynaud’s phenomenon ! • Systemic lupus erythematosus • Systemic sclerosis (scleroderma) • Rheumatoid arthritis • Cold agglutinins • Polycythaemia • Oral contraceptives • Beta-blockers such as atenolol (as in this case) • Occupational (vibrating tools) • Cervical rib Tests to rule out a possible cause include a full blood count, urea and electrolytes, cryoglobulins, erythrocyte sedimentation rate, rheumatoid antibodies, antinuclear factor and antimitochondrial antibodies. Duplex scanning can be used to assess the arterial supply of the limb.It is important to keep the extremities warm and avoid the cold by use of gloves/warm socks or even moving to a warmer climate if possible. Drugs (e.g. beta-blockers, contraceptives) that exacerbate the condition should be stopped. Similarly smokers should be encouraged to stop. Calcium-blocking drugs (e.g. nifedipine) and 5-hydroxytryptamine antagonists have all been used with some success. KEY POINTS • Medications should be excluded as a cause of Raynaud’s phenomenon.

General Medicine • General Surgery