Alasdair Scott Bsc (Hons) MBBS Phd

PACES

Alasdair Scott BSc (Hons) MBBS PhD

2012

Contents Cardiology ...... 3 Pulmonology ...... 16 The Medical Abdomen ...... 30 Neurology ...... 49 Shorts ...... 71

Contents General Cardio Tips ...... 4 Aortic Stenosis ...... 5 Mitral Regurgitation ...... 6 Aortic Regurgitation ...... 7 Mitral Stenosis ...... 8 Rheumatic Fever ...... 9 Infective Endocarditis ...... 9 Valve Replacement ...... 10 Valve Prostheses: Key Facts ...... 11 Atrial Fibrillation ...... 12 AF: Key Facts ...... 13 Pacemakers ...... 14 Chronic Heart Failure ...... 15

Examination Viva

Midline Sternotomy Completion  Observation chart Positive Finding Indications  Drug chart Metallic click Mechanical valve  12-lead ECG Murmur Tissue valve Valvotomy Presentation Vein harvest on legs CABG  On peripheral inspection… Old scar, young pt. Repair of congenital defect  The pulse… Immunosuppression Heart transplant  On examination of the precordium… Nothing Trauma: tamponade, aortic  Significant negatives IMA CABG . Absence of CCF Tissue valve . Disease severity . Evidence of cause  Differential Dx Cardiac Causes of Clubbing  Hx  Infective endocarditis  Congenital cyanotic heart disease Discussion . Fallot’s Tetralogy  Ix  VSD  Rx  Pulmonary stenosis  RVH Hx  Overriding aorta  Symptoms: dyspnoea, chest pain, palpitations, syncope . Transposition of the Great Vessels  LVF: PND, orthopnoea  Atrial myxoma  IE: fever, wt. loss, night sweats . Assoc. ¯c Carney Complex / LAME Syndrome  CV Risk: smoking, DM, lipids, HTN, FH  Lentigines: spotty skin pigmentation  PMH: rheumatic fever  Atrial Myxoma  DH: antiplatelet agents, statins  Endocrine tumours: pituitary  Schwannomas Ix

Collapsing Pulse ECG  Caused by hyperdynamic circulation  Evidence of ischaemia . AR  Arrhythmia . Thyrotoxicosis . Pregnancy Blood . Anaemia  FBC: anaemia exacerbates cardiac symptoms

 U+E: renovascular disease Absent Radial Pulse  NT-proBNP: heart failure  Dead  Fasting lipids and glucose: cardiac risk  Trauma  Thrombosis or embolism Imaging  Coarctation of the aorta  CXR  Takayasu’s Arteritis . Cardiomegaly . Pulmonary oedema Impalpable Apex Beat: COPD . Valve calcification  COPD  Echo  Obesity . Dx  Pericardial effusion . Valve function  Dextrocardia . LV Function  Cardiac catheterisation Features of Pulmonary HTN . Evaluate coronary arteries  ↑ JVP  Left parasternal heave Mx  Loud P2 + PSM of TR  Pulsatile hepatomegaly General  Ascites and peripheral oedema  MDT: GP, cardiologist, cardiothoracic surgeon, dietician, specialist nurses Heart Sounds  Optimise CV risk: statins, anti-HTN, DM, anti-plat  Monitor: regular f/up and echo  S1: mitral valve closure Specific  S2: aortic valve closure Surgical  S3: rapid ventricular filling of dilated left ventricle  S4: atrial contraction against stiff ventricle © Alasdair Scott, 2012 4 Aortic Stenosis

Examination Viva

Peripheral Inspection Hx: Clinical Symptoms of Severe AS  Often nothing specific  Angina: 50% dead in 5yrs  Syncope: 50% dead in 3yrs  Dyspnoea: 50% dead in 2yrs Pulse  Slow-rising (anacrotic)  Narrow pulse pressure (<30mmHg) Ix

ECG Precordium  LVH  Pacemaker  Arrhythmias  Aortic thrill  Apex: Forceful, non-displaced (pressure overload) Blood: FBC, U+E, NT-proBNP, lipids, glucose  Heart Sounds . Quiet A2 . Early syst. ejection click if pliable (young) valve CXR . S4 (forceful A contraction vs. hypertrophied V)  Calcified AV  Murmur  LVH . ESM  Pulmonary oedema . Right 2nd ICS . Sitting forward in end-expiration Echo + Doppler . Radiates to carotids  Severity  Cause: Bicuspid valve, thick calcified cusps Clinical Signs of Severe AS  LV function  Quiet / absent A2  Other valve function  S4  Narrow pulse pressure Echo Features of Severe AS (AHA 2006) 2  Decompensation: LVF  Valve area <1cm  Pressure gradient >40mmHg  Jet velocity >4m/s Significant Negatives Cardiac Catheterisation  Infective endocarditis  Valve gradient  LVF  Assess coronaries (needed if surgery planned)  Indicators of severity

Differential Mx

 Aortic sclerosis: no radiation, normal pulse character General  MR  MDT: GP, cardiologist, cardiothoracic surgeon,  HOCM: valsalva ↑s murmur, squatting ↓s murmur dietician, specialist nurses  Right-sided: PS  Optimise CV risk: statins, anti-HTN, DM, anti-plat

 Monitor: regular f/up and echo

Causes Surgical: Valve Replacement ± CABG  Age-related senile calcification  Indications  Bicuspid aortic valve . Symptomatic AS  Rheumatic heart disease . Severe asymptomatic AS ¯c ↓ EF (<50%) . Severe AS undergoing CABG or other valve op  Mortality: 3-5% depending on pts. EuroSCORE

Other Options  TAVI: Transcatheter Aortic Valve Implantation  Balloon valvuloplasty

Examination Viva

Peripheral Inspection Ix  Warfarin medic alert bracelet ECG  Arrhythmias Pulse  LVH  AF  P-mitrale

Blood: FBC, U+E, NT-proBNP, lipids, glucose Precordium

 Left parasternal heave (RVH) CXR  Apex: displaced  LA and LV hypertrophy . Volume overload as ventricle has to pump Mitral valve calcification forward SV and regurgitant volume  . → eccentric hypertrophy  Pulmonary oedema

 Heart Sounds Echo + Doppler . Soft S1 . S2 not heard separately from murmur  Severity . ± loud P2 (if PTH)  LV function  Murmur  Other valve function . Blowing PSM . Apex Echo Features of Severe MR (AHA 2006) . Left lateral position in end expiration  Jet width >0.6cm . Radiates to the axilla  Systolic pulmonary flow reversal  Regurgitant volume >60ml Clinical Signs of Severe MR  LVF Cardiac Catheterisation  AF  Assess coronaries (needed if surgery planned)

Significant Negatives Mx

 Infective endocarditis General  Indicators of severity: AF, LVF  MDT: GP, cardiologist, cardiothoracic surgeon,

dietician, specialist nurses

Optimise CV risk: statins, anti-HTN, DM, anti-plat Differential   Monitor: regular f/up and echo  AS  VSD Specific  Right-sided: TR  AF: rate control and anticoagulate  Emboli: anticoagulate

 ↓ afterload Causes . ACEi or β-B (esp. carvedilol) O  Functional: LV dilatation (e.g. 2 to HTN or idiopathic) . Diuretics  Annular calcification → contraction  Rheumatic heart disease Surgical  Mitral valve prolapse  Valve replacement or repair  Aim to replace the valve before significant LV dilation and dysfunction.  Indications . Symptomatic

Prognosis  Often asymptomatic for >10yrs  Symptomatic: 25% mortality @ 5yrs

Examination Viva

Peripheral Inspection Ix

Eponymous Signs ECG  Quincke’s: capillary pulsation in nail beds  LVH  Corrigan’s: visible vigorous carotid pulsation  LV strain: lateral T wave inversion  De Musset’s: head nodding  Traube’s: pistol-shot sound over femorals Blood  Duroziez’s  Standard: FBC, U+E, NT-proBNP, lipids, glucose . Systolic murmur over the femoral artery ¯c  AI disease: ESR, HLA-B27, ANA proximal compression. . Diastolic murmur ¯c distal compression  Mueller’s: systolic pulsations of the uvula CXR  Rosenbach’s: systolic pulsations of the liver  Cardiomegaly  Pulmonary oedema Cause  Marfanoid: tall, thin, long arms, high-arched palate Echo + Doppler  Ank spond: cervical kyphosis  Severity . Jet width (>65% of outflow tract = severe) Pulse . Regurgitant jet volume . Premature closing of the mitral valve  Collapsing pulse  Cause: bicuspid valve, vegetations, dissection  Wide pulse pressure: e.g. 180/45  LV function

 Other valve function Precordium  Aortic thrill Cardiac Catheterisation  Apex: displaced (volume overload)  Assess coronaries (needed if surgery planned)  Heart Sounds  Grade severity . Soft S2 . ± S3  Murmur Mx . High-pitched EDM

. LLSE (3rd left IC parasternal) General . Sitting forward in end-expiration  MDT: GP, cardiologist, cardiothoracic surgeon,  Possible Additional Murmurs dietician, specialist nurses . Ejection systolic flow murmur  Optimise CV risk: statins, anti-HTN, DM, anti-plat . Austin-Flint murmur O  Monitor: regular f/up and echo  Rumbling MDM @ apex 2 regurgitant jet

fluttering the anterior mitral valve Specific

↓ afterload Clinical Signs of Severe AR  . ACEi or β-B (esp. carvedilol)  Collapsing pulse . Diuretics  Wide pulse pressure

 LVF Surgical: Valve Replacement

 Aim to replace the valve before significant LV dilation Significant Negatives and dysfunction.  Infective endocarditis  Indications  Indicators of severity, LVF, wide PP, collapsing pulse . Symptomatic: NYHA >2 . LV dysfunction Differential  Pulse pressure >100mmHg  MS  ECG changes: T inversion in lateral leads  Right-sided: PR, TS  LV enlargement on CXR or EF <50%

Causes

Chronic  Bicuspid aortic valve  Rheumatic heart disease  Autoimmune: Ank spond, RA  Connective tissue: Marfan’s, Ehler’s Danlos

Acute  Infective endocarditis  Type A aortic dissection © Alasdair Scott, 2012 7 Mitral Stenosis

Examination Viva

Peripheral Inspection Ix  Middle-aged female  Warfarin medic alert bracelet ECG  Malar Flush: CO → backpressure + vasoconstriction  P-mitrale  AF

Pulse Bloods: FBC, U+E, NT-proBNP, lipids, glucose

 AF

CXR

 LA hypertrophy → splaying of carina Precordium O  Calcified mitral valve  Left parasternal heave: RVH 2 to PHT  Pulmonary oedema  Apex: Tapping (palpable S1), non-displaced  Heart sounds Echo + Doppler . Loud S1  Severity . ± loud P2 (if PHT)  Cusp calcification . Early diastolic opening snap  LV function  Murmur  Other valve function . Rumbling MDM  TOE: left atrial thrombus if intervention planned . Apex

. Left lateral position in end expiration Echo Features of Severe MR (AHA 2006) . With the Bell 2 . Radiates to the axilla  Valve orifice <1cm . Pre-systolic accentuation if pt. in sinus rhythm  Pressure gradient >10mmHg  Atrial contraction  Pulmonary artery systolic pressure >50mmHg  Possible Additional Murmurs . ± Graham Steell murmur (EDM 2O to PR) Cardiac Catheterisation  Assess coronaries (needed if surgery planned) Clinical Signs of Severe MR  Grade severity  Malar flush  Longer murmur  LVF Mx

General  MDT: GP, cardiologist, cardiothoracic surgeon, dietician, Significant Negatives specialist nurses  Infective endocarditis  Optimise CV risk: statins, anti-HTN, DM, anti-plat  Severity: LVF, malar flush, long murmur  Monitor: regular f/up and echo  Evidence of PHT . Malar flush Specific . ↑ JVP ¯c large V waves  Consider rheumatic fever prophylaxis: e.g. Pen V . Left parasternal heave  AF . Loud P2 . Rate control: β-B . Anticoagulate (4% stroke risk /yr)  Diuretics provide symptom relief Differential  AR Surgical  Right-sided: PR, TS  Indicated in mod–severe MS (asympto and symptomatic)  Percutaneous balloon valvuloplasty . Rx of choice Causes . Suitability depends on valve characteristics  Rheumatic heart disease  Pliable, minimally calcified  Other causes are rare . CI if left atrial mural thrombus . Prosthetic valve  Surgical valvotomy / commissurotomy: valve repair . Congenital  Valve replacement if repair not possible

Pathophysiology Normal Valves → Acute Endocarditis  Ab cross-reactivity following S. pyogenes infection → T2 hypersensitivity reaction (molecular mimicry). Risk Factors  Abs cross-react ¯c myosin, muscle glycogen and SM cells  IVDU  Path: Aschoff bodies and Anitschkow myocytes.  Skin wounds  Immunosuppression: CRF, DM Dx: revised Jones Criteria  Evidence of GAS infection plus: Organisms . 2 major criteria, or  S. aureus . 1 major + 2 minor  S. epidermidis

Evidence of GAS infection Cardiac Disease → Subacute Endocarditis  +ve throat culture  Rapid strep Ag test Risk Factors  ↑ ASOT or DNase B titre  Prosthetic valves  Recent scarlet fever  Valve disease

Major Criteria Minor criteria Organisms  Pancarditis  Fever  S. viridans  Arthritis  ↑ESR or ↑CRP  S. bovis (do colonoscopy for colonic neoplasm)  Subcut nodules  Arthralgia  HACEK → culture negative IE  Erythema marginatum . not if arthritis is a major  Sydenham’s chorea  Prolonged PR interval Clinical Features . not if carditis is a major  Prev rheumatic fever Hands Other  Clubbing  Fever  Splinters  Roth spots Ix  Janeway lesions  Splenomegaly  Bloods: FBC, ESR, ASOT  Oslers nodes  Haematuria  ECG  Echo Cardiac  New / changing murmur Rx  MR: 85%  Bed rest until CRP normal for 2wks  AR: 55%  Benpen 0.6-1.2mg IM for 10 days  Analgesia for carditis/arthritis: aspirin / NSAIDs Dx: Duke Criteria  Add oral pred if: CCF, cardiomegaly, 3rd degree block  2 major  Chorea: Haldol or diazepam  1 major + 3 minor  All 5 minor Prognosis Major  Attacks last ~ 3mo 1. +ve Blood Culture  60% c carditis develop chronic rheumatic heart disease. ¯  Typical organism in 2 separate cultures, or  Recurrence ppted by  Persistently +ve cultures, e.g. 3, >12h apart . Further strep infection 2. Endocardial Involvement . Pregnancy  +ve echo: vegetation, abscess, dehiscence . OCP or  Valve disease: regurgitation → stenosis  New valvular regurgitation . Mitral (70%)

. Aortic (40%) Minor . Tricuspid (10%) 1. Predisposition: cardiac lesion, IVDU . Pulmonary (2%) 2. Fever >38

3. Emboli: septic infarcts, splinters, Janeway lesions Secondary Prophylaxis 4. Immune: GN, Osler nodes, Roth spots, RF  Prevent recurrence 5. +ve blood culture not meeting major criteria  Pen V 250mg/12h PO for 5-10yrs Empiric Rx  Acute severe: Fuclox / vanc + gent IV  Subacute: Benpen + gent IV

Prophylaxis  Abx prophylaxis solely to prevent IE not recommended

Examination Viva

Peripheral Inspection Hx  DH: warfarin dosing + interactions General . Look @ pts. yellow warfarin book  Audible valve click  Anticoagulation → bruising  Warfarin alert bracelet Ix  Anaemia Bedside Scars  ECG  Midline sternotomy: CABG, AVR, MVR  Left lat. inf. thoracotomy: MVR, mitral valvotomy Blood  Neck scars from line insertion  FBC: anaemia – MAHA, bleeding  Groin / femoral scars from angiography  U+E: renovascular disease  Vein harvesting scar on the medial leg  NT-proBNP: heart failure . May have had CAGB too  Fasting lipids and glucose: cardiac risk  INR: warfarin Pulse  Variable Imaging  AF suggests mitral valve replacement due to MS  CXR: heart failure  Time prosthetic clicks ¯c pulse  Echo + Doppler . Occur in time = mitral valve . Valve regurgitation or stenosis . Peri-valvular leak Precordium . Vegetations . LV function

. Other valve function Two Main Questions

1. When and where is the closing prosthetic sound?

2. Are there any murmurs? Discussion Starr-Edwards: 3 artificial sounds  Valve complications  Quieter click as valve opens  Valve types  Loud thud as valve closes  Infective endocarditis  Rumbling sound as ball rolls in cage

Tilting disc or bileaflet: 1 artificial sound  High-pitched click as valve closes

Biological Valve  Often normal heart sounds

Aortic  Lub-Click  ± systolic flow murmur  Abnormal: AR (EDM)

Mitral  Click-Dub  ± diastolic flow murmur  Abnormal: MR (PSM)

Murmurs  Well-seated valves may have soft flow murmurs . Aortic: systolic . Mitral: diastolic  Poorly-seated valves → regurgitation . Aortic: diastolic . Mitral: systolic

Significant Negatives  Signs of infective endocarditis  Signs of heart or valve failure  Anaemia  Bruising © Alasdair Scott, 2012 10 Valve Prostheses: Key Facts

Mechanical Indications  Mainly left-sided valve dysfunction Types . AS most commonly  Ball and cage: e.g. Starr-Edwards  Factors to consider  Tilting disc: e.g. Bjork-Shiley . Severity of valve dysfunction  Bileaflet: e.g. St. Jude . Severity of heart function . Co-morbidities Features . Pt. choice  Longer life-span: ~20yrs  Mechanical or prosthetic  Require oral anticoagulation: Warfarin INR 3-4 . Age . Tolerance of long-term anticoagulation Use  E.g. pregnancy, falls  Bileaflet valves are most commonly used . Pt. choice

 Younger pts. to minimise need for revision.

 Already on warfarin: e.g. AF Complications

Complications of surgery Biological  Operative mortality: 5%

Types Complications of valve  Porcine valves: e.g. Carpentier Edwards  Thromboembolism: 1-2% per annum despite warfarin  Bovine pericardium sewn into a metal frame  Anaemia: warfarin and haemolysis . Discontinued  Bleeding: minor – 7%/yr, major – 3%/yr  Infective endocarditis Features . Early: Staph. epidermidis  Less durable cf. mechanical valves: ~10yrs . Late: Strep. viridans  Don’t require long-term oral anticoagulation . May require 2nd valve replacement . Take aspirin . Mortality: 60% . NB. avoid erythromycin if on warfarin Use  Failure  Older patients . Chronic: stenosis or incompetence  Women of child-bearing age . Acute: dehiscence, breakage, thrombus  Bleeding risk: e.g. peptic ulcer, frequent falls

Examination Viva

Peripheral Inspection Hx  Symptoms: palpitations, dyspnoea, chest pain General . Aware of specific onset  Warfarin alert bracelet  Causes  Warfarin: look @ yellow book Cause  ↑T4: tremor, thin, palmar erythema, sweating, eye signs Ix  MS: mitral flush ECG

 Confirm Dx: irregularly irregular, no P waves Pulse  Cause: ischaemia, P-mitrale  Irregularly irregular Bloods  FBC: pneumonia, sepsis Precordium  U+E: ↓K  MS: MDM  TFTs: ↓TSH, ↑fT4  MR: PSM  Troponin  Other murmurs  D-dimer: PE

CXR Completion  Pulmonary oedema  Respiratory examination: pneumonia  Calcified mitral valve  Exercise pt. to bring out any murmur  Pneumonia

Echo Significant Negatives  Valve pathology  LV function  Murmur  TOE: left atrial thrombus  Evidence of thyrotoxicosis

 LVF  Bruising from warfarin

Causes

Common Other  IHD  Pneumonia  Rheumatic heart disease  PE  Thyrotoxicosis  Post-op  Hypertension  Hypokalaemia  Alcohol  RA

Clinical Points Anticoagulation

Differential of Irregularly Irregular Pulse CHA2-DS2-VAS Score  AF  Determines necessity of anticoagulation in AF  Multiple ventricular ectopics  Dabigatran may be cost-effective alternative to warfarin

Clinical Distinction  Exercise pt. CHA2-DS2 VAS . AF: pulse stays irregularly irregular  CCF  Vascular disease . VE: ↑ HR → regular pulse  HTN  Age: 65-74yrs  ↓ diastole time closes window for ectopics  Age≥75 (2 points)  Sex: female  DM Pulse Deficit  Stroke or TIA (2 points)  Difference in HR @ wrist and @ apex  Rapid ventricular rate → ↓ diastolic filling → ↓CO Score  0: aspirin AF Control  ≥1: Warfarin (INR 2-3)  Time the apical rate: target <100 @ rest Warfarin

Mx Contraindications  Bleeding diathesis Acute AF ≤48hrs  Compliance issues: dosing, monitoring  Haemodynamically unstable → cardioversion  Risk of falls  Stable  PUD . Rate control: diltiazem or metoprolol  Pregnancy . Start LMWH  Pt. choice . Cardiovert: DC or medical (flec or amiodarone) Complications Paroxysmal AF  Bleeding  Recurrent episodes lasting <7d  Osteoporosis  Pill in pocket: flecainide or amiodarone  Prevention: β-B or sotalol Advice  Requires regular monitoring and titration of dose Persistent AF  Avoid certain foods: e.g. grapefruit  Care starting new meds  Lasting >7d  Wear medic alert bracelet Rhythm control  Come to hospital if uncontrolled bleeding  Younger pts., treated precipitants  ≥3wks anticoagulation ¯c Warfarin first or TOE to exclude mural thrombus  Cardioversion: DC or medical  May need maintenance anti-arrhythmic

Rate control  1st: β-B or rate-limiting CCB  2nd: add digoxin (not monotherapy)

Permanent AF  Failed cardioversion / unlikely to succeed  Rate control

Other options  Radiofrequency ablation of AV node  Maze procedure  Pacing

Examination Viva

Peripheral Inspection Hx  Groin scars from catheter insertion  Arrhythmia  Medic alert bracelet . Syncope . Palpitations . Dyspnoea Pulse . Cardiac arrest  AF  Type of pacemaker

Precordium Ix  Left infraclavicular incisional scar  Palpable pacemaker ECG . Large: may be implantable defibrillator  Pacing spikes  ± murmur: esp. AS . May be absent if pt. producing adequate intrinsic rhythm  Evidence of ischaemia Significant Negatives CXR  AF  Visualise pacemaker  LVF  Count leads  Valvular pathology  Thick leads suggests implantable defibrillator  Complications of pacemaker: infection, erosion Echo  LV function  Valve pathology  Structural abnormalities indicating cause

Pace Makers

Permanent Pacing Indications  Complete AV block  Mobitz Type 2  Symptomatic bradycardia: e.g. sick sinus syndrome  Drug-resistant tachyarrhythmias  Biventricular pacing in chronic heart failure

Letters  1st: chamber paced (A, V, D)  2nd: chamber sensed (A, V, D)  3rd: response (Inhibited, Triggered, Dual)

Single Lead  One lead senses and responds  E.g. VVI

Dual Lead  Sense and respond in either chamber

Biventricular  Leads to both ventricles ± RA  Used for cardiac resynchronisation therapy in HF

Implantable defibrillator: may be incorporated into any pacemaker

Complications  Insertion . Bleeding . Arrhythmia  Post Insertion . Erosion . Lead migration . Pocket infection . Malfunction © Alasdair Scott, 2012 14 Chronic Heart Failure

Definition Ix  CO is inadequate for body’s requirements despite adequate filling pressures. Bloods: FBC, U+E, NT-proBNP, lipids, glucose

NT-proBNP Left  Secreted from ventricles in response to ↑ stretch and ↑HR  ↑ levels is most accurate diagnostic indicator of HF Causes  NICE recommends that heart failure is not Dx w/o ↑ BNP  1: IHD  2: Idiopathic dilated cardiomyopathy CXR: ABCDEF  3: Systemic HTN  Alveolar shadowing  4: Mitral and aortic valve disease  Kerley B lines  Cardiomegaly (cardiothoracic ratio >50%) Symptoms  Upper lobe Diversion  Fatigue  Effusions  Exertional dyspnoea  Fluid in the fissures  Orthopnoea + PND  Nocturnal cough (± pink, frothy sputum) ECG  Wt. loss and muscle wasting  Ischaemia  Hypertrophy Signs  AF or other arrhythmia  Cold peripheries ± cyanosis  Often in AF Echo: the key investigation  Cardiomegaly ¯c displaced apex  Global systolic and diastolic function  S3 + tachycardia = gallop rhythm . Ejection fraction normally ~60%  Wheeze (cardiac asthma)  Focal / global hypokinesia  Bibasal creps  Hypertrophy  Valve lesions

Right Mx

Causes General  LVF  MDT: GP, cardiologist, physio, dietician, specialist nurses  Cor pulmonale  Optimise CV risk: statins, anti-HTN, DM, anti-plat  Tricuspid and pulmonary valve disease  Monitor: regular f/up and echo

Symptoms Specific  Anorexia and nausea  1st: β-B + ACEi + loop diuretic

. Bisoprolol Signs . Lisinopril  ↑JVP + jugular venous distension . Frusemide  Tender smooth hepatomegaly (may be pulsatile) nd  2 : add Spironolactone  Pitting oedema rd  3 : consider digoxin  Ascites th  4 : consider cardiac resynchronisation therapy

New York Classification Surgery 1. No breathlessness  LVAD 2. Breathless ¯c moderate exertion  Heart transplant 3. Breathless ¯c mild exertion 4. Breathless at rest Trials Showing Drug Benefit in Heart Failure

 ACEi: Consensus 1  ARB = ACEi: ELITE-2  β-B: CIBIS-2, MERIT-2  Spironolactone: RALES

Contents COPD ...... 17 COPD: Key Facts ...... 18 Asthma ...... 19 Pulmonary Fibrosis ...... 21 Bronchiectasis ...... 22 Bronchiectasis: Causes ...... 23 Pleural Effusion ...... 24 Lung Cancer ...... 25 Lobectomy and Pneumonectomy ...... 25 Lung Cancer: Key Facts ...... 26 Pneumonia ...... 27 Pneumonia: Key Facts ...... 28 Old TB ...... 29

Examination Viva

Peripheral Inspection Hx  Symptoms: cough, sputum, dyspnoea Paraphernalia  Limitation: exercise tolerance  Inhalers  Cause: smoking Hx, FHx  Peak flow meter  Control: exacerbations, admissions  Nebuliser  Therapy: inhalers, vaccinations, home O2

General  Airflow obstruction Definitions . Pursed lip breathing . Splinting diaphragm  Chronic bronchitis . Cough productive of sputum on most days for ≥3mo on ≥2  Cushingoid consecutive years  Cyanosed  Emphysema  Cachetic . Histological description of alveolar wall destruction c ¯ Specific airway collapse and air trapping

 Hands . Tar staining . CO2 retention flap Ix . Bounding pulse  Face Bedside . Plethora: ↑Hb  PEFR . Central cyanosis  BMI: independent mortality RF in COPD  Sputum: MC+S Chest  Barrel-shaped Spirometry: obstructive  ↓ cricosternal distance  ↑ TLC and residual volume (RV)  ↓ expansion bilaterally  FEV1 <80%  PN: resonant  FEV1:FVC <0.7  Auscultation  ↓ transfer factor . ↓ breath sounds . Expiratory wheeze Bloods . Prolonged expiratory phase  FBC: polycythaemia, ↑ WCC in exacerbations  ABG: Type 2 resp failure Evidence of Hyperexpansion  CRP: if infective exacerbation  ↓ cricosternal distance  Albumin: malnutrition  Loss of cardiac dullness  α1-AT levels: if young and FHx  Palpable liver edge Imaging Extra  CXR . Acute Cor Pulmonale  Consolidation  ↑ JVP  Pneumothorax  Left parasternal heave: RV hypertrophy . Chronic  Loud P2 ± S3  Hyperinflation: >10 posterior ribs, flat diaphragm  MDM of tricuspid regurg  PHT: prominent pulmonary As, peripheral oligaemia  Ascites and pulsatile hepatomegaly  Bullae  Peripheral oedema  Echo . Cor pulmonale

Other Significant Negatives  6 minute walk  CO2 retention  ECG: RVH  Cor pulmonale  Clubbing: could indicate Ca Discussion

Chronic COPD Mx  . GOLD classification Differential . LTOT  Chronic asthma  Acute exacerbation Mx  Bronchiectasis . Ventilation  Prognosis . BODE index

Chronic Mx Mx of Acute Exacerbations

GOLD Classification  Global Initiative for Obstructive Lung Disease Controlled O2 Therapy  Multidimensional classification to tailor therapy to pt.  Sit-up  24% O2 via Venturi mask: SpO2 88-92%, Parameters  Vary FiO2 and SpO2 target according to ABG  mMRC dyspnoea score  Aim for PaO2 >8 and ↑ in PCO2 of <1.5kPa  Airflow limitation  No. of exacerbations per year mMRC Dyspnoea Score Nebulised Bronchodilators 1. SOB only on vigorous exertion  Air driven ¯c nasal specs 2. SOB on hurrying or walking up stairs  Salbutamol 5mg/4h 3. Walks slowly or has to stop for breath  Ipratropium 0.5mg/6h 4. Stops for breath after <100m / few min 5. Too breathless to leave house or SOB on dressing

Airflow Limitation Steroids (IV and PO) 1. Mild: FEV1 >80% (but FEV/FVC <0.7 and symptomatic)  Hydrocortisone 200mg IV 2. Mod: FEV1 50-79% Prednisolone 40mg PO for 7-14d 3. Severe: FEV1 30-49%  4. Very Severe: FEV1 <30%

General Mx Abx  If evidence of infection MDT  Doxy 200mg PO STAT then 100mg OD PO for 5d  GP, dietician, physio, resp physician, specialist nurses  Regular review 1-2x / yr NIV if no response Smoking Cessation: single most important intervention  Repeat nebs and consider aminophylline IV  Specialist nurse and support programme  Consider NIV (BiPAP) if pH<7.35 and/or RR >30  Nicotine replacement therapy  Consider invasive ventilation if pH<7.26  Varenicline: partial nicotinic agonist . Depends on pre-morbid state: exercise capacity,

home O2, comorbidity Pulmonary Rehabilitation Therapy  Tailored exercise programme  Disease education  Psychosocial support Ix  PEFR Co-morbidities  Bloods: FBC, U+E, ABG, CRP, cultures  Nutritional assessment and dietary support  Sputum culture  CV risk Mx  CXR: infection, pneumothorax  Vaccination: pneumococcal and seasonal influenza Discharge Medical Mx  Spirometry  Principal Therapies  Establish optimal maintenance therapy . Anti-muscarinics: short- or long-acting  GP and specialist f/up . β-agonists: short- or long-acting  Prevention using home oral steroids and Abx . Inhaled corticosteroids: in combination c β-B ¯  Pneumococcal and Flu vaccine  Other Therapies  Home assessment . Theophylline or Roflumilast: PDIs . Carbocisteine: mucolytic BODE Index  Home emergency pack for acute exacerbations  Multidimensional tool to predict mortality in COPD  LTOT  Uses multiple independent risk factors . Aim: PaO ≥8 for ≥15h / day (↑ survival by 50%) 2 . BMI . Indications . Obstruction: FEV  Sable non-smokers c PaO <7.3 1 ¯ 2 . Dyspnoea: MRC score  PaO2 <8 + cor pulmonale or polycythaemia . Exercise capacity: 6 min walk

Surgical Mx Mortality  Recurrent pneumathoraces or large bullae  15% in-hospital mortality  Bullectomy or lung reduction surgery

Examination Viva

Peripheral Inspection Hx  Symptoms: cough, dyspnoea, wheeze, diurnal variation Paraphernalia  Limitations: exercise, sleep, work  Inhalers  Cause: atopy, exercise, cold, smoking  Peak flow meter  Control: SABA use, attacks, admissions, ITU  Nebuliser . Check peak flow diary  Therapy: oral steroid use, check inhaler technique General  Assocs.  Cushingoid . GORD: dyspepsia . Churg-Strauss: recent onset, rash, neuropathy Specific  Oral thrush Definition  Episodic, reversible airway obstruction due to bronchial Chest hyper-reactivity to a variety of stimuli.  Harrison sulcus  Auscultation . Usually normal Ix . May be ↓ AE and mild wheeze Bedside  PEFR Significant Negatives  CO2 retention Bloods  Cor pulmonale  FBC (eosinophila)  Clubbing: could indicate Ca  ↑IgE  Aspergillus serology

Differential CXR: hyperinflation  Normal  Pulmonary oedema: cardiac asthma Spirometry: obstructive  COPD  ↓ FEV1, ↑RV  FEV1:FVC < 0.75  ≥15% improvement in FEV1 ¯c β-agonist

PEFR monitoring / diary  Diurnal variation >20%  Morning dipping

Atopy: skin-prick testing, RAST

General  MDT: GP, specialist nurses, respiratory physician  Technique for inhaler use  Avoidance: allergens, smoke (ing), dust  Monitor: Peak flow diary (2-4x/d)  Educate . Liaise ¯c specialist nurse . Need for Rx compliance . Emergency action plan

Medical: 5-stage BTS Guidelines

Well Controlled  No exacerbations  No reliever therapy: no PRN salbutamol  No night time waking  <20% diurnal variation  Normal lung function

Presentation Mx  Acute breathlessness and wheeze

O2, Nebs and Steroids Hx 1. Sit-up  Precipitant: infection, travel, exercise? 2. 100% O2 via non-rebreathe mask (aim for 94-98%)  Usual and recent Rx? 3. Nebulised salbutamol (5mg) and ipratropium (0.5mg)  Previous attacks and severity: ICU? 4. Hydrocortisone 100mg IV or pred 50mg PO (or both)  Best PEFR? 5. Write “no sedation” on drug chart

Ix  PEFR If Life Threatening  ABG  Inform ITU . PaO2 usually normal or slightly ↓  MgSO4 2g IVI over 20min . PaCO2 ↓  Nebulised salbutamol every 15min (monitor ECG) . If PaCO2 ↑: send to ITU for ventilation  FBC, U+E, CRP, blood cultures

If Improving Assessment  Monitor: SpO @ 92-94%, PEFR 2  Continue pred 50mg OD for 5 days Severe  Nebulised salbutamol every 4hrs  PEFR <50%  Can’t complete sentence in one breath  RR >25  HR >110 IV Rx if No Improvement in 15-30min:

 Nebulised salbutamol every 15min (monitor ECG) Life Threatening  Continue ipratropium 0.5mg 4-6hrly  PEFR <33%  MgSO 2g IVI over 20min  SpO <92%, PCO >4.6kPa, PaO <8kPa 4 2 2 2  Salbutamol IVI 3-20ug/min  Cyanosis  Consider aminophylline  Hypotension . Load: 5mg/kg IVI over 20min  Exhaustion, confusion  Unless already on theophylline  Silent chest, poor respiratory effort . Continue: 0.5mg/kg/hr  Tachy-/brady-/arrhythmias . Monitor levels  ITU transfer for invasive ventilation Differential  Pneumothorax  Acute exacerbation of COPD  Pulmonary oedema Monitoring  PEFR every 15-30min Admission Criteria . Pre- and post-β agonist  SpO : keep >92%  Life-threatening attack 2  ABG if initial PaCO normal or ↑  Feature of severe attack persisting despite initial Rx 2  May discharge if PEFR > 75% 1h after initial Rx

Discharge When  Been stable on discharge meds for 24h  PEFR >75% ¯c diurnal variability <20%

Discharge Plan  TAME pt.  PO steroids for 5d  GP appointment w/i 1 wk.  Resp clinic appointment w/i 1mo

Examination Viva

Peripheral Inspection Hx  HPC: dyspnoea, cough, sputum, wt. loss General  Cause: arthritis, radiation, occupation, hobbies  Clubbing  DH  Cushingoid  Smoking status  No sputum  Tachypnoea, central cyanosis Ix

Evidence of Specific Cause Bedside  RA: rheumatoid hands, nodules  PEFR  SS  ECG: RVH . Sclerodactyly, calcinosis . Microstomia, beak nose, telangiectasia Blood  SLE: malar rash  FBC: anaemia exacerbates dyspnoea  AS: kyphosis  ABG: ↓PaO2, ↑PaCO2  Sarcoidosis: EN  IPF: ↑ESR, ↑CRP, ANA (30%), RF (10%), ↑Ig  Radiation: tattoos on chest  EAA: +ve se precipitins  CTD: C3/C4, CCP (RF, ANA), scl-70, centromere Chest  Sarcoid: se ACE, Ca2+  ± thoracotomy scar: single lung Tx  Tracheal shift towards fibrosis: upper lobe Imaging  Fine end-inspiratory crackles  CXR: reticulonodular shadowing, ↓ lung volume . No change ¯c coughing  HRCT: fibrosis, Honeycomb Lung Extras Spirometry: restrictive  Cor pulmonale  ↓TLC¸ ↓RV, ↓FEV and ↓FVC Significant Negatives  FEV1:FVC >0.8  ↓ transfer factor  Cyanosis  Cor pulmonale Other  Specific cause: e.g. RA hands or sclerodactyly  Echo: PHT

 BAL: may indicate disease activity Differential . ↑ lymphocytes > PMN: better prognosis  Bronchiectasis  Lung biopsy: usual interstitial pneumonia  Chronic lung abscess Mx

Causes MDT: GP, pulmonologist, physio, psych, palliative care, specialist nurses, pts. family Upper  Aspergillosis : ABPA Rx specific cause  Pneumoconiosis: Coal, Silica  EAA: steroids  Extrinsic allergic alveolitis  Sarcoidosis: steroids  Negative, sero-arthropathy  Connective tissue disease: steroids  TB Supportive care Lower  Stop smoking: single most beneficial strategy  Sarcoidosis (mid zone)  Pulmonary rehabilitation  Toxins: BANS ME  LTOT  Asbestosis  Symptomatic Rx  Idiopathic pulmonary fibrosis . Anti-tussives: e.g. codeine phosphate  Rheum: RA, SLE, SS, Sjogren’s, PM/DM . Heart failure: diuretics, β-B, ACEi

Drugs: BANS ME Surgery: lung Tx offers only cure for IPF  Bleomycin, Busulfan  Amiodarone Prognosis  Nitrofurantoin  IPF: 50% 5yr survival  Sulfasalazine  MEthotrexate Panther Study  Pred + AZA + NAC → ↑ mortality: trial arm stopped  NAC alone: trial arm still running

Examination Viva

Peripheral Inspection Hx  HPC: dyspnoea, cough, sputum, haemoptysis, wt. loss General  Cause: recurrent infections, arthritis, diarrhoea  Clubbing  Smoking status  Sputum pot  Small and young: CF Ix  Cachexia  LNs Bedside  Tachypnoea  PEFR  Dipstick: proteinuria – amyloidosis Evidence of Specific Cause  RA: rheumatoid hands Sputum: MC+S, cytology  Yellow nails  CF: young pt., nasal polyps Blood  Hypogammaglobulinaemia: splenomegaly  FBC: ACD  IBD: abdominal scars  Serum Ig: may do provocative testing  Aspergillus: RAST, precipitins, ↑IgE, eosinophilia Chest  RA: anti-CCP, RF, ANA  ± thoracotomy scar  Portacath or Hickman line / scars: CF Imaging  Coarse, wet crackles  CXR: tramlines and ring shadows (bunch of grapes) . May change with cough  HRCT . Localised / patchy: 2O to infection . Signet ring sign: thickened dilated bronchi + . Widespread: 2O to systemic disease smaller adjacent vascular bundle  ± monophonic wheeze . Pools of mucus in saccular dilatations  Dextrocardia Spirometry Extras  Obstructive

 Cor pulmonale Other

 Bronchoscopy + mucosal biopsy Completion . Focal obstruction  Examine the nose for polyps . PCD  Examine the abdomen for scars and splenomegaly  CF sweat test  Aspergillus skin prick testing

Significant Negatives Complications  Cor pulmonale  Cachexia  Specific cause: e.g. RA hands  Pulmonary HTN  Massive haemoptysis Differential  Type 2 respiratory failure  Idiopathic pulmonary fibrosis  Amyloidosis  Chronic lung abscess Mx

Conservative Causes  MDT: GP, pulmonologist, physio, dietician, immunologist

 Physio: postural drainage, active cycle breathing, rehab Congenital

 CF Medical  PCD / Kartagener’s  Abx  Young’s: azoospermia + bronchiectasis . Exacerbations: e.g. cipro for 7-10d  Hypogammaglobulinaemia: XLA, CVID, SAD . May use prophylactic azithromycin  Bronchodilators: nebulised β agonists Acquired  Treat underlying cause  Idiopathic . CF: DNAase, pancreatin (Creon), ADEK vitamins  Post-infectious: pertussis, TB, measles . ABPA: Steroids  Obstruction: tumour, foreign body . Immune deficiency: IVIg  Associated: RA, IBD (esp. UC), ABPA  Vaccination: flu, pneumococcus

Surgical  May be indicated in severe localised disease or obstruction

Cystic Fibrosis PCD and Kartagener’s  Autosomal recessive defect in ciliary motility Genetics  Poor mucociliary clearance → chronic recurrent  Incidence: 1/2500 live Caucasian births inflammation and bronchiectasis.  Carrier frequency: 1/25  ↓ sperm motility in males → infertility  Autosomal recessive . Mutation in CFTR gene on Chr 7 Kartagener’s Syndrome . Commonly ∆F508  Situs inversus + PCD (~50% of individuals ¯c PCD) . Situs inversus Pathophysiology . Chronic sinusitis  → ↓ luminal Cl secretion and ↑ Na reabsorption → . Bonchiectasis viscous secretions.  Bronchioles → bronchiectasis Young’s Syndrome  Pancreatic ducts → DM, malabsorption  Bronchiectasis  GIT → Distal Intestinal Obstruction Syndrome  Rhinosinusitis  Liver → gallstones, cirrhosis  Azoospermia (no sperm in semen) → ↓ fertility  Fallopian tubes → ↓ female fertility  Seminal vesicles → male infertility Hypogammaglobulinaemia  Primary immune deficiency due to ↓ Ig Dx  Genetic screening for common mutations Presentation  Immunoreactive trypsinogen (neonatal screening)  Recurrent sinopulmonary infections → bronchiectasis  Sweat test: Na and Cl > 60mM  Diarrhoea . False +ve: hypothyroidism, Addison’s  Commonly encapsulates: pneumococcus, haemophilus  Faecal elastase: tests pancreatic exocrine function Causes Ix  Bloods: FBC, LFTs, clotting, ADEK levels, glucose X-linked Agammablobulinaemia: Bruton’s tolerance test  X-linked recessive mutation of Bruton’s tyrosine kinase  Sputum MC+S  Failure to generate mature B cells → ↓ Ig  CXR: diffuse tramlines and rings  Rx: pooled Ig → passive immunity  Abdo US: fatty liver, cirrhosis, pancreatitis  Spirometry: obstructive defect Common Variable Immunodeficiency  Aspergillus serology / skin test (20% develop ABPA)  Commonest 1O immune deficiency: 1/5000  Splenomegaly: 25-50% Mx  Normal IgM, ↓IgG, ↓IgA

MDT: GP, gastro and resp physicians, physio, dietician, Specific Antibody Deficiency: SAD specialist nurse  Normal Ig levels but inability to make specific antibodies

Chest Yellow Nail Syndrome  Physio: postural drainage, active cycle breathing  Very rare  Abx: acute infections and prophylaxis  Yellow dystrophic nails  Mucloytics: DNAse  Pleural effusions  Segregate from other CF pts.: risk of transmission  Lymphoedema: lymphatic hypoplasia . Pseudomonas  Bronchiectasis . Burkholderia  Vaccination: flu, pneumococcus  Advanced: heart-lung transplant Allergic Bronchopulmonary Aspergillosis  T1 and T3 HS reaction to Aspergillus fumigatus GI  Bronchoconstriction → bronchiectasis  Pancreatic enzyme replacement: pancreatin (Creon)  ADEK supplements Presentation  Insulin  Dyspnoea, wheeze  Productive cough Other  Bronchiectasis  Rx of complications: e.g. DM  Fertility and genetic counselling Ix  DEXA osteoporosis screen  ↑IgE and eosinophilia  +ve skin prick test or RAST Prognosis  Mean survival 35yrs but rising Rx  Poorer prognosis if infected ¯c Burkholderia cepacia  Prednisolone + bronchodilators © Alasdair Scott, 2012 23 Pleural Effusion

Examination Viva

Peripheral Inspection Hx  Symptoms: SOB, pleurisy Paraphernalia  Cause  Chest drain . Fever, sputum . Smoking, wt. loss, haemoptysis Evidence of Specific Cause . Previous MI, orthopnoea, PND  Cancer: clubbing, cachexia, LNs . Hepatitis  Pneumonia: febrile  CCF: ↑JVP, S3, ascites, ankle oedema  CLD: clubbing, leukonychia, spiders, gynaecomastia Ix  CTD: rheumatoid hands, malar rash Sputum: MC+S, cytology Chest  Tracheal shift: away from lesion Imaging  ↓ expansion unilaterally  CXR  PN: stony dull . Dependent homogenous opacification ¯c meniscus  Auscultation . Unilateral or bilateral . ↓ AE . Cardiomegaly . ↓ VR . Coin lesions . Hilar LNs Significant Negatives . Apical TB  US: may guide pleurocentesis  Absence of  Volumetric CT . Fever

. Clubbing Blood . ↑ JVP and peripheral oedema . Features of CTD  FBC: ↓Hb  U+E: ↑ Cr  LFTs: ↓ albumin  TFT: ↑TSH Differential of Dull Lung Base  ESR: ↑ in CTD Consolidation: bronchial breathing + crackles   Ca: ↑ in Ca  Collapse: ↑ VR Diagnostic Pleurocentesis

 Percuss upper boarder and go 1-2 spaces below

 Infiltrate down to pleura ¯c lignocaine + aspirate ¯c 21G Causes needle

 Send for Transudate Exudate . Chemistry: protein, LDH, pH, glucose, amylase Modified Starling’s Forces ↑ Capillary Permeability . Bacteriology: MCS, auramine stain, TB culture Protein <25 Protein >35 . Cytology Usually bilateral Often unilateral . Immunology: RF, ANA, complement Causes Causes - CCF - Infection: pneumonia, TB Light’s Criteria for Dx of an Exudative Effusion O O - Renal failure - Ca: 1 or 2  Effusion : serum protein ratio >0.5 - ↓ albumin - Inflammation: RA, SLE  Effusion : serum LDH ratio >0.6 - Hypothyroidism - Infarction: PE  Effusion LDH is 0.6 x ULN - Meig’s syn. - Trauma Empyema: turbid fluid, ↓ glucose and pH <7.2

Pleural Biopsy  If pleural fluid is inconclusive  CT-guided ¯c Abrams needle

Mx  Rx underlying cause  May use drainage if symptomatic (≤2L/24h) . Repeated aspiration or ICD  Pleurodesis ¯c talc if recurrent malignant effusion  Persistent effusions may require surgery

Peripheral Inspection Examination

General Peripheral Inspection  Cachexia  Clubbing  Hoarse voice or stridor  Cachexia

Hands Chest  Clubbing ± HPOA  Scars Tar staining  . Lateral thoracotomy  Claw hand ¯c wasting of interossei . Clamshell: double lung Tx . Chest drains Face  Chest wall asymmetry / deformity  Anaemia  Horner’s Pneumonectomy Lobectomy  Plethora Tracheal + apex shift Tracheal shift - To abnormal side - Mainly upper lobectomy Neck - To abnormal side  LNs: check axilla too Throughout abnormal side Focal signs  Dilated veins - ↓ expansion - ↓ expansion - Dull percussion - Dull percussion - NO breath sounds - Reduced breath sounds Chest  Thoracotomy scar  Radiotherapy square burn + tattoo Completion  Acanthosis nigricans  History to establish cause  CXR Collapse  Tracheal deviation towards lesion  ↓ expansion Viva  PN: dull  Auscultation . ↓ or absent AE Differential . ± crackles  Lobectomy / pneumonectomy  ↑ VR  Scar but normal lung . Thoracotomy: abscess, empyema, biopsy, wedge Effusion . Transplant: ? other lung normal  Tracheal deviation away  ↓ expansion Indications for Lobectomy / Pneumonectomy  PN: stony dull  90% for non-disseminated bronchial carcinoma  Auscultation: ↓ AE  Other  ↓ VR . Bronchiectasis . COPD: lung-reduction surgery . TB: historic, upper lobe

Extras Operative Mortality  Hepatomegaly or spinal tenderness  Lobectomy: 7%

Complications  Pneumonectomy: 12%

 SVCO ↑ risk c . Plethoric, oedematous face and upper limbs ¯ . Dilated neck and chest veins  ↑ ASA grade . Stridor  Age >70  RLNP: hoarse voice ¯c bovine cough  Poor resp function  Pancoast Tumour . FEV1:FVC <55% . Horner’s . Claw hand ¯c interossei wasting Discussion  Dermatomyositis  Lung Ca  TB

Differential  Consolidation  Collapse  Effusion

Epidemiology Ix  3rd commonest malignancy in men and women  Commonest cause of cancer death 1. Bloods  FBC: anaemia, ↑WCC if consolidation Pathology  U+E: ↓ Na (SIADH or Addison’s) O  LFTs: deranged LFTs 2 to liver mets Non-Small Cell Lung Cancer  Bone profile: ↑ Ca2+ (bone mets, ↑PTHrP)  SCC: 35% . Highly related to smoking 2. Dx of Mass . Centrally located  CXR . PTHrP → ↑ Ca2+ . Coin lesions  Adenocarcinoma: 25% . Effusion . RF: female non-smokers . Consolidation or collapse . Peripherally located . Hilar LNs . 80% present ¯c extrathoracic mets . Bony mets  Large-cell: 10%  Contrast-enhanced volumetric CT thorax

Small Cell Lung Cancer: 20% 3. Determine Cell Type  Highly related to smoking  Cytology  Central location . Induced sputum  80% present ¯c advanced disease . US-guided pleurocentesis  Ectopic hormone secretion  Histology . Percutaneous FNA: adenocarcinoma . Endoscopic transbronchial biopsy: SCC

Hx 4. Staging  Symptoms  CT: neck, thorax, upper abdo ± brain . Cough + haemoptysis  PET . Dyspnoea  Radionucleotide bone scan . Chest pain  Thoracoscopy, mediastinoscopy + LN sampling . Anorexia and wt. loss

 Smoking 5. Pulmonary Function Tests  Occupational expose  Assess fitness for surgery

 Pneumonectomy CI if FEV1 <1.2L

Complications Mx Local  Recurrent laryngeal N. palsy General  Phrenic N. palsy  MDT  SVCO  Stop smoking  Horner’s (Pancoast’s tumour)  Optimise nutrition and CV function  AF NSCLC Paraneoplastic  Surgery  Endo . Rx of choice if no metastatic spread . ADH → SIADH (euvolaemic ↓Na+)  Stage 1/2:~25% . ACTH → Cushing’s syndrome . Wedge resection, lobectomy, pneumonectomy . Serotonin → carcinoid (flushing, diarrhoea)  Curative Radio: if poor cardiorespiratory function . PTHrP → 1O HPT (↑Ca2+, bone pain) – SCC  Chemo: platinum-based + biologics  Rheum . Dermatomyositis / polymyositis SCLC  Neuro  Usually disseminated @ presentation . Cerebellar degeneration  Some benefit ¯c chemo . Peripheral neuropathy  Derm Palliative Care . Acanthosis nigricans  Analgesia: opiates for pain and cough . Trousseau syndrome: thrombophlebitis migrans  Radiotherapy: haemoptysis, bone or CNS mets  SVCO: dex + radio or intravascular stent Metastatic  Persistent effusions: chemical pleurodesis  Pathological #  Hepatic failure Prognosis  Confusion, fits, focal neuro  NSCLC: 50% 5ys w/o spread; 10% ¯c spread Addison’s   SCLC: 1-1.5yrs median survival treated; 3mo untreated

Examination Viva

Peripheral Inspection Hx  Ill looking  Symptoms  Febrile . Fever, rigors, anorexia, malaise  ↑RR, ↑HR, AF . Cough + sputum ± haemoptysis  Cough . Pleurisy  Rusty sputum  Smoking  Travel and contacts  Immunosuppression: HIV, steroids Chest: Consolidation  ↓ expansion Ix  PN: dull Bedside  Auscultation . Bronchial breathing  Sputum MC+S, cytology . ↓ AE  Urine . Focal coarse crackles . Pneumococcal Ag . Pleural rub . Hb: cold agglutinins → haemolysis . ↑VR Bloods  FBC: ↑ WCC Extras  U+E: dehydration, ↓Na  Para-pneumonic effusion  CRP: trend  Erythema multiforme: mycoplasma  LFT: ↑LFTs in mycoplasma, Legionella  Culture: 25% positive  Paired Sera: Mycoplasma, Chlamydia, Legionella  ABG Differential  Collapse CXR  Effusion  Consolidation ¯c air bronchogram

 Effusion  Cavities: esp. S. aureus

Other  Pleurocentesis  BAL

Mx  Assess severity and Mx accordingly

Specific  Abx  Analgesia

Supportive  Oxygen  Fluids  Chest physio

Complications  Septic shock + MOF: ITU  Para-pneumonic effusion or empyema: drainage  Respiratory failure: ventilation  Abscess: drainage

f/up  CXR @ 6 wks . Check for underlying Ca and resolution  Smoking cessation  Pneumovax (23 valent) . ≥65yrs . Chronic HLRP failure or conditions . Immunosupp: DM, hyposplenism, chemo, HIV . Re-vaccinate every 6yrs © Alasdair Scott, 2012 27 Pneumonia: Key Facts

Epidemiology Severity: CURB-65 (only if x-ray changes)  Incidence: 1/100  Confusion (AMT ≤8) Score  Mortality: 10% in hospital, 30% in ITU  Urea >7mM  0-1 → home Rx  Resp. rate >30/min  2 → hospital Rx Anatomic Classification  BP <90/60  ≥ 3 → consider ITU  ≥65 Bronchopneumonia  Patchy consolidation of different lobes Other Markers of Severity  WCC: <4 or >12 Lobar Pneumonia  Temp: >38 or <32  Fibrosuppurative consolidation of a single lobe  PaO2: <8KPa  Congestion → red → grey → resolution  AF  Multiple lobar involvement

Complications  Septic shock and MOF  Para-pneumonic effusion / empyema  Abscess: S. aureus, Klebsiella, anaerobes  Respiratory failure

SIRS

Aetiological Classification Inflam response to a variety of insults manifest by ≥ 2 of:  Temperature: >38°C or <36°C Community Acquired Pneumonia  Heart rate: >90  Commonest organisms  Respiratory rate: >20 or PaCO <4.6 KPa . Pneumococcus: 50% 2  WCC: >12x109/L or <4 x109/L or >10% bands . Mycoplasma: 6% . Haemophilus: esp. if COPD . Chlamydia pneumonia Sepsis . Viruses: 15%  SIRS caused by infection  Other organisms . S. aureus Severe Sepsis . Moraxella  Sepsis ¯c at least 1 organ dysfunction or hypoperfusion . Legionella  Rx: amoxicillin + clarithromycin Septic Shock  Severe sepsis with refractory hypotension Hospital Acquired Pneumonia  >48hrs after hospital admission MODS  Common organisms  Impairment of ≥2 organ systems . Pseudomonas  Homeostasis cannot be maintained without therapeutic . MRSA intervention. . Gm-ve enterobacteria

 Rx: co-amoxiclav or tazocin ± vanc

Aspiration  ↑ Risk: stroke, bulbar palsy, ↓GCS, GORD, achalasia  Typically posterior segment of RLL  Orgnaisms: anaerobes  Rx: co-amoxiclav

Immunocompromised  PCP: co-trimoxazole  TB: RIPE  Fungi: amphotercin  CMV/HSV: ganciclovir

Atypical Pneumonia  Refers to organisms which cause atypical generalised symptoms and bronchopneumonia . Fever, headaches, myalgia  Poor correlation between clinical and x-ray findings  Often intracellular: mycoplasma, Chlamydia, Legionella © Alasdair Scott, 2012 28 Old TB

Examination TB: Key Facts

Chest Pathophysiology

Inspection Primary TB  Asymmetry: absent ribs  Childhood or naïve TB infection  Scars  Organism multiplies @ pleural surface → Ghon Focus . Thoracoplasty  Macros take TB to LNs . Supraclavicular fossa: phrenic nerve crush . Nodes + lung lesion = Ghon complex  Mostly asympto: may → fever and effusion Palpation  Cell mediated immunity / DTH controls infection in 95%  Tracheal deviation towards apical fibrosis . Fibrosis of Ghon complex → calcified nodule  ↓ expansion (Ranke complex)  Rarely may → 1O progressive TB (immunocomp) PN: dull Primary Progressive TB Auscultation  Resembles acute bacterial pneumonia  ± bronchial breathing  Mid and lower zone consolidation, effusions, hilar LNs  ↓ AE  Lymphohaematogenous spread → extra-pulmonary and  Crackles milliary TB  ↑VR Latent TB  Infected but no clinical or x-ray signs of active TB Viva  Non-infectious  May persist for years  Weakened host resistance → reactivation Past Mx of TB  It was believed that lower PAO2 would inhibit TB Secondary TB proliferation.  Usually reactivation of latent TB due to ↓ host immunity   inducing apical collapse was a treatment  May be due to reinfection

 Typically develops in the upper lobes Techniques  Hypersensitivity → tissue destruction → cavitation and  Plombage: insertion of polystyrene balls into thoracic formation of caseating granulomas. cavity

 Phrenic nerve crush: diaphragm paralysis Dx  Thoracoplasty: rib removal to collapse lung

 Apical lobectomy Latent TB

 Tuberculin Skin Test Complications of Old TB  If +ve → IGRA  Aspergilloma in old TB cavity  Bronchiectasis Active TB . LN compression of large airways  CXR . Traction from fibrosis . Mainly upper lobes.  Scarring predisposed to bronchial Ca . Consolidation, cavitation, fibrosis, calcification  If suggestive CXR take ≥3 sputum samples (one AM) Current Mx of TB . May use BAL if can’t induce sputum . Microscopy for AFB: Ziehl-Neelsen stain Initial Phase (RHZE): 2mos . Culture: Lowenstein-Jensen media (Gold stand)  RMP: hepatitis, orange urine, enzyme induction  INH: peripheral sensory neuropathy, ↓PMN PCR  PZA: hepatitis, arthralgia (CI: gout, porphyria)  Can Dx rifampicin resistance  EMB: optic neuritis → loss of colour vision first  May be used for sterile specimens

Continuation Phase (RH): 4mos Tuberculin Skin Test  RMP  Intradermal injection of purified protein derivative  INH  Induration measured @ 48-72h  False +ve: BCG, other mycobacteria, prev exposure  False –ve: HIV, sarcoid, lymphoma

Interferon Gamma Release Assays (IGRAs)  Pt. lymphocytes incubated ¯c M. tb specific antigens → IFN-γ production if previous exposure.  Will not be positive if just BCG (uses M. bovis)  E.g. Quantiferon Gold and T-spot-TB

Contents Chronic Liver Disease ...... 31 CLD: Key Facts ...... 32 Ascites ...... 33 Medical Jaundice ...... 34 Liver Transplant ...... 35 Hepatomegaly ...... 36 Splenomegaly ...... 37 Myloproliferative Disorders ...... 38 Spleen and Splenectomy ...... 38 Enlarged Kidneys ...... 39 Cystic Renal Disease ...... 40 RCC / Hypernephroma ...... 40 Renal Transplant ...... 41 Renal Transplant: Key Facts ...... 42 Renal Replacement Therapy ...... 43 Renal Access ...... 44 CRF: Key Facts ...... 45 CRF: Specific Causes ...... 46 Inflammatory Bowel Disease ...... 47 IBD: Key Facts for Medicine ...... 48

Examination Viva

Peripheral Inspection Hx  Cause General . EtOH  Jaundice . Sexual Hx, IVDU, transfusions  Ascites . FH  Cachexia . Other AI disease: e.g. DM, thyroid  Tattoos and track marks . DH  Pigmentation Ix Hands  Clubbing (esp. in PBC) Initial Workup  Leukonychia  Urine: dip ± MC+S (? UTI)  Terry’s nails (white proximally, red distally)  Bloods: FBC, U+E, LFTs, INR, glucose  Palmer erythema  Ascitic tap: chemistry, cytology, MC+S, SAAG 3  Dupuytren’s contracture . PMN >250mm indicates SBP  US + PV duplex Face . Liver size and texture  Pallor: ACD . Focal lesions  Xanthelasma: PBC . Ascites  Keiser-Fleischer rings . Portal vein flow  Parotid enlargement (esp. ¯c EtOH) Liver Screen Trunk  EtOH: MCV, GGT, AST:ALT >2  Spider naevi  Viral: Hep B and C serology  Gynaecomastia  NASH: lipids  Loss of 2O sexual hair  AutoAbs: SMA, AMA, pANCA, ANA  Ig: ↑IgG – AIH, ↑IgM – PBC Ankles  Genetic: caeruloplasmin, Ferritin, α1-AT  Peripheral oedema  Ca: AFP, Ca 19-9

Abdomen Other  Liver biopsy Inspection  MRCP: PSC  Distension ± Para- / umbilical hernia  Dilated veins  Drain scars Rx

Palpation General  ± hepatomegaly  MDT: GP, hepatologist, dietician, palliative care, family  ± splenomegaly  EtOH abstinence  Shifting dullness  Good nutrition  Cholestyramine for pruritus Significant Negatives  Screening . HCC: US + AFP  Evidence of decompensation . Varices: OGD . Jaundice

. Encephalopathy: asterixis, confusion . Foetor hepaticus: ammonia and ketones Specific . Hypoalbuminaemia: oedema and ascites  HCV: interferon-α + ribavarin . Coagulopathy: bruising  PBC: ursodeoxycholic acid  Evidence of SBP: esp. if ascites  Wilson’s: penicillamine  Cause: xanthelasma, pigmentation, KF rings, tattoos  HH: venesection, desferrioxamine

CLD Differential Complications  Varices: β-B, banding  Common  Ascites: fluid and salt restrict, spiro, fruse, tap, daily wt . EtOH . Viral  Coagulopathy: Vit K, FFP, platelets . NASH  Encephalopathy: avoid sedatives, lactulose, rifaximin  Rarer  Sepsis / SBP: tazocin or cefotaxime . Genetic: HH . Avoid gent: nephrotoxicity . AI: AH  Hypoglycaemia: dextrose . Drugs: methotrexate  Hepatorenal syndrome: IV albumin + terlipressin

Causes Encephalopathy  Common . Chronic EtOH Pathophysiology . Chronic HCV (and HBV)  ↓ hepatic metabolic function . NAFLD / NASH  Diversion of toxins from liver directly into systemic  Other system. . Congenital: HH, Wilson’s, α1ATD, CF  Ammonia accumulates and pass to brain where . AI: AH, PBC, PSC astrocytes clear it causing glutamate → glutamine . Drugs: Methotrexate, amiodarone, isoniazid  ↑ glutamine → osmotic imbalance → cerebral oedema. . Neoplasm: HCC, mets . Vasc: Budd-Chiari, RHF, constrict. pericarditis Presentation  Asterixis, Ataxia Complications  Confusion 1. Liver failure / decompensation  Dysarthria 2. SBP  Constructional apraxia 3. Portal HTN: SAVE  Seizures 4. HCC Ix: ↑ plasma NH4 Child-Pugh Grading of Cirrhosis  Evaluates prognosis in Cirrhosis Rx  Graded A-C using severity of 5 factors  Nurse in well lit, calm environment . Albumin  Correct any precipitants . Bilirubin  Avoid sedatives . Clotting  Lactulose . Distension: ascites . ↓ nitrogen-forming bowel bacteria . Encephalopathy . 2-4 soft stools/d  Rifaximin PO: kill intestinal microflora Score 1yr Mortality Tx Mortality A: 5-6 0 10 Hepatorenal Syndrome B: 7-9 20 30  Renal failure in pts. ¯c advanced CLF C: 10-15 50 80 Pathophysiology: “Underfill theory”  Cirrhosis → splanchnic arterial vasodilatation → effective Decompensation circulatory volume → RAS activation → renal arterial vasoconstriction. Precipitants → HEPATICS  Persistent underfilling of renal circulation → failure  Haemorrhage: e.g. varices  Electrolytes: ↓K, ↓Na Classification  Poisons: diuretics, sedatives, anaesthetics  Type 1: rapidly progressive deterioration (survival <2wks)  Alcohol  Type 2: steady deterioration (survival ~6mo)  Tumour: HCC  Infection: SBP, pneumonia, UTI, HDV Rx  Constipation (commonest cause)  IV albumin + terlipressin  Sugar (glucose) ↓: e.g. low calorie diet  Haemodialysis as supportive Rx  Liver Tx is Rx of choice General Mx  HDU or ITU SBP  Rx any precipitant  Good nutrition: e.g. via NGT ¯c high carbs Presentation  Thiamine supplements  Pt. ¯c ascites and peritonitic abdomen  Prophylactic PPIs vs. stress ulcers  Complicated by hepatorenal syn. in 30%

Monitoring Common organisms: E. coli, Klebsiella, Streps  Fluids: urinary and central venous catheters 3  Bloods: daily FBC, U+E, LFT, INR Ix: ascites PMN >250mm + MC+S  Glucose: 1-4hrly + 10% dextrose IV 1L/12h Rx: Tazocin or cefotaxime until sensitivities known Mx Complications  Ascites: daily wt, fluid and Na restrict, diuretics, tap Prophylaxis: high recurrence  cipro long-term  Coagulopathy: Vit K, FFP, platelets  Encephalopathy: avoid sedatives, lactulose, rifaximin Poor Prognosis  Sepsis / SBP: tazocin or cefotaxime  Worsening encephalopathy  Hypoglycaemia: dextrose  ↑ age  Hepatorenal syndrome: IV albumin + terlipressin  ↓ albumin  ↑ INR © Alasdair Scott, 2012 32 Ascites

Examination Viva

Peripheral Inspection Hx  SBP: fever, abdo pain Cause  Cause  Signs of CLD . Liver disease  CCF: ↑ JVP, bibasal creps, peripheral oedema . Cardiac failure, MI  Nephrotic: periorbital oedema  Budd Chiari: abdo pain, hepatomegaly, jaundice Ix

Abdomen Bedside  Shifting dullness  Urine: dip ± MC+S  Portal HTN: splenomegaly . Exclude nephrotic syn. . ? UTI Completion  CVS and Resp for CCF Bloods FBC  Urine dip: proteinuria in nephrotic syndrome   U+E  LFTs: esp. albumin  INR Significant Negatives  Glucose  CLD  Liver screen  Acute liver failure / decompensation  Cause: ↑ JVP, periorbital oedema Ascitic tap  Chemistry  Cytology: malignancy, PMN (>250/mm3 = SBP) Causes of Ascites  Bacteriology: MC+S, Ziehl-Neelson Stain  SAAG Commonest  Cirrhosis US + PV duplex  CCF  Liver size and texture  Carcinomatosis  Focal lesions  Ascites Serum Ascites Albumin Gradient  Portal vein flow  SAAG = Se albumin – Ascites Albumin Rx SAAG ≥1.1g/dL = Portal HTN (97% accuracy)  Cirrhosis in 80% General  EtOH abstinence SAAG <1.1g/dL  Daily wts: aim for ≤0.5kg/d reduction  Neoplasia: e.g. peritoneal mets or ovarian Ca  Fluid restrict: <1.5L/d  Inflammation: pancreatitis  Low Na diet: 40-100mmol/d  Nephrotic syndrome  Infection: TB peritonitis Diuretics  Spironolactone  Add frusemide if response poor Portal HTN  Portal pressure >10mmHg (norm 5-10) Therapeutic Paracentesis  80% cirrhosis in UK  Temporary insertion of pig-tail drain or Bonnano catheter  Indications Pre-hepatic . Respiratory compromise  Portal vein thrombosis . Pain / discomfort . PV, ET . Renal impairment . PNH  Risks . Nephrotic syndrome . Severe hypovolaemia: replenish albumin . SBP Hepatic  Cirrhosis Refractory Ascites  TIPSS Post-hepatic  Transplant  Cardiac: RHF, TR, constrictive pericarditis  Budd-Chiari (hepatic vein thrombosis) SBP  Rx: Tazocin or cefotaxime until sensitivities known  Prophylaxis: high recurrence  cipro long-term

Examination Viva

Peripheral Examination Hx

Cause Pre-hepatic  CLD  Anaemia: tired, SOB, palpitations, ankle swelling  Pancreatic Ca: cachexia, Virchow’s node  FH: HS  Haemolysis: pallor  CTD: arthritis

Abdomen Hepatic  EtOH intake  Excoriations and pruritus  Foreign travel: Hep A  Splenomegaly  Blood transfusions, IVDU, sex: Hep B and C  Hepatomegaly  Sore throat: EBV  Palpable gallbladder: Ca head of pancreas Drug Hx: OCP, Abx, neuroleptics, OTCs 

Completion Post-hepatic  Urine dip: look for BR, urobilinogen and Hb  Dark urine, pale stools  Itching Significant Negatives  Stones: RUQ pain or biliary colic  Acute liver failure / decompensation  Malignancy  CLD . Wt. ↓ and ↓ appetite  Organomegaly . Change in bowel habit: esp. steatorrhoea . Back pain Differential  CLD: EtOH, viral, NAFLD Ix  Splenomegaly . Haemolysis Urine Dip . CLD ( → portal HTN) . Viral hepatitis: e.g. EBV Pre-hepatic Hepatic Post Hepatic  Hepatomegaly No BR (acholuric) ↑cBR ↑↑cBR . Hepatitis ↑ urobilinogen ↑ urobilinogen No urobilingoen . CLD Hb  No CLD or organomegaly Haemosiderin . Biliary obstruction . Haemolysis Bloods . Drugs: fluclox, OCP  FBC and film ± DAT: haemolysis . Gilberts  U+E: hepatorenal syndrome  LFTs Commonest Causes . Conjugated vs. unconjugated BR  Haemolysis . Hepatocellular dysfunction LFTs  CLD . Cholestatic LFTs  Gallstones  Clotting: ↑INR in CLD and Vit K deficiency  Liver screen Pre-hepatic Hepatic Post-hepatic Unconjugated Un- / Conjugated Conjugated Imaging Haemolysis CLD Gallstones  Abdo US + PV duplex - AIHA Hepatitis  MRCP, CT, MRI - HS - EtOH Ca Head Panc - SCD - Viral Other Drugs LNs @ porta hepatis  Liver biopsy: check clotting first - Paracetamol - Ca - Statins - TB Rx: Cause - Anti-TB Pre-hepatic  Splenectomy Other Causes Hepatic Pre-hepatic Hepatic Post-hepatic  EtOH: abstinence + support Haemolysis Congenital PBC  Viral: supportive or anti-virals - PNH AI PSC O O  Drugs: avoid - MAHA Ca: 1 , 2 Cholangio Ca - Malaria Vasc Drugs Post-Hepatic - G6PD ↓ BR excretion - OCP  PBC / PSC: ursodeoxycholic acid - Augmentin, fluclox  Stones / Ca: relieve obstruction © Alasdair Scott, 2012 34 Liver Transplant

Examination Viva

Peripheral Inspection Hx  Cause General . EtOH  Evidence of CLD . Sexual Hx, IVDU, transfusions  Pigmentation: HH . FH  Tattoos and needle marks: Hep B/C . Other AI disease: e.g. DM, thyroid . DH Immunosuppressant Stigmata  Transplant  Cushingoid . Cadaveric or live segmental  Skin tumours: AKs, SCC (100x ↑ risk), BCC and MM . Any complications  Gingival hypertrophy: ciclosporin  Current health . Acute rejection: fever, graft pain Abdomen . Immunosuppression  Mercedes-Benz scar  Infection: e.g. CMV pneumonitis  Skin Ca  DH

Significant Negatives  Evidence of CLD or cause for Tx Ix  Evidence of immunosuppression  Absence of features of liver failure = working Tx Bloods  FBC: infection

 U+E: ciclosporin can → renal impairment Differential for Mercedes Benz Scar  LFTs: assess graft function  Hepatobiliary surgery  Clotting . Liver transplant  Fasting glucose: tacrolimus and steroids → DM . Segmental resection  Drug levels: ciclosporin, tacrolimus . Whipples’: pancreaticoduodenectomy

Other

 Liver biopsy: if rejection suspected

Top Causes for Liver Tx  Cirrhosis  Acute liver failure . Hep A, B . Paracetamol overdose  Malignancy

Success of Liver Tx  80% 1-yr survival  70% 5-yr survival

Immunosuppression Regimen  Tacrolimus / ciclosporin  Azathioprine  Prednisolone ± withdrawal @ 3mo

Examination Viva

Peripheral Inspection Hx  Hepatitis / CLD: EtOH, viral exposure, FH Cause  Cardiac: dyspnoea, PND, previous MI, rheumatic fever  CLD  Haem: tiredness, bruising, infections, bone pain  EtOH: palmar erythema, Dupuytren’s  HH: skin discolouration  Ca: cachexia Ix  CCF: ↑ JVP, bibasal creps, ascites, peripheral oedema  Haematological: pallor, bruising, purpura, LNs Urine dip  BR, urobilinogen Abdomen  Proteinuria: amyloid

Hepatomegaly Bloods  Define fingerbreadths below costal margin at which liver  FBC edge palpable. . ↓Hb: malignancy, chronic disease . Moves inferiorly on inspiration . Lymphocytosis: hepatitis viruses, EBV (atypical) . Can’t get above it  U+E: CCF → renal impairment . Dull PN  LFT  Features to note  Clotting . Edge: smooth, craggy, nodular  Liver screen . Tenderness . Pulsatile Imaging  Percuss above and below to confirm enlargement  Abdo US + PV and hepatic duplex  Auscultate for liver bruit . Liver size and texture . HCC . Focal lesions . Ascites Other . Portal vein flow  Splenomegaly . Hepatic veins: thrombosis  Inguinal nodes  CT: e.g. for tumour  Ascites  MRI: good quality images of liver parenchyma

Completion Liver Biopsy  CVS and Resp: CCF  Check clotting first  Nodular Pattern . Micronodular: EtOH, HH, Wilson’s . Macronodular: viral Significant Negatives  Iron: Pearl’s stain  Splenomegaly  Copper: Rhodamine stain  Acute liver failure / decompensation  α1ATD: PAS stain (α1AT globules accumulate in liver)  Cause: CLD, ↑JVP, pallor, bruising, LNs  Amyloid: apple-green birefringence ¯c Congo Red  Granulomata: PBC Common Causes  Hepatitis: EtOH, viral, NAFLD  CLD Rx: Cause  Congestion 2O to cardiac failure  EtOH: abstinence + support

 Viral: supportive or anti-viral therapy Other Causes: MACHO O  HH: venesection ± desferrioxamine  Malignancy: 2  Wilson’s: penicillamine  Anatomical: Riedel’s lobe, hyperexpanded chest  CCF: ACEi, β-B and diuretics  Congestion: TR, Budd Chiari  Haematological: monitoring or chemo  Haem: leukaemia, lymphoma, myeloproliferative, SCD  Other: sarcoidosis, amyloidosis, Gaucher’s, ADPKD

Examination Viva

Peripheral Inspection Hx  Haem: tiredness, bruising, infections, bone pain Cause  CLD: EtOH, viral exposure, FH  Haematological: pallor, bruising, purpura, LNs, cachexia  Infections: fever, sore throat, jaundice, foreign travel . Cervical, axilla, inguinal  Inflammation: arthritis  Portal HTN: CLD signs  IE: splinter’s, clubbing Haematological Ix  Felty’s Syndrome: rheumatoid hands FBC Abdomen  CML: ↑↑↑WBC – PMN, basophils, myelocytes  MF: pancytopenia Inspection  CLL: lymphocytosis  Asymmetry  Haemolysis: ↓ Hb, ↑MCV, ↑RDW

Palpation Film  Splenomegaly  MF: leukoerythroblastic ¯c teardrop poikiolcytes . Can’t get above it  CLL: smear cells . Moves inferiorly toward RIF on respiration  Haemolysis: spherocytes, reticulocytosis . Notch . Dull PN Other Bloods . Not ballotable  DAT  Size: big or small?  U+E and urate: ↑ malignancy → uropathy  Hepatomegaly?  Inguinal nodes? Imaging  Abdo US Completion  CT chest and abdomen  Cardio and Resp exam: IE and sarcoid  PET scan  Urine dip: haematuria (IE), proteinuria (amyloid) Histology / Cytology  LN biopsy Significant Negatives  BM aspirate or trephine biopsy (MF)  Hepatomegaly  Haem: pallor, bruising, LNs Genetic Analysis  CLD  CML: Ph Chr, t(9:22)  IE: splinters, clubbing  MF: Jak2+ in 50%  RA hands: Felty’s Syndrome

Infective Ix

Big Spleen: limited differential Dx Urine Dip  Myeloproliferative: CML, MF  Haematuria: IE  Lymphoproliferative: CLL, lymphoma  Infiltrative: amyloidosis, Gaucher’s Bloods  Developing world: malaria, visceral leishmaniasis  FBC: lymphocytosis (may be atypical in EBV)  U+E: renal impairment in IE  Thick and thin films

Small Spleen: all causes of isolated splenomegaly Imaging

Common  Abdo US  Haem: myelo- / lympho-prolif disorders, haemolysis  Echo: IE  Portal HTN: mostly 2O to cirrhosis  Infection: EBV Liver Ix

Other Bloods  Infection: herpes viruses, hepatitis virus, IE, malaria  FBC  Inflammation: RA, SLE, Sjogren’s  LFT  Rare: sarcoidosis, amyloidosis, Gaucher’s, CVID  Clotting  Liver screen

Hepatosplenomegaly Imaging  As for isolated splenomegaly except for inflammatory  Abdo US + PV duplex causes © Alasdair Scott, 2012 37 Myloproliferative Disorders Spleen and Splenectomy

CML Anatomy  Intraperitoneal structure lying in the LUQ  Clonal proliferation of myeloid cells  Measures 1x3x5 inches  15% of leukaemia  Weighs ~7oz

 Lies anterior to ribs 9-11 Symptoms  Hypermetabolism: wt. loss, fever, night sweats, lethargy Function: part of the mononuclear phagocytic system  Massive HSM → abdo discomfort  Phagocytosis of old RBCs, WBCs  Bruising / bleeding (platelet dysfunction)  Phagocytosis of opsonised bugs: esp. encapsulates  Gout  Antibody production  Hyperviscosity  Sequestration of formed blood elements

. Platelets, lymphocytes and monocytes Philadelphia Chromosome  Haematopoiesis  Reciprocal translocation: t(9;22)  Formation of BCR-ABL fusion gene . Constitutive tyrosine kinase activity Hypersplenism  Present in >80% of CML  Pancytopenia due to pooling and destruction w/i an enlarged spleen.  Discovered by Nowell and Hungerford in 1960  Anaemia, bruising, infections  Sequestration crisis in SCD → hypovolaemic shock Ix  ↑↑WBC Hyposplenism . PMN and basophils . Myelocytes Causes  ± ↓Hb and ↓plat (accelerated or blast phase)  Splenectomy  ↑urate  Coeliac disease  BM cytogenetic analysis: Ph+ve  IBD

 SCD Rx  Imatinib: tyrosine kinase inhibitor Film . → >90% haematological response  ↑ platelets transiently after splenectomy . 80% 5ys  Howell-Jolly bodies  Allogeneic SCT  Pappenheimer bodies . Indicated if blast crisis or TK-refractory  Target cells

Mx Primary Myelofibrosis  Immunisations  Clonal proliferation of megakaryocytes → ↑ PDGF → . Pneumovax Myelofibrosis . HiB  Extramedullary haematopoiesis: liver and spleen . Men C . Yrly flu Symptoms  Daily Abx: Pen V or erythromycin  Elderly  Warning: Alert Card and/or Bracelet  Massive HSM  Hypermetabolism: wt. loss, fever, night sweats Splenectomy  BM failure: anaemia, infections, bleeding Indications Ix  Trauma Rupture: e.g. 2O to EBV  Film: leukoerythroblastic c¯ teardrop poikilocytes   Cytopenias  AIHA  BM: dry tap (need trephine biopsy)  ITP HS  50% JAK2+ve   Hypersplenism

Rx Complications Supportive: blood products   Redistributive thrombocytosis → early VTE  Splenectomy . Temporary post-op aspirin prophylaxis  Allogeneic BMT may be curative in younger pts.  Gastric dilatation: transient ileus . May disturb gastro-omental vessel ligatures Prognosis . Prophylactic NGT post-op  5yr median survival  Left lower lobe atelectasis  Pancreatitis: tail shares blood supply ¯c spleen  ↑ susceptibility to infections . Encapsulates: haemophilus, pneumo, meningo

Examination Viva

Peripheral Inspection Hx  ADPKD: FH, loin pain, haematuria, headaches Renal Impairment  RCC: haematuria, loin pain  HTN  Compensatory hypertrophy: previous infections, stones  Pallor Ix Renal Replacement Therapy  AV fistula (or scar) Urine  Tunnelled dialysis lines (or scar)  Dip: haematuria, proteinuria  Tenchkhoff catheter (or scar)  Cytology

Immunosuppressant Stigmata Bloods  Cushingoid  FBC: ↓Hb 2O to ESRF  Skin tumours: AKs, SCC, BCC and MM  U+E: ↓eGFR, electrolyte disturbance  Gingival hypertrophy: ciclosporin  Bone profile: ↓Ca, ↑ PO4, ↑PTH

Imaging Abdomen  Abdo US . Confirm renal enlargement Inspection  Cysts  Nephrectomy scar  Hydronephrosis  Rutherford Morrison scar  Masses  Tenchkhoff catheter (or scar) . Liver enlargement  CT/MRI Palpation . MRA: Berry aneurysms  Palpable Kidney . CT abdo: esp. if RCC suspected . Flank mass . Can get above it Other . Ballotable  Genetic studies to look for mutation in . Moves inferiorly ¯c respiration . PKD1 gene on Chr 16: 85% . Resonant PN . PKD2 gene on Chr 4: 15%  Hepatomegaly  Family screen  Renal Transplant

Auscultation Mx of ADPKD  Renal bruit General Completion  ↑ water intake, ↓ Na, ↓ caffeine (may ↓ cyst formation)  External genitalia: hydrocele 2O to RCC  Monitor U+E and BP  Urine dip: proteinuria, haematuria  Genetic counselling  CVS: mitral valve prolapse . 50% chance of transmission . 10% are de novo mutations  MRA screen for Berry aneurysms Significant Negatives  Unilateral enlargement Medical  Hepatomegaly  Rx HTN aggressively: <130/80 (ACEi best)  Evidence of RRT or immunosuppression  Rx infections

Surgical: Nephrectomy Differential  Recurrent bleeds or infections  Abdominal discomfort Bilateral  ADPKD ESRF in 70% by 70yrs  Bilateral RCC (5%)  Mx complications: CRF HEALS  Bilateral cysts: e.g. in VHL  Dialysis or transplant

 Amyloidosis

Unilateral  Simple renal cyst  RCC  Compensatory hypertrophy  + contralateral nephrectomy: ADPKD © Alasdair Scott, 2012 39 Cystic Renal Disease RCC / Hypernephroma

ADPKD Epidemiology  90% of renal cancers Epidemiology  Age: 55yrs  Prev: 1:1000  Sex: M>F=2:1  5% of ESRF in UK  Genetics Risk Factors . PKD1 gene on Chr 16: 85%  Smoking . PKD2 gene on Chr 4: 15%  Obesity . Involve cell-cell interactions  HTN

 Dialysis: 15% of pts. develop RCC Presentation  4% heritable: e.g. VHL syndrome  Age: 30-50s  HTN Pathology  Recurrent UTIs  Adenocarcinoma from proximal renal tubular epithelium  Loin pain: cyst haemorrhage or infection  Clear Cell (glycogen) subtype: 70-80%  Haematuria

Extra-Renal Involvement Presentation  Hepatic cysts → hepatomegaly  50% incidental finding  Intracranial Berry aneurysms → SAH  Triad: Haematuria, loin pain, loin mass  MV Prolapse: mid-systolic click + late systolic murmur  Invasion of L renal vein → varicocele (1%)  Cannonball mets → SOB Prognosis  70% ESRF by 70yrs Paraneoplastic Features  EPO → polycythaemia  PTHrP → ↑ Ca ARPKD  Renin → HTN  ACTH → Cushing’s syn. Epidemiology  Amyloidosis  Prev: 1:40000  Genetics: PKHD1 (fibrocystin) gene on Chr6 Spread  Direct: renal vein Presentation  Lymph  Perinatal  Haematogenous: bone, liver and lung  Oligohydramnios: may → Potter sequence . Clubbed feet, pulm. hypoplasia, cranial Ix abnormalities  Blood: polycythaemia, ESR, U+E, ALP, Ca  Bilateral abdominal masses  Urine: dip, cytology  HTN and CRF  Imaging . CXR: cannonball mets Extra-Renal Involvement . US: mass  Congenital hepatic fibrosis → Portal HTN . IVU: filling defect . CT/MRI Prognosis  ESRF by 20yrs Mx  Need Tx  Medical . Reserved for pts. ¯c poor prognosis Simple Renal Cysts . Temsirolimus (mTOR inhibitor)  Common: 1/3 of pts over 60yrs  Surgical  May present as renal mass and haematuria . Radical nephrectomy  Contain fluid only: no solid elements . Consider partial if small tumour or 1 kidney  Main differential is RCC  Prognosis: 45% 5ys

Dialysis Associated Renal Cysts  Seen after prolonged dialysis Von Hippel-Lindau O  2 to obstruction of renal tubules by oxalate crystals  Autosomal Dominant  ↑ risk of RCC in cyst: 15% of pts on haemodialysis  Renal and pancreatic cysts  Bilateral renal cell carcinoma Tuberous Sclerosis (Bourneville’s Disease)  Haemangioblastomas  AD condition ¯c hamartomas in skin, brain, eye, kidney . Often in cerebellum → cerebellar signs  Skin: nasolabial adenoma sebaceum, ash-leaf  Phaeochromocytoma macules, peri-ungual fibromas  Islet cell tumours  Neuro: ↓IQ, epilepsy, astrocytoma  Renal: cysts, angiomyolipomas © Alasdair Scott, 2012 40 Renal Transplant

Examination Viva

Peripheral Inspection Hx  Cause Renal Impairment . DM  HTN . GN  Pallor  Transplant . Cadaveric or live Renal Replacement Therapy . Any complications: e.g. urinary leaks, infection  AV fistula (or scar)  Current health  Tunnelled dialysis scars . Acute rejection: fever, graft pain  Tenchkhoff catheter scars . Graft function: Cr levels, BP, urine output . Immunosuppression Immunosuppressant Stigmata  Infection: e.g. CMV pneumonitis  Cushingoid  Skin Ca  Skin tumours: AKs, SCC (100x ↑ risk), BCC and MM . CV risk  Gingival hypertrophy: ciclosporin  DH

Cause  DM Ix . Finger pricks from BM monitoring . Insulin marks on abdomen, lipodystrophy Urine  Cystic Kidney Disease  Dip: haematuria, proteinuria . Nephrectomy scars or ballotable kidneys  MC+S  Connective Tissue Disease . SLE, SS, RA Bloods  FBC: infection  U+E: eGFR – look @ trend Abdomen  LFTs: ciclosporin can → hepatic dysfunction  Fasting glucose: tacrolimus is diabetogenic Inspect  Drug levels: ciclosporin, tacrolimus  Rutherford Morrison Scar in RIF  Nephrectomy scars Other  Tenchkoff catheter scars  Renal biopsy: if rejection suspected

Palpate  Smooth oval mass under scar Discussion  Dull PN  Renal failure: causes, Ix, Mx  Can get below it  Renal replacement therapy  Doesn’t move with respiration  Renal Tx: complications, immunosuppression

Auscultate  Renal bruit over transplant

Completion  Dipstick: haematuria and proteinuria  Drug chart: any potentially nephrotoxic drug (e.g. ACEi)  BP: HTN common post-Tx

Significant Negatives  Evidence of immunosuppression  Signs of a cause: DM and PKD  Working Tx . Renal replacement therapy not in use . No pain over Tx site

Gum Hypertrophy Differential  Drugs: ciclosporin, phenytoin, nifedipine  Familial  AML  Scurvy  Pregnancy

Commonest Indications for Renal Tx Complications  Diabetic nephropathy  GN Post-op  Polycystic Kidney Disease  Bleeding  Hypertensive nephropathy  Graft thrombosis  Infection  Urinary leaks Assessment  Virology: CMV, HIV, VZV, hepatitis  Co-morbidities: esp. CVD Rejection  ABO  anti-HLA Abs: may be acquired from blood transfusion Hyperacute rejection: minutes  Haplotype  Path: ABO incompatibility . Importance: HLA-DR > HLA-B > HLA-A  Presentation: thrombosis and SIRS . 2 alleles @ each locus → 6 possible mismatches . ↓ mismatches → ↑ graft survival Acute Rejection: <6mo  Pre-implantation cross-match  Path: Cell-mediated response . Recipient serum vs. donor lymphocytes  Presentation . Fever and graft pain . ↓ urine output Contraindications . ↑ Cr  Active infection  Rx: Responsive to immunosuppression  Cancer  Severe co-morbidity Chronic Rejection: >6mo  Failed pre-implantation x-match  Presentation: Gradual ↑ in Cr and proteinuria  Path: Interstitial fibrosis + tubular atrophy  Rx: supportive, not responsive to immunosuppression

Types of Graft  Cadaveric: brainstem death ¯c CV support Drug Toxicity  Non-heart beating donor: no active circulation  Live-related Ciclosporin: calcineurin inhibitor (blocks IL2 production) . Optimal surgical timing  Nephrotoxic: may contribute to chronic rejection . HLA-matched  Gingival hypertrophy . Improved graft survival  Hypertrichosis  Live unrelated  Hepatic dysfunction

Tacrolimus: calcineurin inhibitor (blocks IL2 production) Immunosuppression  < nephrotoxicity cf. ciclosporin  Pre-op: campath / alemtuzumab (anti-CD52)  Diabetogenic  Post-op  Cardiomyopathy . Short-term: prednisolone  Neurotoxicity: e.g. peripheral neuropathy . Long-term: tacrolimus or ciclosporin Steroids → Cushing’s Syndrome

Prognosis ↓ immune Function  t½ for cadaveric grafts: 15yrs  ↑ risk of infection: CMV, PCP, fungi, warts  t½ for HLA-identical live grafts: >20yrs  ↑ risk of malignancy . Skin: SCC, BCC, MM, Kaposi’s O . Post-Tx lymphoproliferative disease (2 EBV)

Cardiovascular Disease  Hypertension  Atheromatous vascular disease . A leading cause of death

Indications Haemofiltration  Suggested to start when GFR<15ml/min + symptoms  Usually only used in ITU  Psychological preparation necessary  Takes longer cf. HD but there is less haemodynamic  PD vs. HD depends on med, social and psych factors instability.

Mechanism General Dialysis Complications  Use a Vas Cath  20% annual mortality  Blood filtered across a highly permeable membrane by  Cardiovascular disease hydrostatic pressure and water and solutes are removed  Malnutrition by convection.  Infection  Ultrafiltrate is replaced by isotonic replacement. . uraemia → granulocyte dysfunction → ↑ sepsis- related mortality  Amyloidosis Peritoneal Dialysis . β2-microglobulin accumulation . Carpal tunnel, arthralgia Mechanism  Renal cysts → RCC  Dialysate introduced into peritoneal cavity by Tenchkhoff catheter.  Uraemic solutes diffuse into fluid across peritoneum Haemodialysis  Ultrafiltration: addition of osmotic agent (e.g. glucose)  ~3L 4x /day ¯c ~4h dwell times Mechanism Types Counter-current flow  CAPD: fluid exchange during day ¯c long dwell @ night  Blood flows on one side of semipermeable membrane  APD: fluid exchanged during night by machine ¯c long  Dialysate flows in the opposite direction on the other dwell throughout day. side.  Solute transfer by diffusion Advantages  Simple to perform Ultrafiltration  Requires less equipment  Fluid removal by creation of –ve transmembrane . Easier @ home or on holiday pressure by decreasing the hydrostatic pressure of the  Less haemodynamic instability  useful if cardio disease dialysate.

Disadvantages Complications  Inconvenience  Disequilibration syndrome (usually only 1st dialysis)  Body image . Rapid changes in plasma osmolarity → cerebral  Anorexia oedema

. n/v, headache and ↓GCS  Fluid balance: BP↓, pulmonary oedema Complications  Electrolyte imbalance  Peritonitis  Aluminium toxicity (in dialysate) → dementia  Exit site infection  Psychological factors  Catheter malfunction  Obesity (glucose in dialysate)  Mechanical: hernias and back pain

AV Fistula Tunnelled Cuffed Catheter

Examination Tessio Lines  Two lines tunnelled under skin and entering IJV Inspection  Swelling ¯c surgical scar over distal forearm or @ elbow Disadvantages  Evidence of use: needle marks  May have ↑ recirculation cf. AVF  Evidence of infection  Lower flow rates  ↑ risk of infection and thrombosis Palpation  Check if painful Complications  Temperature  Adverse events @ insertion: e.g. pneumothorax  Palpable thrill  Line or tunnel infection  Blockage Auscultate  Retraction  Audible bruit

Significant Negatives  Evidence of infection, stenosis, aneurysm

Viva

Definition  Surgically created connection between artery and vein . Radio-cephalic @ wrist = Cimino-Brescia . Brachio-cephalic @ the elbow . Venous limb (from machine) is proximal  Side-to-side anastomosis ¯c ligation of the distal vein

Advantages  High flow rates, low recirculation (<10%)  Low infection rates  Less chance of stenosis cf. grafts

Disadvantages  Take ~6 weeks to arterialise  Affect pts. body image  Must take care: avoid shaving, don’t take BP/blood here

Complications  Thrombosis and stenosis  Infection  Bleeding  Aneurysm

Steal syndrome  Distal tissue ischaemia . Pallor, pain, ↓ pulses . May → necrosis  ↓ wrist:brachial pressure index  Rx: banding (plication)

Features Complications: CRF HEALS  Kidney damage ≥3mo indicated by ↓ function  Cardiovascular disease  Symptoms usually only occur by stage 4 (GFR<30)  Renal osteodystrophy  ESRF is stage 5 or need for RRT  Fluid (oedema)  HTN Classification  Electrolyte disturbances: K, H  Anaemia Stage GFR  Leg restlessness 1 >90  Sensory neuropathy 2 60-89 3 30-59 4 16-29 Renal Osteodystrophy 5 <15 Features Causes  Osteoporosis: ↓ bone density  Osteomalacia: ↓ mineralisation of osteoid (matrix) Common Other  2O/3O HPT → osteitis fibrosa cystica  DM  RAS . Subperiosteal bone resorption  HTN  GN . Acral osteolysis: short stubby fingers  CTD: SLE, SS, RA . Pepperpot skull  Polycystic disease  Osteosclerosis of the spine → Rugger Jersey spine  Drugs: e.g. analgesic nephropathy . Sclerotic vertebral end plate ¯c lucent centre  Pyelonephritis: usually 2O to VUR  Extraskeletal calcification: e.g. band keratopathy  Myeloma and amyloidosis Mechanism Ix  ↓ 1α-hydroxylase → ↓ vit D activation → ↓Ca → ↑PTH  Phosphate retention → ↓Ca and ↑PTH (directly) Urine  ↑PTH → activation of osteoclasts ± osteoblasts  Dip: haematuria, proteinuria, glycosuria  Also acidosis → bone resorption  PCR . Normal = <20mg/mM . Nephrotic = >300mg/mM General Mx  BJP: myeloma  Rx reversible causes  Stop nephrotoxic drugs Function  Na, K, fluid and PO4 restriction  FBC: ↓Hb  U+E: ↓ eGFR Optimise CV Risk  Bone: ↓Ca, ↑PO4, ↑PTH, ↑ALP  Smoking cessation, exercise  Statin + antiplatelet Renal Screen  Rx DM  DM: fasting glucose, HbA1c  ESR  Immune Specific Mx . SLE: ANA, C3, C4 . Goodpasture’s: anti-GBM Hypertension . Vasculitis: ANCA  Target <140/90 (<130/80 if DM) . Hepatitis: viral serology  In DM kidney disease give ACEi/ARB (inc. if normal BP)  Se protein electrophoresis

Oedema: frusemide Imaging

 CXR: pulmonary oedema Bone Disease  Renal US  Phosphate binders: calcichew, sevelamer . Usually small (<9cm)  Vit D analogues: alfacalcidol (1 OH-Vit D ) . May be large: polycystic, amyloid 3  Ca supplements  Bone X-rays: renal osteodystrophy (pseudofractures)  Cinacalcet: Ca mimetic  CT KUB: e.g. cortical scarring from pyelonephritis

Anaemia Renal biopsy: if cause unclear and size normal  Exclude IDA and ACD  Histology subtype  EPO to raise Hb to 11g/dL (higher = thrombosis risk)  Amyloid: apple-green birefringence c Congo Red ¯ Restless Legs: clonazepam

Diabetic Nephropathy Myeloma  Commonest cause of ESRF: >20%  Advanced / ESRF occurs in 40% of T1 and T2 DM Pathology  Excess production of monoclonal Ab ± light chains Pathology (excreted and detected in 60% as urinary BJP).  Diabetic nephropathy describes conglomerate of lesions  Light chains block tubules and have direct toxic occurring concurrently. effects → ATN.  Hyperglycaemia → hypertrophy and ROS production  Myeloma also assoc. ¯c ↑↑Ca2+  Hallmark is glomerulosclerosis and nephron loss  Nephron loss → RAS activation → HTN Presentation  ARF / CRF Clinically  Amyloidosis  Microalbuminuria . 30-300mg/d or albumin:creatinine >3mg/mM Rx . Strong independent RF for CV disease  Ensure fluid intake of 3L/d to prevent further  Progresses to proteinuria: albuminuria >300mg/d impairment  Usually coexists ¯c other micro- and macro-vasc disease  Dialysis may be required in ARF

Screening  T2DMs should be screened for microalbuminuria 6moly Renovascular Disease: RAS

Mx Cause  Good glycaemic control delays onset and progression  Atherosclerosis in 80% . UKPDS: UK Prospective Diabetes Study  Fibromuscular dysplasia . DCCT: Diabetes Control and Complications Trial  Thromboembolism  Control HTN: BP target 130/80  External mass compression  ACEi/ARB: even if normotensive  Stop smoking Presentation  Combined kidney pancreas Tx possible in selected pts  Refractory hypertension  Renal bruits

 Worsening renal function after ACEi/ARB Rheumatological Disease  Flash pulmonary oedema (no LV impairment on echo)  Other signs of PVD RA  NSAIDs → ATN Ix  Penicillamine and gold → membranous GN  CT/MR angio  AA amyloidosis occurs in 15%  Renal angiography

Rx SLE  Rx medical CV risk factors  Involves glomerulus in 40-60% → ARF/CRF  Angioplasty and stenting  AVOID ACEi/ARB Pathogenesis  Immune complex deposition → T3 hypersensitivity  Typically membranous GN  Proteinuria and ↑BP

Rx  Proteinuria: ACEi  Aggressive GN: immunosuppression

Diffuse Systemic Sclerosis  Renal crisis: malignant HTN + ARF . Commonest cause of death  Rx: ACEi if ↑BP or renal crisis

Examination Viva

Peripheral Inspection Hx  Symptoms General . Wt. loss, fever, malaise  Often young female pt. . Abdominal pain . Laparotomy scars . Diarrhoea, blood and/or mucus PR  Malnutrition or wt. loss  Peri-anal disease: abscesses, fistulae  Cushingoid  Extra-intestinal: EN, arthritis, iritis, gallstones, PSC  Pallor  Therapy . Admissions Hands . Medical therapy  Clubbing . Operations  Leukonychia  Beau’s lines Ix

Eyes Bloods  Pale conjunctivae  FBC: ↓Hb, ↑WCC  Iritis, episcleritis  U+E: dehydration, ↓K  LFTs: ↓ albumin, deranged LFTs Mouth  Clotting: ↑INR  Aphthous ulcers  ↑ ESR, ↑ CRP: used to monitor activity  Gingival hypertrophy (ciclosporin)  Haematinics: Fe, B12, folate

Legs Markers of Activity in CD  Erythema nodosum  ↓Hb, ↑ESR, ↑CRP, ↑WCC, ↓albumin  Pyoderma gangrenosum Stool  Culture + CDT: exclude infective causes Abdominal . Campy, Yersinia, Shigella, C. diff, TB

Inspection Imaging  Scars  AXR . Toxic megacolon in UC . May be multiple and atypical in Crohn’s O . Healed stoma sites . Bowel obstruction 2 to strictures in Crohn’s . Healed drain sites  Contrast studies  Stomas or healed stoma sites . Ba or Gastrograffin enema in UC  Enterocutaneous fistulae . Small bowel follow-through in Crohn’s  MRI: perianal disease in Crohn’s Palpation  Tenderness Endoscopy  RIF mass  Ileocolonoscopy + regional biopsy  ± hepatomegaly . Ix of choice . Safe in acute disease . Distinguish UC from Crohn’s Completion . Assess disease severity  Wireless capsule endoscopy  Inspect perineum for perianal disease

 Examine for extra-intestinal features . Large joint monoarthritis Discussion . Sacroileitis  Clinicopathological distinction between UC and CD . Bronchiectasis  Main complications of IBD  Extra-intestinal manifestations  Definition and Mx of severe exacerbation Differential  Chronic Mx  Crohn’s  UC  Malabsorption: coeliac  Mid-line lap: FAP

Pathology Complications

UC Crohn’s UC Crohn’s

Macroscopic Toxic megacolon Fistulae Location Rectum + colon Mouth to anus Haemorrhage Perianal abscess ± backwash ileitis esp. terminal ileum Malignancy Strictures Distribution Contiguous Skip lesions - CRC Malabsorption Strictures No Yes - Cholangiocarcinoma VTE Toxic dilatation Microscopic Inflammation Mucosal Transmural Ulceration Shallow, broad Deep, thin, serpiginous → cobblestone mucosa Extra-Intestinal Features Fibrosis None Marked Granulomas None Present Skin  Clubbing Pseudoplyps Marked Minimal  Erythema nodosum Fistulae No Yes  PG (esp. UC)

Acute Severe Exacerbation Mouth  Aphthous ulcers

Dx: True-Love and Witts Criteria Eyes  Anterior uveitis  Symptoms  Episcleritis . BMs >6 x /d . Large PR bleed Joints  Large joint arthritis  Systemic Signs  Sacroileitis . ↑ HR >90 . Pyrexia >37.8 Hepatic  Fatty liver  Laboratory Values  Chronic hepatitis → cirrhosis . ↓ Hb <10.5g/dL  Gallstones (esp. CD) . ESR >30mm/Hr  PSC + cholangiocarcinoma (esp. UC)

Mx Other  AA amyloidosis  Oxalate renal stones General  Resus: Admit, NBM, IV hydration  Hydrocortisone: 100mg IV QDS + PR if rectal disease Mx of Mild-Mod Disease  Thromboprophylaxis: LMWH  Dietician review MDT: GP, gastroenterologist, dietician, nurses, surgeon Nutrition: ADEK vitamins, high fibre diet (esp. CD) Monitoring  Bloods: FBC, ESR, CRP, U+E Induction  Vitals + stool chart  Daily examination UC CD Oral Oral Crohn’s  Abx: metronidazole PO or IV 1: 5-ASAs 1: Ileocaecal: budesonide  Consider parenteral nutrition 2: prednisolone 1: Colitis: sulfasalazine  Improvement: → oral pred (40mg/d) 3: ciclosporin / infliximab  Refractory: methotrexate ± infliximab 2: prednisolone (tapering) 3: methotrexate UC 4: infliximab / adalimumab  Improvement: → oral pred + 5-ASA  Refractory: ciclosporin or infliximab Topical: Enemas / foams - 5-ASA Indications for Surgery - Pred  Obstruction  Megacolon Maintenance  Perforation  Severe GI bleeding UC CD  Failure to respond to medical therapy 1: 5-ASA 1: azathioprine 2: axathioprine 2: methotrexate 3: infliximab / adalimumab 3: infliximab / adalimumab

Contents Parkinson’s Disease ...... 50 Parkinsonism: Key Facts ...... 51 Cerebellar Syndrome ...... 52 Cerebellar Syndrome: Key Causes ...... 53 UMN Signs ...... 54 Cord Disease ...... 55 Acute Stroke: Key Facts ...... 56 Non-Acute Stroke: Key Facts ...... 57 Multiple Sclerosis ...... 58 Motor Neurone Disease ...... 59 LMN Signs ...... 60 Peripheral Polyneuropathy ...... 61 Diabetic Neuropathy ...... 62 Charcot-Marie-Tooth Syndrome ...... 62 Myasthenia Gravis ...... 63 GBS ...... 63 Facial Nerve Palsy ...... 64 Facial Nerve Palsy: Key Causes ...... 65 Facial Anaesthesia...... 65 Abnormal Pupils ...... 66 Visual Fields ...... 67 Ophthalmoplegia ...... 68 Hearing Loss ...... 69 Speech ...... 70

Examination Viva

Inspection Hx  Asymmetrical resting tremor: 5Hz  Symptoms: tremor, rigidity, akinesia . Exacerbated by counting backwards  Autonomic  Hypomimia (↓ facial expression) . Postural hypotension  Extrapyramidal posture . Urinary problems, constipation . Hypersalivation  ADLs Arms . Handwriting, buttons, shoe-laces  Demonstrate bradykinesia . Getting in and out of a car  Tone  Sleep . Cogwheel rigidity . Turning in bed . Enhanced by synkinesis . Insomnia  Normal power and reflexes . Daytime sleepiness  Coordination  Complications . May be abnormal if MSA . Depression . Drug SEs: esp. motor fluctuations Eyes  Cause . Sudden onset  Movements . Eye or balance problems . Nystagmus: MSA . Visual hallucinations, ↓ memory . Vertical gaze palsy: PSP . DH  Saccades . FH . Slow initiation and movement

Ix Extras  Glabellar tap Bloods  Gait  Caeruloplasmin: ↓ in Wilson’s . Slow initiation . Shuffling Imaging . Hurrying: festination  CT / MRI: exclude vascular cause . Absent arm swing  DaTscan  Write sentence and draw spiral 123 . Ioflupane I injection  BP lying and standing . Binds to dopaminergic neurones and allows visualisation of substantial nigra Completion . Can exclude other causes of tremor: e.g. BET  Mini mental state examination  Drug chart Mx  Abdominal examination: hepatomegaly + signs of CLD General  MDT: neurologist, PD nurse, physio, OT, social worker, Causes GP and carers  Idiopathic PD  Assess disability  Parkinson Plus Syndromes . e.g. UPDRS: Unified Parkinson’s Disease Rating Scale . Progressive supranuclear palsy  Physiotherapy: postural exercises . MSA  Depression screening . Lewy Body Dementia . Corticobasilar degeneration Specific  Multiple infarcts in the substantia nigra  L-DOPA + Carbidopa or benserazide  Wilson’s disease  Da agonists: ropinerole, pramipexole  Drugs: neuroleptics and metoclopramide  Apomorphine: SC rescue drug  MOA-B inhibitors: rasagiline  COMT inhibitors: tolcapone  Amantidine  Anti-muscarinics: procyclidine

Adjuncts  Domperidone: nausea  Quetiapine: psychosis  Citalopram: depression

Other  Deep brain stimulation  Basal ganglia disruption © Alasdair Scott, 2012 50 Parkinsonism: Key Facts

Idiopathic PD Other Causes of Parkinsonism

Epidemiology Multisystem Atrophy  Mean onset 65yrs  2% prevalence Pathology  Papp-Lantos Bodies: α-synuclein inclusions in glial cells Pathophysiology  Destruction of dopaminergic neurones in pars Features compacta of substantia nigra.  Autonomic dysfunction: postural hypotension  β-amyloid plaques  Parkinsonism  Neurofibrillary tangles: hyperphosphorlated tau  Cerebellar ataxia

Features: TRAPPS PD If autonomic features predominate, may be referred to as Shy Drager Syndrome  Asymmetric onset: side of onset remains worst

 Tremor: ↑ by stress, ↓ by sleep Progressive Supranuclear Palsy  Rigidity: lead-pipe, cog-wheel  Postural instability → falls  Vertical gaze palsy  Akinesia: slow initiation, difficulty ¯c repetitive movement, micrographia, monotonous voice, mask-like face  Pseudobulbar palsy: speech and swallowing problems  Parkinsonism  Postural instability: stooped gait ¯c festination . Symmetrical onset  Postural hypotension: + other autonomic dysfunction . Tremor is unusual  Sleep disorders: insomnia, EDS, OSA, RBD  Psychosis: esp. visual hallucinations Corticobasilar Degeneration  Depression / Dementia / Drug SEs  Unilateral parkinsonism: esp. rigidity

Sleep Disorder  Aphasia  Affects ~90% of PD pts.  Astereognosis: cortical sensory loss . → Alien limb phenomenon: autonomous arm  Insomnia + frequent waking → EDS movements . Inability to turn

. Restless legs . Early morning dystonia (drugs wearing off) Lewy Body Dementia . Nocturia . OSA Pathology  REM Behavioural sleep Disorder  α-synuclein and ubitquitin Lewy Bodies in brainstem and . Loss of muscle atonia during REM sleep neocortex . Violent enactment of dreams  Da SEs: insomnia, drowsiness, EDS Features  Fluctuating cognition Autonomic Dysfunction  Visual hallucinations  Combined effects of drugs and neurodegeneration  Parkinsonism  Postural hypotension  Constipation Vascular Parkinsonism  Hypersalivation → dribbling (↓ ability to swallow saliva)  Sudden onset  Urgency, frequency, nocturia  Parkinsonism worse in legs than arms  ED  Pyramidal signs  Hyperhidrosis  Prominent gait abnormality

L-DOPA SEs: DOPAMINE Causes of Tremor  Dyskinesia  Resting: parkinsonism  On-Off phenomena = Motor fluctuations  Intention: cerebellar  Psychosis  Postural  ABP↓ . Worse ¯c arms outstretched  Mouth dryness . BET  Insomnia . Endocrine: ↑T4  N/V . Alcohol withdrawal  EDS (excessive daytime sleepiness) . Toxins: β-agonists . Sympathetic: anxiety Motor Fluctuations  End-of-dose: deterioration as dose wears off ¯c Benign Essential Tremor progressively shorter benefit.  AD  On-Off effect: unpredictable fluctuations in motor  Occur with movement and worse ¯c anxiety, caffeine performance unrelated to timing of dose.  Doesn’t occur ¯c sleep  Better ¯c EtOH

Examination Viva

Gait Hx  Walk  MS: paraesthesia, visual problems, muscle weakness  Heal-to-Toe  Alcohol consumption  On tip toes  Infarct: onset, stroke risk factors  On heal  Schwannoma: hearing loss, vertigo, tinnitus, ↑ICP  Romberg’s  FH  DH

Arms Outstretched  Ataxia Ix

 Rebound ECG

 Arrhythmia

DaNISh Bloods  Dysdiadochokinesia: hands and feet  EtOH: FBC, U+E, LFT  Nystagmus + Rapid Saccades  Thrombophilia: clotting . Saccades: overshoot  Wilson’s: ↓ caeruloplasmin  Intention tremor and dysmetria  Slurred speech CSF  Oligoclonal bands

Completion Imaging  Cranial nerves: brainstem stroke, MS, CPA lesion  MRI is best to visualise the posterior cranial fossa  Peripheral nervous system: MS  Signs of CLD Other  Drug chart: phenytoin  CPA lesion: pure tone audiometry

Causes: DAISIES Mx  Demyelination  Alcohol General MDT: GP, neurologist, radiologist, neurosurgeon,  Infarct: brainstem stroke  specialist nurses, physio, OT  SOL: e.g. schwannoma + other CPA tumours  CV Risk  Inherited: Wilson’s, Friedrich’s, Ataxia Telangiectasia, ↓ EtOH VHL 

 Epilepsy medications: phenytoin Specific  System atrophy, multiple  MS: methylprednisolone

EtOH: Pabrinex, tapering course of chlordiazepoxide   Infarct: consider thrombolysis Neurophysiology  Schwannoma: gamma-knife, surgery  Cerebellar signs are ipsilateral  Wilson’s: penicillamine  Bilateral cerebellar signs more likely to represent a global pathology . Alcohol . MS . Phenytoin  Cerebellar vermis lesion . Ataxic trunk and gait . Normal arms

Nystagmus  Cerebellar Cause . Fast phase towards lesion . Maximal looking towards lesion  Vestibular Cause . Fast phase away from lesion . Maximal looking away from lesion

Lateral Medullary Syndrome / Wallenberg’s Friedrich’s Ataxia

Cause Pathophysiology  Occlusion of vertebral artery or PICA  Auto recessive mitochondrial disorder  Progressive degeneration of Features . Dorsal column  Signs are ipsilateral apart from body anaesthesia to pain . Spinocerebellar tracts and cerebellar cells . Corticospinal tracts Structure Symptom  Onset in teenage years Nucleus Ambiguus Dysphagia  Assoc. ¯c HOCM and mild dementia - motor to CN 9/10 Inferior cerebellar peduncle Ataxia Main Features Nystagmus  Pes cavus Vestibular nucleus Vertigo  Bilateral cerebellar ataxia Spinothalamic tract ↓ Pain: contralateral  Leg wasting + areflexia but extensor plantars Spinal trigeminal nucleus ↓ Pain: ipsilateral  Loss of vibration and proprioception Sympathetic fibres Horner’s Additional Features DANVAH  High-arched palate  Dysphagia  Optic atrophy and retinitis pigmentosa  Ataxia  HOCM: ESM + 4th heart sound  Nystagmus  DM in 10%: dip the urine  Vertigo  Anaesthesia: dissociated pain loss  Horner’s syndrome Ataxia Telangiectasia

 Autosomal recessive  Defect in DNA repair Vestibular Schwannoma  Onset in childhood / early adult

Pathophysiology Features  Benign, slow-growing tumour of superior vestibular nerve  Progressive ataxia  SOL → CPA syndrome: 80% of CPA tumours  Telangiectasia: conjunctivae, eyes, nose, skin creases  Assoc. ¯c NF2  Defective cell-mediated immunity and Ab production . Infections Presentation  Lymphoproliferative disease  Unilat SNHL, tinnitus ± vertigo  ↑ICP: headache  Ipsilateral CN 5, 6, 7 and 8 palsies and cerebellar signs Wilson’s . Facial anaesthesia + absent corneal reflex  AR mutation of ATP7B gene on Chr13 . LR palsy

. LMN facial nerve palsy Features: CLANK . SNHL Cornea: Keiser-Fleischer rings . DANISH   Liver: CLD Ix  Arthritis  MRI of cerebellopontine angle  Neuro: parkinsonism, ataxia, psychiatric problems  Kidney: Fanconi’s syn Rx  Gamma-knife  Surgery

CPA Tumour Differential  Vestibular Schwannoma  Meningioma  Cerebellar astrocytoma  Metastases

Von Hippel-Lindau  Renal cysts  Bilateral renal cell carcinoma  Haemangioblastomas . Often in cerebellum → cerebellar signs  Phaeochromocytoma  Islet cell tumours

Examination Viva

Inspection Hx  Walking aids  MS: tingling, eye problems, ataxia, other weakness  May have disuse atrophy and contractures  Cord compression: back pain, fever, wt. loss  Limb position  Trauma . Leg: extended, internally rotated ¯c foot plantar flexed  FH . Arm: flexed, internally rotated, supinated

Gait Ix  Unilateral → circumducting  Bilateral → scissoring MRI  Cord and brain UMN Signs  ↑ tone Further Ix Depend on Cause  Pyramidal distribution of weakness  MS . Leg: extensors stronger than flexors . LP: oligoclonal bands . Arm: flexors stronger than extensors . Abs: MBP, NMO  Hyper-reflexia . Evoked potentials  Extensor plantars  Compression . FBC: infection Sensation . CXR: malignancy . DRE  Examine for sensory level: suggests cord lesion  SCDC . B12 level Completion . Pernicious anaemia Abs: IF, parietal cell  CN: evidence of MS  Cerebellum: evidence of MS Mx

Bilateral LL: Spastic Paraparesis Supportive  MDT: GP, neurologist, radiologist, neurosurgeon, Common specialist nurses, physio, OT  MS  Orthoses  Cord compression  Mobility aids  Cord Trauma  Urinary: ICSC  CP  Contractures: baclofen, botulinum injection, physio

Other  Familial spastic paraparesis  Vascular: e.g. aortic dissection → Beck’s syndrome  Infection: HTLV-1  Tumour: ependymoma  Syringomyelia

Mixed UMN and LMN Features  MND  Ataxia, Friedrich’s  SCDC: B12  Taboparesis

Unilateral LL

Hemisphere → Spastic Hemiparesis  Stroke  MS  SOL  CP

Hemicord → Spastic Hemiparesis or Monoparesis  MS  Cord Compression

Cord Compression Syringomyelia

Key Features Characteristics  Pain  Syrinx: tubular cavity in central canal of the cord. . Local, deep  Symptoms may be static for yrs but then worsen fast . Radicular . e.g. on coughing, sneezing as ↑ pressure →  Weakness extension . LMN @ level  Commonly located in cervical cord . UMN below level  Syrinx expands ventrally affecting:  Sensory level . Decussating spinothalamic neurones  Sphincter disturbance . Anterior horn cells . Corticospinal tracts Causes  Trauma: vertebral # Causes  Infection: epidural abscess, TB  Blocked CSF circulation ¯c ↓ flow from posterior fossa  Malignancy: breast, thyroid, bronchus, kidney, prostate . Arnold-Chiari malformation (cerebellum herniates  Disc prolapse: above L1/2 through foramen magnum) . Masses Ix  Spina bifida  2O to cord trauma, myelitis, cord tumours and AVMs  MRI is definitive modality

 CXR for primaries Cardinal Signs 1. Dissociated Sensory Loss Rx . Loss of pain and temperature → scars from burns  This is a neurosurgical emergency . Preserved touch, proprioception and vibration.  Malignancy . Root distribution reflects syrinx location . Dexamethasone IV  Usually upper limbs and chest: “cape” . Consider chemo, radio and decompressive 2. Wasting/weakness of hands ± Claw hand laminectomy 3. Loss of reflexes in upper limb  Abscess: abx and surgical decompression 4. Charcot joints: shoulder and elbow

Other Signs Cauda Equina Lesions  UMN weakness in lower limbs ¯c extensor plantars Pain   Horner’s syndrome . Back pain  Syringobulbia: cerebellar and lower CN signs . Radicular pain down legs  Kyphoscoliosis  Weakness

. Bilateral flaccid, areflexic lower limb weakness  Sensation Ix . Saddle anaesthesia  MRI spine  Sphincters . Incontinence / retention of faeces / urine Surgery . Poor anal tone  Decompression at the foramen magnum for Chiari mal

Causes and Mx as above Human T-lymphotropic Virus-1  Retrovirus Anterior Spinal Artery / Beck’s Syndrome  ↑ prevalence in Japan and Caribbean  Infarction of spinal cord in distribution of anterior spinal artery: ventral 2/3 of cord. Features  Causes: Aortic aneurysm dissection or repair  Adult T cell leukaemia / lymphoma  Effects  Tropical spastic paraplegia / HTLV myelopathy . Para- / quadri-paresis . Slowly progressing spastic paraplegia . Impaired pain and temperature sensation . Sensory loss and paraesthesia . Preserved touch and proprioception . Bladder dysfunction

Definition Acute Management  Rapid onset focal neurological deficit of vascular origin lasting >24hrs. Resuscitate  Ensure patent airway: consider NGT  NBM until swallowing assessed by SALT Pathogenesis  Don’t overhydrate: risk of cerebral oedema  Ischaemic: 80%  BM: exclude hypoglycaemia . Atheroma: large or small vessel . Embolism: cardiac or atherothromboembolism Monitor  Haemorrhagic: 20%  Glucose: 4-11mM: sliding scale if DM  BP: Rx of HTN can → ↓ cerebral perfusion  Neuro obs Clinical Features: Bamford Classification Bloods TACS: carotid / MCA and ACA territory  FBC: infection (sepsis may → stroke)  Hemiparesis and/or hemisensory deficit  U+E: electrolyte disturbances may mimic stroke  Homonymous hemianopia  Glucose: exclude hypoglycaemia  Higher cortical dysfunction  Clotting: ↑ or ↓ INR may indicate cause . Dominant: aphasia . Non-dominant: neglect, apraxia Imaging  Urgent CT/MRI PACS: carotid / MCA and ACA territory  Diffusion-weighted MRI is most sensitive for acute infarct . 2/3 of TACS criteria, usually  CT will exclude primary haemorrhage . Homonymous hemianopia . Higher cortical dysfunction Medical  Consider thrombolysis if 18-80yrs and <4.5hrs since POCS: vertebrobasilar territory onset of symptoms . Any of . Alteplase (rh-tPA) . Cerebellar syndrome . → ↓ death and dependency (OR 0.64) . Brainstem syndrome . CT 24h post-thrombolysis to look for haemorrhage . Homonymous hemianopia  Aspirin 300mg PO/PR once haemorrhagic stroke excluded ± PPI LACS: infarct around basal ganglia, internal capsule, thalamus . Clopidogrel if aspirin sensitive and pons  Pure motor: post. limb of internal capsule Surgery  Pure sensory: post. thalamus (VPL)  Neurosurgical opinion if intracranial haemorrhage  Mixed sensorimotor: internal capsule  May coil bleeding aneurysms  Dysarthria / clumsy hand  Decompressive hemicraniectomy for some forms of  Ataxic hemiparesis: ant. limb of internal capsule MCA infarction.

Stroke Unit Differential  Specialist nursing and physio  Head injury  Early mobilisation  ↑ or ↓ glucose  DVT prophylaxis  SOL  Infection Secondary Prevention  Drugs: e.g. opiate OD Rehabilitation

Stroke Work-Up Rehabilitation  Must occur on a dedicated stroke unit ECG ± 24hr Tape  Arrhythmia MENDS  Old ischaemia  MDT: physio, SALT, dietician, OT, specialist nurses, neurologist, family  Eating Bloods . Screen swallowing: refer to specialist  FBC: ↑ or ↓ Hb  NG/PEG if unable to take oral nutrition  U+E: association ¯c renovascular disease . Screen for malnutrition (MUST tool)  Glucose: exclude DM  Supplements if necessary  Lipids: CV risk  Neurorehab: physio and speech therapy  Clotting and thrombophilia screen . Botulinum can help spasticity  Vasculitis: ESR, ANA  DVT Prophylaxis  Sores: must be avoided @ all costs Thrombophilia Screen  FBC, clotting, fibrinogen concentration  APC resistance / F5 Leiden Prognosis @ 1yr  Lupus anticoagulant  10% recurrence  Anti-cardiolipin Abs  PACS  Assays for protein C and S and AT3 activity . 20% mortality  PCR for prothrombin gene mutation . 1/3 of survivors independent . 2/3 of survivors dependent Imaging  TACS is much worse  CXR . 60% mortality . Cardiomegaly 2O to HTN . 5% independence . Aspiration  Carotid doppler  Echo . Mural thrombus . Regional wall motion abnormality . ASD, VSD: paradoxical emboli

Secondary Prevention  Risk factor control as above . Start a statin after 48h  Aspirin / clopi 300mg for 2wks after stroke then either . Clopidogrel 75mg OD (preferred option) . Aspirin 75mg OD + dipyridamole MR 200mg BD  Warfarin instead of aspirin/clopidogrel if . Cardioembolic stroke or chronic AF . Start from 2wks post-stroke (INR 2-3) . Don’t use aspirin and warfarin together.  Carotid endarterectomy if good recovery + ipsilat stenosis ≥70%

Definition  A chronic inflammatory condition of the CNS characterised by multiple plaques of demyelination disseminated in time and space.

Epidemiology Ix  Lifetime risk: 1/1000  MRI: Gd-enhancing or T2 hyper-intense plaques  Age: mean @ onset = 30yrs . Gd-enhancement = active inflammation  Sex: F>M = 3:1 . Typically located in periventricular white matter  Race: rarer in blacks  LP: IgG oligoclonal bands (not present in serum)  Abs Aetiology . Anti-MBP  Genetic (HLA-DRB1), environmental, viral (EBV) . NMO-IgG: highly specific for Devic’s syn.  Evoked potentials: delayed auditory, visual and sensory Pathophysiology  CD4 cell-mediated destruction of oligodendrocytes → Diagnosis: clinical demyelination and eventual neuronal death.  Demonstration of lesions disseminated in time and space  Initial viral inflam primes humoral Ab responses vs. MBP  May use McDonald Criteria  Plaques of demyelination are hallmark Differential Classification Inflammatory conditions may mimic MS plaques:  Relapsing-remitting: 80%  CNS sarcoidosis  Secondary progressive  SLE  Primary progressive: 10%  Devic’s: Neuromyelitis optica (NMO)  Progressive relapsing . MS variant ¯c transverse myelitis and optic atrophy . Distinguished by presence of NMO-IgG Abs Presentation: TEAM  Tingling Mx  Eye: optic neuritis (↓ central vision + eye move pain)  MDT: neurologist, radiologist, physio, OT, specialist  Ataxia + other cerebellar signs nurses, GP, family  Motor: usually spastic paraparesis Acute Attack Clinical features  Methylpred 1g IV/PO /24h for 3d Sensory: Motor: . Doesn’t influence long-term outcome  Dys/paraesthesia  Spastic weakness . ↓ duration and severity of attacks  ↓ vibration sense  Transverse myelitis Preventing Relapse: Disease Modifying  Trigeminal neuralgia  IFN-β: ↓ relapses by 30% in RRMS MS Eye: Cerebellum:  Glatiramer: similar efficacy to IFN-β  Diplopia  Trunk and limb ataxia Preventing Relapse: Biologicals  Visual phenomena  Scanning dysarthria  Natalizumab: anti-VLA-4 Ab  Bilateral INO  Falls . ↓ Relapses by 2/3 in RRMS  Optic neuritis → atrophy  Alemtuzumab (Campath): anti-CD52 . 2nd line in RRMS GI: Sexual/GU:

 Swallowing disorders  ED + anorgasmia Symptomatic  Constipation  Retention  Fatigue: modafinil  Incontinence  Depression: SSRI (citalopram) Lhermitte’s Sign  Pain: amitryptylline, gabapentin  Neck flexion → electric shocks in trunk/limbs  Spasticity: physio, baclofen, dantrolene, botulinum  Urgency / frequency: oxybutynin, tolterodine Optic Neuritis  ED: sildenafil  PC: pain on eye movement, rapid ↓ central vision  Tremor: clonazepam  Uhthoff’s: vision ↓ ¯c heat: hot bath, hot meal, exercise  o/e: ↓ acuity, ↓ colour vision, white disc, central scotoma, Prognosis RAPD Poor prognostic signs: INO / ataxic nystagmus / conjugate gaze palsy  Older female  Disruption of MLF connecting CN6 to CN3  Motor signs @ onset  Weak adduction of ipsilateral eye  Many relapses early on  Nystagmus of contralateral eye  Many MRI lesions  Convergence preserved

Examination Viva

Inspection Ix  Wasting and fasciculation  Brain/cord MRI: exclude structural cause . Esp. tongue fasciculation . Cervical cord compression → myelopathy . Brainstem lesions Tone  EMG: fasciculation  Spastic  LP: exclude inflammatory cause

Power Diagnostic Criteria  Weak  Revised El Escorial Criteria

Reflexes Mx  Absent and/or brisk General . E.g. absent knee jerks ¯c extensor plantars  MDT: neurologist, physio, OT, dietician, specialist nurse, GP, family Sensation: NORMAL  Discussion of end-of-life decisions . E.g. Advanced directive Completion . DNAR  Speech . Bulbar: nasal Specific . Pseudobulbar: hot-potato  Riluzole: antiglutamatergic that prolongs life by ~3mo  Jaw-jerk . Bulbar: absent Supportive . Pseudo-bulbar: brisk  Drooling: amitriptyline  Eye movements: MND does not involve the eyes  Dysphagia: NG or PEG feeding  Respiratory failure: NIV  Pain: analgesic ladder Differential  Spasticity: baclofen, botulinum  Cervical cord compression → myelopathy  Brainstem lesions Prognosis  Polio: asymmetrical LMN paralysis  Most die w/i 3yrs  Mixed UMN and LMN Signs . Bronchopneumonia and respiratory failure . MND  Worse prog: elderly, female, bulbar involvement . Ataxia, Friedrich’s . SCDC: B12 . Taboparesis Classification

Amyotrophic Lateral Sclerosis: 50%  Corticospinal tracts → UMN and LMN signs + fasciculation

Progressive Bulbar Palsy: 10%  Only affects CN 9-12 → bulbar palsy

Progressive Muscular Atrophy: 10%  Anterior horn cell lesion → LMN signs only  Distal to proximal  Better prognosis cf. ALS

Primary Lateral Sclerosis: 30%  Loss of Betz cells in motor cortex → mainly UMN signs  Marked spastic leg weakness and pseudobulbar palsy  No cognitive decline

Examination Ix

LMN Signs Peripheral Neuropathy  Wasting  See below  Fasciculation  Hypotonia Proximal Myopathy  Hyporeflexia  Bloods . DM: glucose, HbA1c Causes . Muscle damage: CK, ESR, AST, LDH . Endocrine: TSH, Ca, 9am cortisol, IGF-1  Pathology anywhere from anterior horn to muscle itself . Abs: anti-Jo1

 CXR: paraneoplastic Bilateral, Symmetrical and Distal  EMG  Motor Peripheral Polyneuropathy  Genetic analysis  ± sensory disturbance  Muscle biopsy . = Mixed Peripheral Polyneuropathy Mononeuropathy Differential  Bloods  HMSN . DM: glucose, HbA1c  Paraneoplastic . B12, folate  Lead poisoning . Vasculitis: ESR, ANA, ANCA  Acute: GBS, Botulism  EMG + nerve conduction

Radiculopathy / Plexopathy Bilateral, Symmetrical and Proximal  MRI  Proximal myopathy

Differential  Inherited: muscular dystophy  Inflammation . Polymyositis . Dermatomyositis  Endocrine . Cushing’s Syndrome . Acromegaly . Thyrotoxicosis . Osteomalacia . Diabetic Amyotrophy  Drugs: alcohol, statins, steroids  Malignancy: paraneoplastic

Unilateral

Isolated to single limb + no sensory signs  Old polio

Localised to group of muscles c¯ same supply  Segmental: nerve roots, plexus  Peripheral: mononeuropathy

Hand Wasting  Anterior horn: syringomyelia, MND, polio  Roots (C8 T1): spondylosis  Brachial Plexus . Compression: cervical rib . Avulsion: Klumpke’s palsy  Neuropathy . Generalised: HMSN . Mononeuritis multiplex: DM . Compressive mononeuropathy  Muscle . Disuse: RA . Distal myopathy: myotonic dystrophy © Alasdair Scott, 2012 60 Peripheral Polyneuropathy

Examination Viva

Sensory Hx  Bilateral, symmetrical  Time-course  Glove and stocking distribution: length dependent  Precise symptoms  ↓ tendon reflexes: loss of ankle jerks in DM . Ataxia: B12  Signs of trauma or joint deformity (Charcot’s joints) . Painful dysesthesia: EtOH, DM  Loss of proprioception → +ve Romberg’s  Assoc. events . D&V: GBS Motor . ↓wt: Ca  Bilateral, symmetrical . Arthralgia: connective tissue  LMN weakness  Travel, EtOH, drugs . Wasting and fasciculation . ↓ tone Ix . Hyporeflexia Dipstick: glucose Completion  Drug chart Bloods DM: Glucose, HBA1c  Dipstick: glucose   EtOH: FBC ± Film, LFTs, GGT  Gait + Romberg’s test  CRF: U+E  CN  B12, folate  Vasculitis: ESR, ANA, ANCA Causes  Thyroid disease: TFTs

Imaging Mainly Sensory  CXR: exclude paraneoplastic phenomena  DM

 Alcohol Other  B12 deficiency  Nerve conduction studies  CRF and Ca (paraneoplastic) . Demyelination → ↓ conduction speed  Vasculitis . Axonal degeneration → ↓ conduction amplitude  Drugs: e.g. isoniazid, vincristine  Electromyography  Genetic: PMP22 gene in CMT Mainly Motor  Nerve biopsy  HMSN / CMT  Paraneoplastic: Ca lung, RCC  Lead poisoning  Acute: GBS and botulism Mx

General  MDT: GP, neurologist, specialist nurses, physio, OT  Foot care and careful shoe choice  Splinting joints can prevent contractures

Specific  Optimise glycaemic control: DCCT, UKPDS trials  Replace nutritional deficiencies  Avoid EtOH or other precipitants  Vasculitis: steroids and other immunosuppressants  Neuropathic pain: amitriptyline, gabapentin  GBS: IVIg

Inspection Examination  Evidence of finger pricks from BM monitoring  Peripheral vascular disease Inspection  Charcot joints  Pes cavus  Symmetrical distal muscle wasting Motor . → claw hand  Bilateral loss of ankle jerks . → champagne bottle leg . 2O to sensory neuropathy  Thickened nerves: esp. common peroneal around  Mononeuritis multiplex fibula . Foot drop Motor Sensory  High-stepping gait: foot drop  Distal sensory loss in stocking distribution  Weak foot and toe dorsiflexion  Absent ankle jerks Completion  Examine the fundi Sensory  Examine the upper limbs and cranial nerves  Variable loss of sensation in a stocking distribution . Sensory neuropathy . Mononeuritis multiplex  CN3 Viva  CN6  Ulnar nerve Hx  Urine dip: glucose, proteinuria  Family Hx

Viva Pathophysiology  Group of inherited motor and sensory neuropathies Hx  Pain: esp. @ night HMSN1  Glycaemic control  Commonest form  Complications of insulin  Demyelinating  Other micro- and macro-vascular complications  AD mutation in the peripheral myelin protein 22 gene

Pathophysiology HMSN2  Second commonest form  Metabolic: glycosylation, ROS, sorbitol accumulation  Axonal degeneration  Ischaemia: loss of vasa nervorum  Autosomal dominant

Ix  Urine: glucose, ACR  Blood . Glucose Ix . HbA1c  Nerve conduction studies . U+E . HMSN1: demyelination → ↓ conduction velocity . HMSN2: axonal degeneration → ↓ amplitude Rx  Genetic testing . HMSN1: Peripheral myelin protein 22 (PMP22)  MDT: GP, endocrinologist, neurologist, DNS gene  Good glycaemic control  Amitriptyline, Gabapentin  Capsaicin cream Mx: Supportive Femoral Neuropathy / Amyotrophy  MDT: GP, neurologist, specialist nurses, physio, OT  Painful asymmetric weakness and wasting of quads ¯c loss  Foot care and careful shoe choice of knee jerks  Orthoses: e.g. ankle braces  Dx: nerve conduction and electromyography

Autonomic Neuropathy  Postural hypotension – Rx: fludrocortisone  Gastroparesis → early satiety, GORD, bloating  Diarrhoea – Rx: codeine phosphate  Urinary retention  ED

Examination Classification  AIDP: acute autoimmune demyelinating Inspect polyneuropathy  Thymectomy scar  Miller-Fisher: ophthalmoplegia + ataxia + areflexia

Eyes  Bilateral ptosis: worse on sustained upward gaze Pathophysiology  Complex ophthalmoplegia  Molecular mimicry: Abs x-react ¯c ganglioside

 Bacteria: C. jejuni, mycoplasma Facial Movements  Viruses: CMV, EBV  Myasthenic snarl on smiling

Voice  Nasal Features  Deterioration: ask pt. to count to 50  Symmetrical ascending flaccid paralysis  Sensory disturbance: paraesthesia Limbs  Autoimmune neuropathy: labile BP  Fatiguability: repeatedly flap arm

Completion Ix  Assess respiratory muscle function: spirometry (FVC)  Evidence of infection: e.g. stool MC+S  Anti-ganglioside Abs  LP: ↑↑ CSF protein  Nerve conduction studies: demyelination Viva

Ix Mx  Abs: Anti-AChR, Anti-MuSK  EMG: ↓ response to titanic train of impulses Supportive  Tensilon test: improvement ¯c edrophonium  Airway / ventilation: ITU if FVC < 1.5L (anticholinesterase)  Analgesia: NSAIDs, gabapentin  TFTs: Graves in 5%  Autonomic: may need inotropes, catheter  CT mediastinum: thymoma in 10%  Antithrombotic: TEDS, LMWH

Associations Immunosuppression  <50, female  IVIg . AI disease: DM, RA, Graves, SLE  Plasma exchange  >50, male . Thymoma Physiotherapy  Prevent flexion contractures Mx Prognosis Acute  85% complete recovery  Plasmapheresis or IVIg  10% unable to walk alone at 1yr  Monitor FVC: consider ventilation  5% mortality

Chronic  Pyridostigmine  Immunosuppression: steroids and azathioprine  Thymectomy: benefit even if no thymoma

LEMS  Abs vs. VGCC  Often paraneoplastic: e.g. SCLC  Lower limb girdle weakness  Weakness improves on repetitive testing

Bilateral Ptosis  MG  Myotonic dystrophy  Congenital  Senile  Bilateral Horner’s (rare)

Examination Viva

Inspection Hx  Unilateral facial droop  Symptoms  Absent nasolabial fold . Eye dryness  ± absent forehead creases . Drooling  ? scar or parotid mass . ↓ taste: ageusia  Ear rash . Hyperacusis  Cause Weakness . Onset: rapid in Bell’s . Rash or external ear pain  Raising eyebrows: frontalis . Hx of DM  Screwing up eyes: orbicularis oculi . SOL: headache, nausea . Bell’s sign: eyeball rolls back on closure . Other CN: vertigo, tinnitus, diplopia  Smiling: orbicularis oris . Limb weakness

. Rash, fever UMN or LMN?  UMN → sparing of frontalis and orbicularis oculi Aguesia and Hyperacusis  Due to bilateral cortical representation  Chorda tympani and nerve to stapedius arise just distal to geniculate ganglion w/i the temporal bone. Other CN Involvement  Loss of these functions indicates a proximal lesion  NB. other CN involvement seen in 8% of Bell’s Palsy  Common in Ramsay Hunt: VZV @ geniculate ganglion

Pons → Millard-Gubler Syndrome Ix  CN6 nucleus → ipsilateral lateral rectus palsy  CN7 nucleus → ipsilateral LMN facial palsy Urine Dip: glucose  Corticospinal tracts → contralateral hemiparesis Bloods CPA: ipsilateral CN 5, 6, 7 and 8 palsies and cerebellar signs  DM: glucose, HbA1c  Facial anaesthesia + absent corneal reflex  Serology: VZV and Lyme  LR palsy  Abs: anti-ACh receptor  LMN facial nerve palsy  SNHL Imaging  DANISH  MRI posterior cranial fossa

Auditory Canal → CN8 Other  Pure tone audiometry Completion  LP: exclude infection  If UMN: likely stroke  Nerve conduction studies . Examine limbs for ipsilateral spasticity . May predict delayed recovery when performed @ . Examine visual fields: ipsilateral homonymous 2wks. hemianopia  If LMN: likely Bell’s Palsy Mx . Look in ears  Prednisolone w/i 72hrs . Examine PNS, CN and cerebellar function  Valaciclovir if VZV suspected . Test taste  Protect eye . Dark glasses Causes . Artificial tears  75% Idiopathic Bell’s Palsy . Tape closed @ night  Supranuclear: vascular, MS, SOL  Pontine: vascular, MS, SOL Prognosis  CPA: vestibular Schwannoma, meningioma, 2O  Incomplete paralysis: recovers completely w/i wks  Intra-temporal: Ramsay Hunt, Cholesteatoma, trauma  Complete: 80% get full recovery  Infra-temporal: Parotid tumour, trauma . Remainder have delayed recovery or permanent  Systemic neurological / cosmetic abnormalities. . Neuropathy: DM, Lyme, Sarcoidosis . Pseudopalsy: MG Complications: Aberrant Neural Connections  Synkinesis: e.g. blinking causes up-turning of mouth Bilateral Facial Nerve Palsy  Crocodile tears: eating stimulates unilateral lacrimation,  Bilateral Bell’s not salivation  Sarcoidosis  GBS  Lyme  Pseudopalsy: MG, Myotonic dystrophy

Bell’s Palsy Examination  75% of Facial Palsies  ↓ absent sensation in trigeminal distribution  Dx of exclusion . Note modality  Inflammatory oedema → compression of CNVII in . Note which trigeminal branch narrow facial canal  Weak masseter and temporalis  Probably of viral origin (HSV1)  Jaw jerk . Brisk: UMN Features . Absent: LMN  Sudden onset  Loss of corneal reflex  Complete LMN facial palsy  Ageusia: corda tympani  Hyperacusis: stapedius Viva  Assoc. ¯c other CN involvement in 8% Causes

Ramsay Hunt Syndrome Supranuclear  American neurologist James Ramsay Hunt in 1907  Demyelination  Reactivation of VZV in geniculate ganglion of CNVII  Infarct  SOL Features  Preceding ear pain or stiff neck Nuclear  Vesicular rash in auditory canal ± TM, pinna, tongue,  CPA lesion: ¯c other CN palsies hard palate (no rash = zoster sine herpete)  Lateral medullary syndrome: loss of pain and temp  Ipsilateral facial weakness, ageusia and hyperacusis  May affect CN8 → vertigo, tinnitus, deafness Peripheral: mononeuropathy  DM, sarcoid, vasculitis Mx  Cavernous sinus  If Dx suspected give valaciclovir and prednisolone w/i . Ophthalmic and maxillary divisions first 72h . Bilateral

Prognosis  Rxed w/i 72h: 75% full recovery  Otherwise: 1/3 full recovery, 1/3 partial, 1/3 poor

Cholesteatoma  Locally destructive expansion of stratified squamous epithelium within the middle ear.  Usually 2O to attic perforation in chronic suppurative OM

Presentation  Foul smelling white discharge  Vertigo, deafness, headache, pain, facial paralysis  Appears pearly white ¯c surrounding inflammation

Complications  Deafness (ossicle destruction)  Meningitis, cerebral abscess

Management  Surgery

Lyme Disease  Borellia burgdorferi  Early Local: Erythema migrans + systemic malaise  Late Disseminated . CN palsy: esp. facial palsy . Polyneuropathy . Meningoencephalitis . Arthritis . Myocarditis . Heart block

Horner’s Syndrome Holmes-Adie (Myotonic) Pupil  Dilated pupil that has no response to light and sluggish Examination response to accommodation.  ↓ or absent ankle and knee jerks Face: PEAS  Benign condition, more common in young females  Ptosis: partial (superior tarsal muscle)  Enophthalmos Argyll Robertson Pupil  Anhydrosis  Small pupil Features  NO ophthalmoplegia  Small, irregular pupils  Accommodate but doesn’t react to light Neck Scars  Atrophied and depigmented iris  Central lines  Carotid endarterectomy Extras

 Offer to look for sensory ataxia: tabes dorsalis Hands  Dip the urine: glucose  Complete claw hand + intrinsic hand weakness

 ↓ / absent sensation in T1 Causes Completion  Quaternary syphilis: RPR or TPHA  DM  Cerebellum, CNs and PNS

RAPD / Marcus Gunn Pupil Differential

Central Features  MS  Minor constriction to direct light  Wallenberg’s  Dilatation on moving light from normal to abnormal eye.

Pre-ganglionic (neck) Features of Optic Atrophy  Pancoast’s tumour: T1 nerve root lesion  ↓ visual acuity  Trauma: CVA insertion or carotid endarterectomy  ↓ colour vision: esp. red desaturation  Central scotoma Post-ganglionic  Pale optic disc  Cavernous sinus thrombosis  RAPD . Usually 2O to spreading facial infection via the ophthalmic veins Causes: CAC VISION . CN 3, 4, 5, 6 palsies  Commonest: MS and glaucoma

Oculomotor Nerve Palsy Congenital  Leber’s hereditary optic neuropathy Features . Epi: mitochondrial, onset 20-30s  Complete ptosis: LPS . PC: attacks of acute visual loss, sequential in each  Eye points down and out: unopposed SOB and LR eye ± ataxia and cardiac defects  Dilated pupil, doesn’t react to light: unless spared  HMSN / CMT  Ophthalmoplegia and diplopia  Friedrich’s ataxia  DIDMOAD Medical vs. Surgical Alcohol and Other Toxins  Parasympathetic fibres originate in Edinger Westphal Nucleus and run on periphery of oculomotor nerve.  Ethambutol  Receive rich blood supply from external pial vessels  Lead  These fibres are affected late in ischaemic causes  B12 deficiency (medical) but early in compression (surgical). Compression Medical  Neoplasia: optic glioma, pituitary adenoma  Mononeuritis: e.g. DM  Glaucoma  MS  Paget’s  Infarction in midbrain . Weber’s: CN3 palsy + contralateral hemiplegia Vascular: DM, GCA or thromboembolic Inflammatory: optic neuritis – MS, Devic’s, DM  Migraine Sarcoid / other granulomatous

Infection: herpes zoster, TB, syphilis Surgical Oedema: papilloedema  ↑ ICP: transtentorial herniation compresses uncus Neoplastic infiltration: lymphoma, leukaemia  Cavernous sinus thrombosis  Posterior communicating artery aneurysm: painful © Alasdair Scott, 2012 66 Visual Fields

Visual Pathway Bitemporal Hemianopia  Retina  Chiasmatic lesion  Optic nerve  Optic chiasm: nasal fibres decussate Extras  Optic tract  Take Hx and examine for features of endocrine disease  LGN of thalamus . Prolactinoma  Optic radiation . Acromegaly . Superior field: temporal . Cushing’s . Inferior field: parietal  Visual cortex Causes  Pituitary tumour Ix . Compresses from below → descending visual loss Craniopharyngioma  Perimetry  . Compresses from above → ascending visual loss  CT/ MRI brain . Benign suprasellar tumour originating from

Rathke’s pouch.

. Calcified as arises from odontogenic epithelium Homonymous Hemianopia  Retrochiasmatic  Greater defect = larger lesion or closer to chiasm  Contralateral Monocular Blindness  No vision in one eye  Check counting fingers, movement and light perception Extras  Lesion proximal to optic chiasm  Examine for ipsilateral hemiparesis . Eye itself: cornea, vitreous, retina  Examine for cerebellar signs . Optic nerve: i.e. optic neuropathy  Right: test for neglect  Left: test for aphasia

Hx  Speed of onset  Vascular risk factors

Vascular Territory  MCA Stroke . MCA supplies the optic radiation in the temporal and parietal lobes . Hemiparesis . Higher cortical dysfunction: neglect, aphasia  PCA Stroke . PCA supplies occipital lobe and visual cortex . Homonymous hemianopia ¯c macula sparing  Branch of MCA supplies part of visual cortex . No hemiparesis . May have cerebellar signs

Causes  Vascular: ischaemia or haemorrhage  SOL: tumour, abscess  Demyelination: MS

Examination Internuclear Ophthalmoplegia

H Test: Left Eye Examination  Failure of ipsilateral adduction  Nystagmus in the contralateral abducting eye  May be bilateral  Convergence preserved

Neurophysiology  To maintain convergent gaze, MLF yokes together the nuclei of CN3 and 6.

 Pontine centre for lateral gaze initiates movement and outputs to CN3 nucleus and CN6 nucleus via the MLF  Failure of adduction is ipsilateral to MLF lesion

Causes Key Elements  MS  Inspect the eye  Infarct: ischaemic or haemorrhagic . Ptosis  Syringomyelia . Alignment  Phenytoin toxicity . Pupil sizes  Ask pt. to tell you if they get double vision  Use H to test movements noting: Complex Ophthalmoplegia . Ophthalmoplegia  Dx of exclusion . Diplopia: do cover test  Ophthalmoplegia doesn’t fit a single pattern . Nystagmus  Saccades: vertical and horizontal Causes  DM: Mononeuritis multiplex Diplopia  MS  Maximal in direction of pull of affected muscle  Myasthenia gravis  Cover test: outer image disappears c affected eye ¯  Thyrotoxicosis

Simple Palsies Ix  Urine dip: glucose rd 3 Nerve  Bloods  Complete ptosis . DM: glucose + HbA1c  Down and out in rest position . TFT: ↓TSH  ± dilated, non-reactive pupil . MG: anti-AChR antibodies  Diplopia maximal: in and up  MRI Brain . Plaques in the periventricular white matter 4th Nerve  Slight head tilt: ocular torticollis  Appear normal in rest position  Failure to depress eye in adduction  Diplopia maximal down and in  Ask if pt. has trouble walking down stairs

6th Nerve  Appear normal in resting position  Failure to abduct  Diplopia maximal in abduction  Commonly a false localising sign of ↑ ICP: contralateral lesion

Causes  Central NS: MS, vascular, SOL  Peripheral NS: DM (mononeuritis), compression, trauma

Ix  Urine dip: glucose  Bloods: glucose + HbA1c  Imaging: MRI brain

Examination Causes  USE a 512Hz TUNING FORK Conductive Rinne’s Test  Impaired conduction anywhere between auricle and  Positive: AC > BC round window.  Negative: BC > AC  Canal obstruction: wax, FB . True: conductive deafness  TM perforation: trauma, infection . False: complete SNHL  Ossicle defects: otosclerosis, infection  Fluid in middle ear Weber’s Test  Normal: central SNHL  SNHL: lateralises to normal ear  Defects of cochlea, cohlear N. or brain  Conductive: lateralises to abnormal ear Congenital  Alports: SNHL + haematuria  Jewell-Lange-Nielsen: SNHL + long QT

Acquired  Presbyacussis  Drugs: gentamicin, vancomycin  Infection: meningitis, measles  Tumour: vestibular schwannoma

Examination Abnormalities

Aims to Test Dysarthria  Dysphonia: impaired production of voice sounds  Lesion in tongue, lips, mouth or disruption of NM pathway  Dysarthria: impaired articulation of sound → words  Dysphasia: impairment of language Pseudo-bulbar  Bilateral UMN lesions → spastic dysarthria Quick Screen  Difficulty ¯c lingual sounds  Ask: How did you get here today? . “Hot Potato speech” . Listen to volume, rhythm, clarity and content  Brisk jaw jerk . Any striking abnormality?  Causes . CVA: e.g. bilateral internal capsule infarcts Dysarthria . MS  Repetition . MND . Yellow lorry: test lingual sounds . Baby hippopotamus: labial sounds Bulbar . The Leith police dismisseth us: multiple processes  Unilateral LMN weakness  Count to thirty: muscle fatigue in MG  Palatal weakness → nasal “Donald Duck” speech  Causes Dysphonia . Brainstem infarct . MND  Voice: quiet or hoarse . GBS  Cough: bovine

Say Ahh: vocal cord tension  Cerebellar

 Slurred, drunken speech Dysphasia  Name three objects: nominal dysphasia  Three stage command: receptive dysphasia Dysphonia . Avoid visual clues by instructing from behind  Hoarse voice  Repeat sentence: Today is Thursday  Bovine cough . Tests for conductive dysphasia Cause Extras  Local cord pathology: laryngitis, tumour, nodule  Dominant parietal lobe lesions → dyslexia, dysgraphia  Recurrent laryngeal N. palsy and dyscalcula.  Read a paragraph: dyslexia  Write a sentence: dysgraphia Dysphasia

Expressive  Broca’s area: frontal lobe  Non-fluent speech  Comprehension intact

Receptive  Wernicke’s Area: temporal lobe  Fluent but meaningless speech  Comprehension impaired

Conductive  Damage to arcuate fasciculus connecting Broca’s and Wernicke’s areas.  Comprehension intact  Unable to repeat words or phrases

Contents Psoriasis ...... 72 Dermatitis ...... 73 Cutaneous Manifestations of DM ...... 73 Skin Malignancy ...... 74 Neurofibromatosis ...... 75 Tuberous Sclerosis ...... 75 Spot Skin Diagnoses ...... 76 Rheumatoid Hands ...... 77 RA: Key Facts ...... 78 Systemic Sclerosis ...... 79 Systemic Lupus Erythematosus ...... 80 Ankylosing Spondylitis ...... 81 Marfan’s Syndrome ...... 82 Tophaceous Gout ...... 83 Osteoarthritis ...... 83 Thyrotoxicosis ...... 84 Hypothyroidism ...... 85 Acromegaly ...... 86 Cushing’s Syndrome ...... 87 Addison’s Disease ...... 88 Steroids: Key Facts ...... 89 Neuro Shorts ...... 89

Examination Viva

Skin Hx  Symmetrical, well-defined salmon-pink plaques  Symptoms  Silvery, micaceous scale . Itch  Locations . Arthritis . Extensors  Triggers . Behind ears . Smoking . Scalp . Stress . Umbilicus . Injury . Sites of trauma: Kobner phenomenon . Drugs: β-B, EtOH  Skin staining from Rx  Treatments . Coal tar: brown . Topical . Dithranol: purple . Phototherapy . Systemic Nails  Discolouration Pathogenesis  Pitting  T4 T cell-driven hypersensitivity reaction  Onycholysis  Hyperkeratosis  Subungual hyperkeratosis  Parakeratosis (nuclei in the stratum corneum)  Intra-epidermal microabscess (of Munro) Joints  Evidence of inflammatory arthropathy Subtypes  Guttate Completion . Drop-like lesions on trunk  Inspect common areas and assess joints . Commoner in children after Strep infection  Assess for Auspitz sign  Pustular: generalised or palmo-plantar . Pinpoint bleeding on scraping scale  Erythroderma  Hx  Flexural: not scaly

Differential Psoriatic Arthritis  Psoriasis  Seronegative arthritis develops in 10-40%  Bowen’s Disease  Asymmetric oligoarthritis  Lichen planus  Distal arthritis  Dermatitis  Symmetric polyarthritis: may mimic RA  Spondylitis  Arthritis mutilans Other Differentials Mx Onycholysis  Psoriasis General  Fungal infection  MDT: GP, dermatologist  Trauma  Avoid precipitants: EtOH, β-B, smoking, stress  Thyrotoxicosis Topical Pitting  Emollients: epaderm, dermol, diprobase  Psoriasis  Steroids: betometasone  Fungal infection  Vit D analogues: calcipotriol  Lichen planus . Combination: Dovobet  Coal Tar: inpt. Use mainly Kobner Phenomenon  Dithranol  Psoriasis  Lichen planus Phototherapy  Viral warts  PUVA  Vitiligo  Narrow-band UVB  Sarcoid Systemic  Cytotoxics: ciclosporin, methotrexate  Retinoids: acetretin  Biologics: anti-TNF

Examination Examination

Skin Hands  Erythematous lichenified patches  Cheiroarthropathy  Predominantly flexors . Tight waxy skin that limits finger extension  Excoriations . Prayer sign  Painful fissures: esp. hands  Granuloma annulare . Flesh-coloured papules in annular configuration Differential . Usually on dorsum of hand  Just hands: irritant contact dermatitis . 10% assoc. ¯c DM  Atopic eczema  Glucose skin prick testing marks  Discoid: well-demarcated patches on trunk and limbs  Seborrhoeic dermatitis Injection Sites  Shoulders, abdomen and thighs  Lipodystrophy Viva Shins Hx  Necrobiosis lipoidica diabeticorum  Atopy: asthma, hay fever, allergies . Well-demarcated waxy, bruise-like plaques . Prominent blood vessels  Patch testing: house dust mites, animal dander . 90% female  Effect of diet

Mx Feet  Charcot’s Joints

General  Ulcers: heel, metatarsal heads, digits

 MDT: GP, dermatologist  Avoid precipitants Other  Infections: candida, cellulitis O Adjuvants  Eruptive tendon xanthoma: 2 to hyperlipidaemia  Antihistamines: pruritis  Abx: 2O infection

Topical  Emollients: dermol, epaderm, diprobase  Soap substitutes: dermol, epaderm  1st: steroids  2nd: tacrolimus

Phototherapy

Systemic: only if severe  Steroids  Ciclosporin

BCC Malignant Melanoma

Examination Examination

Lesions Pt. Characteristics  On face in sun-exposed areas  Fair skin ¯c freckles  Pearly nodule ¯c rolled, telangiectactic edge  Blue Eyes  Light hair Viva Lesion Natural Hx  Asymmetry  Commonest skin cancer  Boarder: irregular  2O to sun exposure  Colour: non-uniform  Slow growing locally destructive: “rodent ulcer”  Diameter > 6mm  Do not metastasise  Evolving / Elevation

Mx Extras  Superficial: curettage  Regional LNs  Deep: surgical excision ± radiotherapy  Fundoscopy  Liver

NB. Glass ye + ascites: ocular melanoma SCC Viva Examination Risk Factors Lesion  Sun exposure: esp. when young Sun-exposed area   Low Fitzpatrick skin type Ulcerated lesion c everted edge  ¯  ↑ no. of common moles  Actinic keratosis: irregular, crusty, warty lesions  +FH  Bowen’s: red/borwn, scaly plaques  ↑ age  Immunosuppression Extras  Examine regional LNs Classification  Examine rest of skin for other lesions  Superficial spreading: 80%  Lentigo maligna melanoma: elderly Viva  Acral lentiginous: Blacks, soles, palms  Nodular: younger, new lesion Evolution  Amelanotic: delayed Dx  Actinic keratosis → Bowen’s → SCC Staging Risk Factors  Breslow Depth  Sun exposure  Clark’s Levels  Immunosuppression: e.g. ciclosporin  Genetic: xerodermapigmentosum Mx  Chronic trauma: Marjolin’s ulcer  Excision biopsy for staging  2O excision margin depends on stage Dx  ± lymphadenectomy  Excisional biopsy  ± adjuvant chemo

Mx  Surgery ± radiotherapy

Examination Examination

Skin Skin  Café-au-lait spots  Facial adenoma sebaceum: perinasal angiofibromata . ≥6, >15mm diameter  Periungual fibromas: hands and feet  Axillary freckling  Shagreen-patch: roughened leathery skin over sacrum  Neurofibromas: gelatinous, violaceous nodules  Ash-leaf macule: hypopigmented macule on trunk . Fluoresce ¯c UV/Wood’s lamp Eyes  Café-au-lait spots  Lisch nodules: melanocytic hamartomas of the iris Extras Extras  Fundus: retinal phakomas (dense white patches)  Visual acuity: optic glioma  Lungs: cystic lung disease  Back: scoliosis  Abdomen O  BP: RAS + phaeochromocytoma . Renal enlargement 2 to cysts  Palpable nerves + peripheral neuropathy . Transplanted kidney  Signs of phenytoin use (80% epileptic) . Gingival hypertrophy Viva . Hisutism

Epidemiology  Autosomal dominant Viva

 NF1 . Chr 17 Epidemiology . 1/2500  Autosomal dominant  NF2  Chr 16 . Chr 22 . 1/35,000 Ix  Skull films: railroad track calcification Complications  CT/MRI brain: tuberous masses in cortex  Epilepsy  Abdo US: renal cysts  Sarcomatous change: 5%  Echo: cardiomyopathy  Scoliosis: 5%  Learning difficulty: 10%

Mx  MDT: GP and neurologist  Excise some neurofibromas  Complications . Yearly BP and cutaneous review . Epilepsy Rx  Genetic counselling

Differential of Café-au-Lait Spots  NF  McCune Albright . Case-au-lait spots . Polyostotic fibrous dysplasia . Endocrinopathy → precocious puberty  Tuberous Sclerosis

Hereditary Haemorrhagic Telangiectasia Erythema Multiforme = Osler-Weber-Rendu Syndrome Examination Examination  Symmetrical targetoid lesions  Multiple telangiectasia on face, lips and buccal mucosa  Especially on the extensor surfaces of peripheries  Cyanosis: large pulmonary AVMs  No signs of CREST Differential of lesions c¯ central clearing  EM Differential  Discoid eczema  HHT  Tinea  CREST  CLD Viva  Ataxia telangiectasia Causes Viva  Infections . HSV (70%) Features . Mycoplasma  Autosomal dominant  Drugs  Multiple telangiectasias . Sulfonamides  AVMs . NSAIDs . Lungs . Allopurinol . Liver . Penicillin . Brain . Phenytoin

Complications Stevens-Johnson Syndrome and TEN  Haemorrhage  Severe variants of EM . Epistaxis  Nearly always drug-induced . GI haemorrhage  SJS: blistering mucosa . Haemoptysis  TEN: generalised erythema followed by erpidermal . SAH necrosis and desquamation  High output cardiac failure  Rx: dexamethasone, IVIg  May have ↑ risk of CRC if SMAD4 mutation

Erythema Nodosum Peutz-Jeghers Examination Examination  Tender, blue/red, smooth shiny nodules  Small pigmented macules on lips, oral mucosa, palms  Commonly found on shins and soles . Can be anywhere ¯c SC fat  Older lesions leave a bruise Differential  Peutz-Jeghers Extras  Carney Complex  Parotid swelling: sarcoidosis  McCune-Albright  Red, sore throat: streptococcal infection  Simple freckles  Joint pains, oral ulceration: Behcet’s

Viva Viva

Causes Features  Systemic disease  Autosomal dominant mutation of STK11 gene on Chr . Sarcoidosis 19 . IBD  Mucocutaneous macules . Behcet’s  GI hamartomatous polyps  Infection . Streptococcal infection Complications . TB  GI hamartomas  Drugs . Intussusception . Sulphonamides . GI bleeding . OCP  Pancreatic endocrine tumours  ↑ risk of cancer: esp. CRC (~20% life-time risk) Other skin manifestations of sarcoidosis  Red/brown nodules and papules  Lupus pernio: brown plaques, commonly on the nose

Hand Examination Viva

Look Hx  Hands  Symptoms . Skin: joint erythema, palmar erythema  Early morning stiffness . Joint Swelling: MCPs and PIPs  Pain . Muscle wasting: interossei, thenar eminence  Swelling . Deformity  Affect on life  Surgical Scars: e.g. carpal tunnel release  Extra-articular features: aNTI CCP OR RF  Wrist  Treatments tried so far + any complications  Elbow: nodules

Feel Ix  Hot swollen painful joints = active synovitis Bloods Move  FBC: ↓Hb, ↓PMN  Fixed flexion on prayer position  ↑ESR and ↑CRP  ↓ ROM  Immune . RF: +ve in 70% Function . Anti-CCP: 98% specific, 75% sensitive  Precision . ANA: +ve in 30%  Power . HLA-DR3/4  Aids X-Ray Presentation  Soft tissue swelling  Periarticular osteopenia  Symmetrical deforming polyarthropathy  Loss of joint space  Signs of active synovitis  Periarticular erosions  Signs of cause  Deformity . Rheumatoid nodules

. Psoriatic plaques

Differential Mx

 Psoriatic arthritis MDT: GP, physio, OT, rheumatologist, orthopod  Jacoud’s arthropathy Conservative

 Physio Systemic Examination  OT: aids and splints  Skin: steroid use  BP and pulse Medical . ↑ risk of AF  Analgesia . ↑ risk of cardiovascular disease  Steroids: IM, PO or intra-articular  Eyes  DMARDS . Epi-/scleritis  Biologicals . Keratoconjunctivits sicca  Other . Anaemia . CV risk  Neck: x-rays for atlanto-axial sublucxation . Prevention of PUD and osteoporosis  Heart: pericardial rub  Lungs Surgical . Pulmonary fibrosis  Carpal tunnel decompression . Percuss for effusions  Tendon repairs and transfers . Pleural rub  Ulna stylectomy Abdomen: splenomegaly   Arthroplasty  Urine dip: nephrotic syndrome amyloid or DMARDs)

Extra-Articular Features: aNTI CCP OR RF Rheumatoid Factor  Nodules  Anti-IgG IgM  Tenosynovitis: de Quervains and atlanto-axial  Present in ~70% ¯c RA subluxation  Also present in ~10% of normal people and in other  Immune: vasculitis, amyloidosis, Sjogren’s, AIHA diseases  Cardiac: pericarditis ± effusion . Sjogren’s: 100%  Carpal tunnel . SLE: ≤40%  Pulmonary: fibrosis, effusions  Higher titres associated ¯c  Ophthalmic: episcleritis, scleritis, Sjogren’s . More severe disease  Renal: nephrosis 2O to amyloidosis . Erosions  Raynaud’s . Extra-articular manifestations  Felty’s: RA + ↓PMN + splenomegaly

Seronegative RA Anatomy of Rheumatoid Hands  RA ¯c absence of RFs  Boutonierre’s: rupture of central slip of extensor  ~30% of pts are seronegative expansion → PIPJ prolapse through “button-hole” . May have non-classical RFs (e.g. IgG vs. IgG) created by the two lateral slips. . 40% +ve for anti-CCP  Swan: rupture of lateral slips → PIPJ hyper-extension  Less severe disease ¯c and much less likely to have extra-articular features.

DMARDs  All can → BM suppression Atlanto-Axial Subluxation  Rheumatoid tenosynovitis → weakening of ligaments Drug Side Effects Monitor supporting the top of the cervical spine Methotrexate BM suppression FBC  Posterior subluxation of the odontoid peg can compress Hepatotoxic LFTs the spinal cord Pulmonary fibrosis CXR . Chronic: progressive spastic tetraparesis Sulfasalazine BM suppression FBC . Acute: inhibitory impulses via vagus N. can → Skin rashes LFTs cardiac arrest Hepatitis  Pre-operatively ↓ sperm count . Main risk is during intubation Hydroxychloroquine Retinopathy Visual acuity . Arrange upper cervical spine radiograph in gentle flexion Penicillamine Drug-induced lupus Urine

Nephrotic syndrome Gold Nephrotic syndrome Urine Anti-CCP Abs  Cyclic Citrullinated Peptide Biologicals . Derived from collagen . Citrullination of arginine 2O to inflammation

Indications  Specificity: 98%  Severe RA not responding to DMARDs  Sensitivity: 75%

Anti-TNF  Screen and Rx TB first: tuberculin skin test, CXR American College of Rheumatology Criteria  Give ¯c hydrocortisone to ↓ hypersensitivity 4/7 of  Agents . Infliximab (Remicade)  Morning stiffness >≥1h . Etanercept (Enbrel)  Arthritis in 3+ joint areas . Adalimumab (Humira)  Arthritis of the hands  SEs  Symmetrical . Hypersenstivity → rash  Rheumatoid nodules . Opportunistic infection: TB  +ve RF  Radiographic changes B-cell Depletion: Rituximab (anti-CD20 mAb)  Screen and Rx TB first: tuberculin skin test, CXR  Opportunistic infections . TB . Viral reactivation: Hep B, PML

Examination Hx  Symptoms Hands . Swallowing difficulty or reflux . Hands change colour in the cold  Scleroderma . Shortness of breath . Tight skin . Hypertension . Can you move skin between your fingers? . Arthralgia  Sclerodactyly

 Calcinosis  Raynaud’s phenomenon → ulceration Ix

Face Urine  Beaked nose: “nasal skin tethering”  GN: proteinuria and haematuria  Microstomia . Ask pt. to open and close mouth ECG  Perioral furrowing  Arrhythmias  Telangiectasia  RV strain  En coup de sabre: scar down central forehead Bloods Extras  FBC: anaemia  BP: HTN  U+E: renal impairment  Lungs: pulmonary fibrosis  Abs  Cardiac: pulmonary HTN . ANA: +ve in 90% . ↑ JVP . Centromere: limited (80%) . Parasternal heave . Scl70 (topoisomerase): diffuse (70%) . Loud P2 . Peripheral oedema and ascites Imaging  Morphea: patches of sclerotic skin  Hand radiographs: calcinosis . Localised scleroderma  CXR: fibrosis  HRCT: fibrosis  Echo: pulmonary HTN Completion  Hx Other  Extra features  Lung function tests: restrictive pattern  Ba swallow: dysmotility

Classification  Localised: morphea Mx  Systemic . Diffuse (30%) MDT: GP, rheumatologist, pulmonologist, cardiologist . Limited (70%): including CREST Specific Limited  Immunosuppression used for organ involvement or  Distribution limited to below elbows and knees and face progressive skin disease.  Slow progression: yrs  Pulmonary HTN in ~15% Raynaud’s  CREST  Gloves and hand-warmers . Calcinosis  CCBs: e.g. nifedipine . Raynaud’s phenomenon  Severe: prostacyclin infusion . Esophageal dysmotility . Sclerodactlyly Renal . Telangiectasia  Aggressive blood pressure control  ACEi Diffuse  Widespread cutaneous and early visceral involvement GI  Rapid progression: months  PPI for reflux

Pulmonary Hypertension  Sildenafil  Bosentan: dual endothelin receptor antagonist

Prognosis  50% 5 year survival  Mortality: respiratory failure and renal impairment © Alasdair Scott, 2012 79 Systemic Lupus Erythematosus

Examination Viva

Face Hx  Malar “butterfly” rash: spares nasolabial folds  Systemic: fever, wt. loss, fatigue  Discoid rash ± scarring  Photosensitivity rashes . Hyperkeratotic papules  Arthralgia  Oral ulceration  Anaemia Features  Multisystem inflammatory disease characterised by a Hands T3 hypersensitivity reaction against circulating immune  Vasculitic lesions: nail fold infarcts complexes.  Raynaud’s phenomenon: digital ulceration  F>>M = 9:1  Jacoud’s arthropathy  ↑ in Afro-Caribbeans and Asians . Mimics RA . Due to tendon contractures . Reducible on extension Ix

Skin Urine dip  Purpura  GN: proteinuria, haematuria  Livedo reticularis Bloods Extras  FBC: anaemia  Eyes: keratoconjunctivitis sicca  U+E: GN  Lungs  ESR . Pleural rub  Abs . Pleural effusion . ANA: 100% . Fibrosis . dsDNA: 60% sensitive but very specific  Cardio: pulmonary HTN . Anti-cardiolipin and lupus anticoagulant  Renal  Complement . HTN . Dipstick for nephrotic syndrome Disease Activity  Neurology  ↑ ESR . Focal neurology . ↑ CRP suggests infection . Chorea  ↓ C3, C4  ↑ dsDNA titre

MDT: GP, rheumatologist in specialist SLE clinics

Mild disease: cutaneous and joints only  Topical corticosteroids  Sun cream  Hydroxychloroquine

Moderate disease: + organ involvement  Prednisolone  Azathioprine

Severe Disease  AIHA, nephritis, pericarditis, CNS disease  High-dose methylprednisolone  Cyclophosphamide

Examination Viva

Back Hx  Thoracic kyphosis + neck hyperextension  Symptoms . “Question mark posture” . Back pain: relieved by exercise  ↓ ROM throughout spine . Morning stiffness  Protruberent abdomen: diaphragmatic breathing . Anterior chest pain: costochondritis . Eye pain Tests of Movement . Shortness of breath  ↑ occiput to wall distance: >5cm  Cause  Schober’s Test: <5cm . Rashes . Diarrhoea  ↓ chest expansion: <5cm . Measure @ nipples

Tests for Sacroiliitis Ix

 Direct pressure ECG  Sacroiliac stretch  AV block . Pain on adduction of hip, c hip and knee flexed ¯ Bloods Extras  FBC: anaemia  Anterior uveitis  ↑ ESR  Apical pulmonary fibrosis  ↑ CRP  Aortic regurgitation  Test for HLA-B27 allele (+ve in 95%)  Achilles tendonitis  Psoriatic plaques: psoriasis can → spondylitis Imaging  Spine Completion . Sacroileitis: sclerosis, erosions  ECG: AV block (10%) . Bamboo spine  Dipstick: proteinuria in amyloidosis  Syndesmophytes  Hx  Ligament calcification  Periosteal bone formation  CXR Differential . Fibrosis  Ankylosing spondylitis  Psoriatic arthritis Other  Other seronegative spondyloarthropathy  DEXA scan . Osteoporosis in 60%

Conservative  Exercise and physio

Medical  NSAIDs  Local steroid injections  Anti-TNF in severe disease  Bisphosphonates for osteoporosis

Surgery  Hip replacement if involved  Spinal osteotomy: rare

Examination Viva

General Hx  Tall ¯c long arms  Cardiac problems . Arm-span > height  Family history

Hands Genetics  Arachnodactyly: encircle waste ¯c hands  Autosomal dominant  Hyperextensible joints  Chromosome 15  Pulse  Defect in the fibrillin protein . Radio-radio delay: coarctation . Collapsing Ix Face  Echo: aortic root dilatation  High-arched palate  Genetic testing  Lens dislocation: upwards

Chest Mx  Pectus carinatum or excavatum  Scars from cardiothoracic surgery Surveillance  Murmur  Monitoring of aortic root size ¯c yearly TTE . AR: pitched early diastolic

. MVP: mid-systolic click, late systolic murmur Rx

 β-B and ACEi: slow aortic root dilatation Completion  Pre-emptive aortic root surgery: prevent dissection /  Formally compare arm-span to height rupture  Palpate for thyroid mass  Screen family members  Hx . Phaeo: episodic headache, sweating, tachycardia

Differential  Marfan’s  MEN2b  Homocystinuria . ↓ IQ . Downward lens dislocation

Examination Examination  Asymmetric oligoarthritis of small joints of hands and feet . Esp. 1st MTP General  Gouty tophi: joints, ears, tendons  Elderly pt.  ↓ ROM and function  Walking stick

Extras Hands  BMI: obesity  Asymmetrical distal interphalangeal joint deformity  HTN . Fixed flexion  Drug chart: thiazides, cytotoxics  Squaring of the CMC joint of the thumb  LNs: lymphoproliferative disorder  Heberden’s nodes: distal  CRF: renal replacement therapy  Bouchard’s nodes: proximal  Disuse atrophy Differential  ↓ function  Pseudogout  Septic arthritis Extras  Calcinosis from CREST  Other joint involvement and scars

Differential Viva  OA  Distal inflammatory arthritis: e.g. psoriatic Hx  Drug Hx Viva  Diet: beef, pork, lamb, seafood  EtOH Hx  CV risk: smoking, lipids, BP, DM, FH  Pain and stiffness

. Esp. after rest Cause . Worse @ end of day  Urate excess . Night pain . Drugs  Loss of function . Drinking EtOH . ADLs . Diet: purine rich foods  Other joint involvement . Decreased excretion: CRF  Social circumstances . Death of cells: leukaemia, lymphoma, psoriasis

Radiographic Features Ix  Loss of joint space

 Osteophytes Bloods  Subchondral sclerosis  Lipids  Subchondral cysts  Glucose  Deformity  Urate levels

X-ray Mx  Punched-out peri-articular erosions Conservative Joint aspiration  ↓ wt. if affects wt. bearing joints  Negatively birefringent needle-shaped crystals  Physio  OT Mx  Social services if unable to perform ADLs

Acute Medical  Remove cause and ↑ hydration  Paracetamol  1st: indomethacin or diclofenac  NSAIDs ± weak opioids  2nd: colchicine rd Surgical  3 : steroids  Joint arthroplasty Chronic  Modify precipitants  Allopurinol: XO inhibitor  Mx cardiovascular risk

Examination Viva

General Hx  Thin  Symptoms of thyrotoxicosis  Anxious . Heat intolerance, sweating . ↑ appetite, ↓wt. . Diarrhoea Periphery . Anxious, irritable  Thyroid acropachy . Visual problems, eye pain  Palmer erythema . Oligomenorrhoea  Hot, sweaty palms  Triggers  Tachycardia or AF . Child-birth  Pre-tibial myxoedema . Stress  Proximal myopathy . Infection  Other AI disease Neck . Vitiligo  Smooth, diffuse goitre . T1DM  May have bruit . Addison’s

Eyes Ix

Non-specific Bloods  Lid-lag  FBC: may be mild anaemia and neutropenia in Graves’  Lid retraction (↑ tone of sup. tarsal muscle)  TFTs: ↓TSH, ↑fT4, ↑fT3  Abs: TSH, TPO Graves’  Other: ↑ Ca, ↑ ESR, glucose (exclude DM)  Soft tissue swelling and Chemosis  Exophthalmos Imaging  Ophthalmoplegia: esp. upgaze  CXR: retrosternal goitre  Exposure keratopathy  US: assess for nodularity  Optic atrophy  Radionucleotide scan (Tc or I) . ↑ uptake in Graves’ Completion . ↓ uptake in thyroiditis

 Cardiovascular examination: risk of heart failure  Examine the eyes for evidence of optic atrophy Mx

 Observation chart Medical  Hx  Propranolol

 Carbimazole . Titrate according to TFTs, or Differential . Block and replace: ↓ risk of hypothyroidism  Graves’  Treat for ~12-18mo: ~30% remain euthyroid  Thyrotoxic phase of a thyroiditis  Simple colloid goitre Radioiodine  CI: pregnancy, around children  SE NB. Pts. ¯c Graves’ are often hyperthyroid but may become . May worsen thyroid eye disease eu- or hypo-thyroid. . Most pts. become hypothyroid

Thyroidectomy  SE . Haematoma . Recurrent laryngeal nerve injury . Hypoparathyroidism . Hypothyroidism

Thyroid Eye Disease  Stop smoking: worsens the prognosis  Symptomatic: artificial tears, dark glasses, elevate bed  Severe . High-dose steroids . Surgical decompression

Examination Viva

General Hx  Large body habitus  Symptoms  Depressed mentation . Cold intolerance  Gruff voice . Appetite but ↑ wt. . Constipation Skin . Menorrhagia  Dry skin . Lethargy, tiredness . Depression  Other AI disease: vitiligo  Cause . Neck pain Periphery . Iatrogenic Cool   Drugs  Bradycardia  Radioiodine  Proximal myopathy  Surgery Slow-relaxing reflexes   Associated AI disease . Vitiligo Face . T1DM  Coarse, puffy looking features . Addison’s  “Peaches-and-cream” complexion  Loss of lateral eyebrows  Xanthelasma Ix  Thin hair Bloods Neck  FBC: ↑MCV ± macrocytic anaemia  Goitre  U+E: ↓Na  Thyroidectomy scar  TFTs: ↑TSH, ↓fT4  Abs: TPO Completion  Other: ↑ cholesterol, glucose (exclude DM)  Cardiac exam: evidence of failure  Neurological exam CXR . Carpal tunnel syndrome  Pericardial effusion . Ataxia  CCF  Observation chart  Hx Mx  Thyroxine Differential . Titrate to clinical response and TSH  No goitre . If elderly introduce slowly to prevent precipitation . Atrophic thyroiditis of angina / MI. . Radioactive iodine . Clinical improvement takes ~2wks . Drugs: e.g. amiodarone  Goitre: Hashimoto’s  Scar: thyroidectomy Causes of Hypothyroidism

Primary O Other Differentials  Autoimmune: 1 atrophic and Hashimoto’s thyroiditis  Iatrogenic: rugs, surgery radioiodine Smooth Goitre  Iodine deficiency: e.g. Derbyshire neck  Simple colloid goitre  Genetic: thyroid agenesis  Hashimoto’s Secondary  Graves’  Hypopituitarism (v. rare) Nodular Goitre  Multinodular goitre  Multiple adenomas

Solitary nodule  Dominant nodule of a multinodular goitre  Adenoma  Malignancy

Examination Viva

Hands Hx  Spade-like: compare directly ¯c your own  Symptoms  Tight rings . Headaches  ↑ skin fold thickness . Problems ¯c vision  Boggy, sweaty palms: if active . Change in appearance  Thenar wasting + loss of sensation: carpal tunnel syn. . Hat and ring size ↑ . Pain or paraesthesia in hands Arms . Snoring, stop breathing when sleeping (OSA)  ↑BP  Associations . Polyuria and polydipsia . Chest pain, SOB, palpitations Face . Change in bowel habit  Coarse facial features: large nose, big ears  Cardiac risk factors  Prominent supra-orbital ridges  Macroglossia  Widely spaced teeth: “show me your gums” Ix

 Prognathism: inspect from side Urine dip: glycosuria  Look up nose for scars

ECG: LVH, ischaemia Extras  Eyes: bitemporal hemianopia Bloods  Neck: goitre + ↑ JVP  ↑ IGF-1  Armpits: acanthosis nigricans  Glucose tolerance test: non-suppression of GH  Abdomen: organomegaly  Other pituitary hormones: TFT, PRL, testosterone  Myopathy: stand from chair w/o using hands  Glucose

Completion Imaging  Urine dip: glycosuria  CXR: cardiomegaly  ECG: LVH and ischaemia  MRI of pituitary fossa: pituitary adenoma  See any previous photographs  Hx Other  Visual perimetry

Macroglossia Complications  Acromegaly  IGT and DM  Amyloidosis  Cardiovascular disease: leading cause of death  Hypothyroidism  CRC  Down’s syn. Mx Acanthosis Nigricans  Endocrine General . Obesity and metabolic syndrome  MDT: GP, endocrinologist, neurosurgeon . DM  CV risk . Cushing’s . Acromegaly 1st line: trans-sphenoidal excision  Malignancy  Complications . Gastric Ca . Meningitis . Pancreatic Ca . Diabetes inspidus . Panhypopituitarism

2nd line: medical therapy  Somatostatin analogues: octreotide  GH antagonist: pegvisomant  Da agonists: cabergoline

3rd line: radiotherapy

Follow upyYearly  Bloods: GH, PRL  Visual fields  ECG  ± MRI head

Examination Viva

Hands Hx  Thin skin: compare ¯c your own  Symptoms  Evidence of cause: e.g. RA . Headaches . Visual disturbance Arms . Wt. gain  BP . Bruising  Cause Face . Steroid use . Smoking  Moon face: “Cushingoid facies”  Acne Causes  Hirsutism

ACTH-independent Abdomen  Steroids: commonest by far  Central obesity  Adrenal adenoma / carcinoma / hyperplasia  Purple striae  Carney complex

Extras ACTH-dependent  Proximal myopathy: stand from sitting  Cushing’s disease  Back  SCLC . Inter-scapular fat pad . Palpate spine for tenderness (crush #) Ix . Kyphosis Urine dip: glycosuria Completion  Urine dip: glycosuria Confirm ↑ cortisol  Visual fields: bitemporal hemianopia  24h urinary free cortisol  Respiratory exam: wheeze, fine crackles  Loss of diurnal variation: ↑ midnight cortisol  Low dose-dexamethasone suppression test Significant Negative  Pigmentation Investigate Cause  Signs of cause: RA, clubbing, COPD  ACTH levels . ↑: pituitary adenoma or ectopic ACTH . ↓: iatrogenic or adrenal Differential  High-dose dexamethasone suppression test  Cushing’s syndrome: effects of ↑ corticosteroids . >50% cortisol suppression if pituitary adenoma  Cushing’s disease  MRI pituitary fossa ± whole body CT . Bilateral adrenal hyperplasia 2O to ACTH-  Bilateral inferior petrosal sinus vein sampling secreting pituitary tumour . Distinguish between ectopic ACTH and CD. . Usually a basophilic microadenoma

Complications  Steroid complications  Osteoporosis  HTN and CV risk

General Mx  Control BP  Anti-DM  Bisphosphonates

Cause  Pituitary adenoma: trans-sphenoidal excision  Adrenal adenoma: adrenelectomy  Ectopic ACTH . Tumour excision . Metyrapone: inhibits cortisol synthesis

Examination Viva

Main Signs Hx  Medic alert bracelet  Symptoms  Hyperpigmentation . Wt. loss + anorexia . Palmar creases . Lethargy, depression . Scars . Dizziness, faints . Buccal mucosa  Cause  Postural hypotension . Other AI disease: DM, vitiligo . TB Extras  Signs of AI disease . DM Ix . Vitiligo . Hyperthyroidism Bloods  Signs of TB  U+E: ↓Na, ↑K  ↓ glucose  Abs: 21-hydroxylase (+ve in 80% ¯c AI disease)

Confirm Dx  8am cortisol: low  8am ACTH: high  SynACTHen test: no ↑ in cortisol

Other  CXR: TB  AXR: adrenal calcification

Acute  0.9% NS IV rehydration  100mg hydrocortisone IV  Rx cause: e.g. infection

Chronic  Replace . Hydrocortisone . Fludrocortisone  Pt. education and advice . Don’t stop steroids suddenly . ↑ dose during illness / stress . Wear medic alert bracelet . Carry steroid card

Side Effects Hemiballismus

MSK Features  Proximal myopathy  Involuntary flinging motions of the extremities  Osteoporosis  Continuous and random  Isolated to one side of the body Endocrine  HPA suppression Cause  Obesity  Damage to the subthalamic nucleus  DM . Usually a small infarct in diabetics . MS Metabolic  Na and fluid retention Mx  HTN  Often resolves spontaneously  Hypokalaemia  Haloperidol

Immune  ↑ susceptibility to infection Benign Essential Tremor

CNS Features  Depression  Action / postural tremor  Psychosis . Worse with movement  Exacerbating factors Eye . Anxiety  Cataracts . Caffeine  Glaucoma  Relieving factors . Alcohol . Sleep Management Considerations  Use steroid-sparing agents where possible Cause  Use lowest dose possible  Autosomal dominant  Don’t stop suddenly or rapidly ↓ dose . Withdraw gradually if used >2-3wks Mx  ↑ dose if stressed: illness or trauma  Alcohol  Caution ¯c other drugs: e.g. NSAIDs  Propranolol Primidone: anti-epileptic  Consider osteoporosis and PUD prophylaxis 

Advice to Patients  Don’t stop steroids suddenly  Consult doctor when unwell  Carry a steroid card / alert bracelet  Avoid OTCs: e.g. NSAIDs

Contents Superficial Lesions ...... 91 Abdomen ...... 105 Breast ...... 128 Vascular ...... 134 Musculoskeletal ...... 150 Practical Surgery ...... 168 Surgical Radiology ...... 178 Instruments ...... 195 Key Anatomy ...... 217

Contents Lump Examination ...... 92 Skin Lumps ...... 93 Goitre ...... 95 Diffuse Goitre: Key Facts ...... 96 Solitary Thyroid Nodules ...... 97 The Neck ...... 98 Midline and Anterior Triangle Lumps ...... 99 Posterior Triangle Lumps ...... 100 Cervical Lymphadenopathy ...... 101 Salivary Glands ...... 102 Hypertrophic and Keloid Scars ...... 103 Digital Clubbing ...... 103

Key Points

Site Colour Tenderness Fluctuance Size Consistency Temperature Pulsatility Shape Contour Transilluminence Spread (LNs) Cough impulse Tethering

Notes  Is it intradermal or subcutaneous? . Intradermal  Cannot draw skin over lump  Sebaceous cyst, neurofibroma, dermatofibroma . Subcutaneous  Can move lump independently from skin  Lipoma, ganglion, lymph node  Fluctuance: assess ¯c press test  Consider auscultating for bowel sounds or bruits (AVMs).

Completion  Examine draining lymph nodes  Examine neurovascular function distal to lump.  Look for similar lumps elsewhere

Onset  When and why did you notice it?  Any predisposing event: e.g. trauma?

Continued Symptoms  What symptoms does it cause: e.g. pain?  How has it changed?  Have you noticed other lumps?

Treatments and Cause  What treatments have you tried?  What do you think the cause is?

Lump Pathology Features Viva Mx Lipoma Benign tumour of mature adipocytes Inspection Occur anywhere fat can expand Dercum’s Disease / Adiposis dolorosa Non-surgical - i.e. NOT scalp or palms - Multiple, painful lipomas Sarcomatous change probably doesn’t - inc. spermatic cord, - Assoc. peripheral neuropathy Surgical Excision occur. submucosa - Obese, postmenopausal women

Liposarcomas arise de novo May be a scar from recurrence Familial Multiple Lipomatosis - Older pts. - Deeper tissues of the lower limbs Madelung’s Disease Palpation Soft Subcutaneous Bannayan-Zonana Syndrome Imprecise margin - Autosomal dominant Fluctuant - Multiple lipomas - Macrocephaly - Haemangiomas

Sebaceous Epithelial-lined cyst containing keratin Inspection Occur @ sites of hair growth Complications Non-surgical cyst - Scalp, face, neck, chest, back - Infection: pus discharge Two histological subtypes - NOT soles or palms - Ulceration Surgical Excision Central Punctum - Calcification 1) Epidermal Cyst - Arise from hair follicle infundibulum Cock’s Peculiar Tumour - Large ulcerating trichilemmal cyst 2) Trichilemmal Cyst / Wen Palpation Firm on the scalp - Arise from hair follicle epithelium Smooth - Resemble an SCC - Often multiple Intradermal - May be autosomal dominant Gardener’s Syndrome: FAP + - Thyroid tumours - Osteomas - Dental abnormalities - Epidermal cysts

Ganglion Cystic swelling related to a synovial-lined Inspection Can be found anywhere Differential Non-Surgical structures: joint, tendon Often dorsum of hand or wrist - Bursae - Aspiration followed by May be scar from recurrence - Cystic protrusion from synovial cavity of 3wks of immobilisation Myxoid degeneration of fibrous tissue Weakly transilluminable arthritic joint. Surgical Excision Contain thick, gelatinous material Palpation Soft - Recurrence in 50% Subcutaneous - Neurovasc damage May be tethered to tendon Seborrhoeic Benign hyperplasia of basal cell layer Stuck on appearance Non-surgical keratosis - Hyperkeratosis: corneum thickening Dark brown Surgical: superficial shaving or cautery - Acanthosis: spinosum thickening Greasy - Hyperplasia of basal cells

Lump Pathology Features Viva Mx Neurofibroma Benign nerve sheath tumour arising Inspection Solitary or multiple NF 1: von Recklinghausen’s Surgical excision only from schwann cells. Pedunculated nodules - AD, Chr 17 indicated if malignant - Cafe-au-lait spots (>6, >15mm) growth suspected. Palpation Fleshy consistency - Freckling Pressure can → paraesthesia - Neurofibromas Local regrowth is common Extras Examine skin: Café-au-Lait Spots - Lisch nodules (iris) Examine the eyes: Lisch nodules Examine the axilla: Freckles Examine the cranial nerves (esp. 8) BP

Papilloma Overgrowth of all layers of the skin ¯c a Skin tag / fibroepithelial polyp Excision + diathermy to central vascular core. control bleeding. Pedunculated Flesh coloured

Pyogenic Rapidly growing capillary haemangioma. Inspection Most commonly on hands, face, gums Possible assoc. ¯c prev trauma Non-surgical granuloma and lips. More common in pregnancy - regression is uncommon Neither pyogenic, nor a granuloma Bright red hemispherical nodule May have serous / purulent discharge Surgical Palpation Soft - curettage ¯c diathermy of Bleed very easily the bases

Dermoid Cyst Epidermal-lined cyst deep to the skin Inspection Smooth spherical swelling Child / young adult: congenital Congenital Sites of embryological fusion - CT to establish extent Congenital / Inclusion Cyst Scar from recurrence Adult: acquired - Surgical excision - Developmental inclusion of - Ask re. trauma epidermis along lines of skin fusion Acquired - Midline of neck and nose - Surgical excision - Medial and lateral ends of eyebrows Palpation Soft Non-tender Acquired / Implantation Cyst Subcutaneous - Implantation of epidermis in dermis - Often 2O to trauma (e.g. piercing)

Dermato- Benign neoplasm of dermal fibroblasts Inspection Can occur anywhere Differential Excision + histology fibroma Mostly on the lower limbs of young to - Malignancy: melanoma, BCC middle-aged women

Small, brown pigmented nodule Palpation Firm, woody feel: characteristic Intradermal: mobile over deep tissue

Kerato- Benign overgrowth of hair follicle cells Fast-growing Regress w/i 6wks acanthoma Cytologically similar to well-differentiated Dome-shaped ¯c a keratin plug Excise to reduce scarring SCCs Intradermal and obtain histology © Alasdair Scott, 2012 94 Goitre

Thyroid Examination Viva

Preparation Goitre Differential  Ensure exposure down to the clavicles  Position pt. away from a wall Diffuse Enlargement  Are you comfortable: not too hot or cold?  Smooth  Hoarse voice: recurrent laryngeal nerve palsy . Simple colloid goitre . Graves General Inspection . Thyroiditis: Hashimoto’s, de Quervain’s, Riedel’s  Nervous/agitated or slow/lethargic  Nodular . Multinodular goitre  Body habitus . Multiple adenomas  Sweaty

 Skin and hair condition Solitary Nodule

 Dominant nodule of a multinodular goitre Hands  Adenoma  Thyroid acropachy  Malignant  Palmar erythema O . 1 : papillary, follicular, medullary, anaplastic  Temperature, sweating . 2O: breast  Fine tremor: piece of paper on out-stretched hands  Cyst  Pulse: rate and rhythm (AF in thyrotoxicosis) Commonest Causes of Eyes  Sympathetic Overstimulation Hyperthyroidism . Lid Retraction: sclera between iris and upper lid  Graves’ (~2/3) . Lid Lag  Toxic Multinodular Goitre ( = Plummer’s)  Graves . Oedema: periorbital and chemosis Hypothyroidism . Exophthalmos: inspect from above and side  Primary atrophic . Ophthalmoplegia: esp. upgaze palsy  Hashimoto’s thyroiditis  Iodine deficiency: commonest Worldwide Exophthalmos Differential  Orbital cellulitis Hx  Trauma  Thyroid status  Masses: meningioma, glioma  Compression symptoms: dysphagia, difficulty breathing  Carotid cavernous fistula: pulsatile exophthalmos  Previous thyroid medications or surgery  Idiopathic orbital inflammatory disease

Neck Ix

Inspect: from front and side. Bloods  TFTs: TSH, fT3, fT4  Look for collar scars 2+  Ask pt. stick out tongue and swallow water  Other: FBC, Ca , calcitonin, ESR  Look in mouth for lingual thyroid  Antibodies: anti-TPO, TSH

Palpate: from behind Imaging  Palpate masses: can you get under it?  CXR: goitre and mets  Repeat the swallow and protrusion test  High resolution US  Lymphadenopathy  CT  Check for tracheal deviation.  Radionucleotide (Tc or I) scan: hot vs. cold

Percuss: for retrosternal extension Histology or cytology  FNAC (can’t distinguish adenoma vs. follicular Ca) Auscultate: thyroid bruits (Graves’)  Biopsy

Legs Laryngoscopy  Pretibial myxoedema: brown swelling above lat. malleoli  Important pre-op to assess vocal cords  Proximal myopathy: ask pt. to stand from chair (Graves)  Ankle reflexes: kneel on chair Discussion . Slow relaxing: hypothyroidism  Multinodular goitre . Brisk: hyperthyroidism  Graves’  Thyroiditis Completion  Thyroid Nodules  Observation chart  Thyroid surgery  History © Alasdair Scott, 2012 95 Diffuse Goitre: Key Facts

Multinodular Smooth

Features Simple Colloid Goitre  Commonest goitre in UK  Hyperplasia of gland 2O to ↑TSH release  Progression of simple diffuse goitre to nodular enlargement. Causes  Middle-aged women  Iodine deficiency: commonest worldwide  Positive family Hx  ↑ physiological demand: pregnancy, puberty  Over-activity in parts may → mild thyrotoxicosis  Goitrogens: e.g. Li, uncooked cabbage . Plummer’s Syndrome  Malignant change occurs in 5% of untreated MNGs Rx  Not usually required Mx  Thyroxine or ↑ dietary iodine  Most pts. don’t require intervention

Non-Surgical Grave’s Disease: ↑ uptake  Thyroxine → regression in 50-70% . Suppress TSH Epidemiology  Toxic Multinodular Goitre  Prev: 0.5% . Propranolol + carbimazole . 60% of cases of thyrotoxicosis . Radioiodine  Sex: F>>M=9:1  Age: 40-60yrs Surgical  Indications: 5 Ms Features . Mechanical obstruction  Diffuse goitre ¯c bruit . Malignancy  Triggers: stress, infection, child-birth . Marred beauty: cosmetic reasons  Ophthalmopathy . Medical Rx failure: thyrotoxicosis . Oedema: periorbital and chemosis . Mediastinal extension: can’t monitor changes . Exophthalmos → exposure keratopathy  Procedure . Ophthalmoplegia: esp. upgaze palsy . Total thyroidectomy . Optic neuropathy: ↓ acuity and RAPD . Removes risk of malignant change in thyroid  Dermopathy: pre-tibial myxoedema remnant.  Acropachy: periosteal reaction (clubbing is soft tissue)

Pathology of Eye Disease Plummer’s vs. Graves  Exophthalmos . Retro-orbital inflammation and lymphocytic Plummer’s Graves’ infiltration → orbital oedema  Older  Younger . 2O to anti-TSH abs  Nodular enlargement  Diffuse enlargement  Lid-lag  No extra features  Extra Features . Not Graves’ specific . Eye signs . Sympathetic overstimulation → restrictive . Dermopathy myopathy of LPS . Acropachy  AF in 40%  AF relatively uncommon Associations  No assoc. AI disease  Assoc. ¯c AI disease  T1DM  Vitiligo  Pernicious anaemia

Rx  Medical: propranolol + carbimazole  Radioiodine  Surgical: subtotal or total thyroidectomy

Thyroiditis: ↓ uptake  Hashimoto’s  de Quervain’s  Subacute lymphocytic: post-partum  Riedel’s

Pathology Features Mx Follicular Adenoma 2-4cm mass Hot ± thyrotoxicosis - <3cm: radioiodine Indistinguishable from follicular Ca on FNAC - >3cm: surgical excision - need excision histology to confirm Dx Cold: excision Thyroid Cyst True cysts are rare Cytology can be false negative in 30% Mostly colloid degeneration, necrosis or <4cm: aspirate and review in 6/12 haemorrhage w/i benign or malignant tumours Surgical Excision Only benign if abolished by aspiration - >4cm - Blood-stained aspirate - Recurrence after aspiration

Malignant

Disease Frequency Age Cell Origin Spread Mx Papillary 80% 20-40 Follicular cells Nodes and lung Total thyroidectomy + - JDG node = T4 to suppress TSH Assoc. ¯c Tg tumour marker lateral aberrant ± node excision irradiation thyroid ± radioiodine

May be multifocal >95% 10ys Follicular 10% 40-60 Follicular cells Blood → bone Total thyroidectomy + F>M = 3:1 and lungs T4 suppression + Tg tumour marker Radioiodine

>95% 10ys Medullary 5% MEN2: young Parafollicular C-cells Do phaeo screen pre-op 30% are familial Sporadic: 40-50 Thyroidectomy + - e.g. MEN2 CEA and calcitonin Node clearance markers Consider radiotherapy Anaplastic Rare >60 Undifferentiated Rapid growth Usually palliative F>M = 3:1 follicular cells Aggressive: local, May try thyroidectomy + LN and blood. radiotherapy

<1% 10ys Lymphoma 5% Lymphocytes Chemoradiotherapy - MALToma in Hashi’s

Thyroid Nodule Facts Complications of Thyroid Surgery  F>M = 4:1  4th and 5th decades Early  10% malignant in middle aged  Reactionary haemorrhage → haematoma  50% malignant in young and elderly  Recurrent laryngeal nerve palsy  FNAC is most important Ix  Hypocalcaemia  Thyroid storm Ix: Triple Assessment  Clinical examination Late  US  Hypothyroidism and hypoparathyroidism  FNAC  Recurrence of disease  Keloid scar Isotope scan: used if pt. is hyperthyroid

Men 1: Wermer Syndrome Practicalities of Thyroid Surgery  Pituitary adenoma  Render euthyroid pre-op ¯c antithyroid drugs  Parathyroid hyperplasia or adenoma  Stop 10 days prior to surgery (they ↑ vascularity)  Pituitary endocrine tumour  Alternatively just give propranolol  Check for phaeo pre-op in medullary carcinoma Men 2  Laryngoscopy: check vocal cords pre- and post-op  Medullary thyroid Ca  Phaeochromocytoma  A: hyperparathyroidism  B: marfanoid habitus © Alasdair Scott, 2012 97 The Neck

Examination Differential

Position Solid Cystic Preparation Anywhere Lipomas and Sebaceous Cysts  Ensure exposure down to the clavicles Midline Ectopic thyroid tissue Thyroglossal Cyst  Position pt. away from wall Thyroid isthmus mass Inclusion dermoid Ant. Triangle LNs Branchial Cyst Inspect: Scars, Sinuses, Masses Chemodectoma Laryngocele  Neck Goitre . Look very carefully for scars: collar incision Parotid tumour . Look for masses: which triangle? Post. Triangle LNs Cystic Hygroma . Does mass move on swallowing or tongue Cervical Rib Pharyngeal Pouch protrusion? Pancoast tumour  Mouth . Lingual thyroid . Ranula (ruptured salivary gland → mucocele) Ix  Eyes  US shows consistency . Thyroid eye disease  FNAC or core biopsy  Consider CT / MRI to define relations

Palpate  Best from behind the pt. Hx  Palpate while pt. swallowing and protruding tongue  Assess for lymphadenopathy Onset  Tracheal deviation  When and why did you notice it?  Any predisposing event: e.g. trauma?

Percuss Continued Symptoms  Retrosternal extension  What symptoms does it cause: e.g. pain?  How has it changed?  Have you noticed other lumps? Auscultate Treatments and Cause  Listen over lump for bruits.  What treatments have you tried?  Gurgle of pharyngeal pouch  What do you think the cause is?

If no obvious masses / skin lesions  Check neck pulses and listen for bruits  Test sensation and neck movements

Completion  If goitre → asses thyroid status  Lump history

Lump Pathology Presentation Viva Mx Thyroglossal Cyst Persistence of any part of the thyroglossal duct Young pt. Differential Sistrunk’s Operation which marks the developmental descent of the - Thyroid nodule and masses - Inject patent tract ¯c dye at start thyroid from the foramen caecum Fluctuant midline neck lump - Dermoid / epidermal cysts - Excise cyst and patent tract Usually subhyoid - Subhyoid bursa - Need to central portion of hyoid Ectopic thyroid tissue can be found anywhere as tract runs through it. along this path of descent. Protrusion of tongue → elevation Epidemiology Swallowing → elevation - Rare Cysts may contain thyroid tissue which can - M=F undergo malignant change → papillary Ca May see opening of a thyroglossal - 40% in 1st decade sinus Complications Following removal there will be a - Infection transverse incision just above the - Sinus formation thyroid cartilage. - Development of Ca - Recurrence post-op

Branchial Cyst Failed fusion of 2nd and 3rd branchial arches Young pt. Complications Surgical Excision - Infection - Bonney’s blue dye can be Lined by squamous epithelium Ant. margin of SCM at junction of - Sinus formation injected into fistula to allow more upper and middle thirds - Recurrence post-op accurate excision Contain “glary” fluid ¯c cholesterol crystals - May be difficult due to proximity Firm, fluctuant ovoid swelling of carotids

Opaque on transillumination Medical - Sclerotherapy is an option May be opening from branchial sinus

Chemodectoma Very rare Ant. triangle @ the angle of the jaw Ix Surgical Excision - Duplex US Tumour of the paraganglion cells of the carotid Pulsatile - Angiography: splaying Ultrasonic surgical dissection bodies: measure pH and PaO2 and PaCO2 - CT / MRI Moves laterally but not vertically Radiotherapy Located @ the carotid bifurcation - Large tumours Pressure can → syncope - Unfit for surgery Mostly benign (5% malignant) May be bilateral

Lump Pathology Presentation Viva Mx Cystic Hygroma Congenital multicystic lymphatic malformation Usually paediatric Complications Surgical excision Lobulated cystic swelling - Obstruction of swallowing Hypertonic saline sclerosant Soft and fluctuant - Respiratory obstruction Compressible Transilluminate brilliantly ↑s in size when infant coughs / cries

Look in the oropharynx - Cyst may extend into retropharyngeal space

Pharyngeal Pouch Herniation of pharyngeal mucosa through its Elderly patient Symptoms Non-surgical muscular coat at its weakest point. - Regurgitation - If small and asymptomatic - Pulsion diverticulum Left sided cystic swelling - Dysphagia Surgical: Dohlman’s Procedure Killian’s dehiscence Palpation → gurgling Complications - Minimally invasive endoscopic - Between thyro- and crico-pharyngeal muscles - Aspiration → pneumonia stapling that form the inferior constrictor Hallitosis - Diverticular neoplasia (<1%)

Ix - Ba swallow

Cervical Rib Overdevelopment of transverse process of C7 Hard swelling: mostly asymmpto Surgical excision

Occur in 1:150 Can → vascular symptoms - Due to subclavian A. compression - Subclavian steal - Raynaud’s

Can → neurological symptoms - Compress lower roots of brachial plexus, T1 or stellate ganglion - Wasting of intrinsic hand muscles - Paraesthesia along medial arm

Examination Viva

Key Features History  Consistency  Symptoms from the lumps  Number . e.g. EtOH-induced pain  Fixation  General symptoms  Symmetry . Fever, malaise, wt. loss  Tenderness  Systemic disease  PMH Technique  Previous operations  Ask pt. to drop chin to relax muscles  Social history  Chin backwards → pre-auricular  Ethnic origin  Down anterior cervical chain  HIV risk factors  Supra- and infra-clavicular nodes  Up posterior cervical chain  Mastoid → occipital nodes Causes: LIST  Lymphoma and Leukaemia Additional Examination  Infection  Face and scalp for infection or neoplasm  Sarcoidosis  Chest exam: infection or neoplasm  Tumours  Breast examination . ENT  Formal full ENT examination . Breast . Lung  Rest of reticuloendothelial system . Gastric

Infection  Bacterial . Tonsillitis, dental abscess . TB . Bartonella henselae (Cat scratch disease)  Viral . EBV . HIV  Protozoal . Toxoplasmosis

Blood  FBC, ESR, film (atypical lymphocytes)  TFTs, serum ACE  Monospot test, HIV test

Radiological  US  CT scan

Pathology  FNAC  Excision biopsy

Examination Viva

Inspection Hx  Skin changes: swelling, scars, sinuses  Pain or swelling related to food: calculi  Swelling / discrete lump  Fever / malaise: mumps . Parotid or submandibular?  Dry eyes / mouth: Sjogren’s . Bilateral or unilateral?  SOB: sarcoid  Facial asymmetry  Inside the mouth ¯c a pen torch nd . Stenson’s duct opposite the 2 maxillary molar Salivary Gland Neoplasms . Wharton’s duct adjacent to the frenulum linguae . Inflammation, stone, pus Features  80% in the parotid gland  80% benign: 80% are pleiomorphic adenomas Palpation  Only 60% of submandibular gland tumours are benign  Any tenderness?  Palpate from behind Common Types  Test muscle fixity: ask pt. to clench teeth  Benign  Palpate for cervical lymphadenopathy . Pleiomorphic adenoma: 80%  <50yrs . Adenolymphoma: Warthin’s tumour Completion  >50yrs  Bimanual palpation of parotid and submandibular ducts  Smoking is important risk factor for stones.  Malignant st  Bimanual palpation of submandibular gland . 1 : Mucoepidermoid nd  Test CN7 . 2 : Adenoid cystic  Perform full ENT examination

Malignant Features Differential  Facial nerve palsy  Rapid growth and pain Diffuse Swelling of Whole Gland  Hyperaemic, hot skin  Infection: Parotitis  Hard consistency  Autoimmune: Sjogren’s  Fixity to skin or underlying muscle  Infiltration: Sarcoid  Systemic: Chronic liver disease, DM, anorexia, bulimia Ix  FNAC Localised Swelling  MRI: determine deep lobe involvement  Calculus  Lipoma Rx  Salivary gland neoplasm  Benign  Leukaemia: ALL . Superficial: superficial parotidectomy . Deep: total parotidectomy  Malignant . Total parotidectomy ± adjuvant radiotherapy

Complications  Immediate . Facial nerve injury . Reactionary haemorrhage  Early . Temporary facial weakness: neuropraxia . Salivary fistula . Loss of pinna sensation: greater auricular nerve damage.  Late: Frey’s Syndrome (gustatory sweating) . Facial sweating while eating . Re-innervation of divided sympathetic nerves by fibres from the secretomotor branch of auriculotemporal branch of CNV3

Features Causes  Scar more prominent than surrounding skin Gastrointestinal  CLD: esp. PBC Hypertrophic  IBD: esp. Crohn’s  Scar confined to wound margins  Coeliac disease  Across flexor surfaces and skin creases  GI lymphoma  Appear soon after injury and regress spontaneously  Any age: commonly 8-20yrs Respiratory  M=F  Chronic suppurative lung disease  All races . CF / bronchiectasis . Abscess . Empyema Keloid  Malignancy: adenocarcinoma or mesothelioma  Scar extends beyond wound margins  Pulmonary fibrosis  Earlobes, chin, neck, shoulder, chest  Appear months after injury and continue to grow Cardiac  Puberty to 30yrs  Infective endocarditis  F>M  Congenital cyanotic heart disease  Black and Hispanic . Fallot’s . Transposition  Atrial myxoma: e.g. in Carney Complex Wound Associations  Infection Miscellaneous  Trauma  Familial  Burns  Thyroid acropachy  Tension  Axillary artery aneurysms and brachial AVMs  Certain body areas

Pathophysiology Mx  Exact aetiology unknown  Platelet clumps and megakaryocytes bypass the lungs Non-surgical and impact in digital capillaries.  They release growth factors such as PDGF → clubbing  Mechanical pressure therapy

 Topical silicone gel sheets

 Intralesional steroid and LA injections Stages Surgical  1: bogginess of the nail bed  2: loss of the nail angle  Revision of scar ¯c closure by direct suturing  3: ↑ curvature

 4: expansion of the distal phalanx

Contents Abdominal Examination ...... 105 Inguinal Hernia ...... 106 Inguinal Hernia: Key Facts ...... 107 Incisional Hernia ...... 108 Umbilical and Paraumbilical Hernia ...... 109 Epigastric Hernia ...... 110 Examination of a Scrotal Lump ...... 111 Hydrocele ...... 112 Epididymal Cyst ...... 113 Varicocele ...... 113 Testicular Tumour ...... 114 Stomas ...... 115 Stomas: Key Facts ...... 116 Surgical Scars ...... 117 Colonic Resections ...... 119 Inflammatory Bowel Disease ...... 122 IBD: Key Facts for Surgery ...... 123 Surgical Jaundice...... 124 Right Iliac Fossa Mass ...... 125 Abdominal Masses...... 126

Set-Up The Abdomen  Pt. exposed from nipples to pubis  Lying flat Inspection  Distension: fat, fluid, flatus, faeces, foetus Peripheral Stigmata  Scars: describe location and healing  Stomas: site, contents, lumens, spout General  Drains: contents, type  General condition of the pt.  Asymmetry: masses . Jaundice (BR >50mM), pallor (Hb <7g/dL) . Cachexia  Abdominal distension Palpation  Abdominal asymmetry  Kneel on floor and look @ pts. face for pain  Drains, stomas, scars . Superficial, then deep  Ask pt. to cough and lift head from bed . Describe any masses  Liver Hands . Note consistency, edge, tenderness, pulse . Percuss CLD Abdominal Clubbing ∆∆  Spleen . Role pt. towards you 1. Clubbing  Cirrhosis: esp. c PBC ¯ . Percuss if palpable 2. Leukonychia  IBD 3. Terry’s nails  Kidneys  Coeliac . White ground glass nail . Left then right  GI lymphoma . Loss of lunula . Ballot ¯c respiration . Pink tips  AAA 4. Palmer erythema . Just to left on midline, above the umbilicus 5. Dupuytron’s contracture 6. Asterixis Percussion Anaemia  Percuss any masses or organomegaly  Koilonychia  If distended, percuss for shifting dullness  Pale palmer creases

Pulse and BP Auscultate Face  Bowel sounds  Aortic bruits Eyes  Keiser Fleischer rings  Pale conjunctivae Palpate Ankles for Oedema  Jaundice  Xanthelasma Completion Mouth  Digital rectal examination  Telangiectasia: HHT  External genitalia  Pigmented macules: Peutz-Jehgers  Stand pt. to examine hernial orifices  Stomatitis and glossitis  Dipstick the urine  Ulceration  Look at the observation chart  Jaundice

Neck  Inspect for scars: venous lines  Sit forward and palpate for lymphadenopathy: esp. Virchow’s node in left supraclavicular fossa

Back Spider Naevi  Inspect back ¯c pt. sitting forward  Central arteriole ¯c radiating vessels  Spider naevi  Fill from the centre  Scars: e.g. loin incisions . Telangiectasia fill from edge  Distribution of SVC Chest  >4 abnormal  Spider naevi  ∆∆: CLD, OCP, pregnancy  Gynaecomastia  Loss of axillary hair

Examination Viva

Set-Up Groin Lump Differential  Expose pt. from umbilicus to knees  Begin ¯c pt. standing Tissue Lump Skin Sebaceous cyst, psoas abscess Fat Lipoma Inspection Connective tissue Fibroma  Look for any masses in groins. Ask pt. to cough. Nerves Neuroma of femoral N. LN  Comment on appearance of mass Lymphatics Saphena varix . Site, size Veins . Features of inflammation (suggesting strangulation) Arteries Femoral artery aneurysm Inguinal canal Inguinal hernia  Look for any scars Hydrocele or lipoma of the cord . Previous hernia operations Femoral canal Femoral hernia . Appendicectomy: ? risk factor for direct hernia Testes Undescended testis

4 distinguishing features of an inguinal hernia Palpation  Above and medial to pubic tubercle  Check if pt. in any pain.  Cough impulse  Palpate from the side of the pt.  Reducible  Palpate mass for cough impulse  Bowel sounds  Define anatomy: relation to pubic tubercle? . Above (and medial): inguinal hernia Hx . Below (and lateral): femoral hernia  Predisposing factors: cough, straining, lifting  Does mass extend into scrotum? . Inguinoscrotal hernia are more likely to be indirect  Pain  Auscultate for bowel sounds  Reducible . Hernia may lack bowel sounds if it just contains fat.  Episodes of obstruction or strangulation  Previous repairs

Repeat Inspection and Palpation c pt. Supine ¯ Mx  Does the mass disappear when lying down? Conservative  Manage RFs: e.g. constipation, cough Test for Direct vs. Indirect Hernia  Weight loss  Ask pt. to reduce hernia  Elasticated corset or truss  Place 2 fingers over deep ring and ask pt. to cough. . Mid pt. of ing. lig. or 1.5cm above femoral pulse Surgical . Hernia controlled = indirect  Open: Lichtenstein Tension Free Mesh . Not controlled = direct  Lap: TEP or TAPP mesh  Not an accurate test: definitive determination in theatre.

Discussion Wash hands  Difference between direct and indirect inguinal hernia  Difference between inguinal and femoral hernias  Inguinal canal anatomy Complete Examination  Contents of the spermatic cord  Examine external genitalia: incidental lumps, testes  Recovery from inguinal hernia repair  Examine contralateral groin  Operative techniques  Examine abdomen  Complications of repair . Evidence of ↑ IAP: masses, ascites . Other hernias: paraumbilical, umbilical

Definition Surgery  Protrusion of a viscus or part of a viscus into an abnormal  Open and lap approaches: lap if bilateral / recurrent position through a defect in its containing cavity.  Mention risk of testicular damage when consenting pt.

Anatomy Open  Open can be done under LA or GA: day case

 RCS recommends the Lichtenstein Tension Free Inguinal Canal Mesh Repair  Ant: ext. oblique + int. oblique for lateral 3rd rd . Less recurrence cf. older Shouldice Repair  Post: transversalis fascia + conjoint tendon for medial 3  Floor: inguinal ligament NB. In children, simple ligation and division of the patent  Roof: arching fibres of transversus and int. oblique processus suffices: no mesh needed.

Femoral Canal Lap  Med: lacunar ligament  2 main techniques  Lat: femoral vein . Totally ExtraPeritoneal (TEP)  Ant: inguinal ligament . Trans-Abdominal Pre-Peritoneal (TAPP)  Post: pectineal ligament (of Cooper)  Better for bilateral hernia  Contents: fat and Cloquet’s Node Complications Contents of Inguinal Canal  M: spermatic cord + ilioinguinal N. Early  F: round lig., ilioinguinal N., gen branch of genfem N.  Urinary retention  Haematoma / seroma formation: 10% Contents of Spermatic Cord  Infection: 1%  3 layers of fascia  Intra-abdominal injury (lap)  3 arteries + 3 veins Late  2 nerves  Recurrence: <2%  3 other things  Ischaemic orchitis: 0.5% . 2O thrombosis of pampiniform plexus Operative Distinction  Chronic groin pain / paraesthesia: 5%  Indirect: arise lateral to inf. epigastric vessels  Direct: arise medial to inguinal ligament, through Post-Op Recovery Hesselbach’s Triangle . Med: rectus abdominis muscle  Pee before leaving . Lat: inf. epigastric artery  Early mobilisation is important . Inf: inguinal ligament  Can be painful: given good analgesia  Avoid constipation: lactulose  Keep the area clean and dry: wash carefully Classification of Inguinal Hernias  Can bathe immediately  Work in 1-2wks (6wks if heavy lifting) Indirect: 80%  Commoner in young  Congenital patent processus vaginalis Femoral Hernia  Emerge through deep ring  Commoner in females (wider femoral canal)  Same 3 coverings as cord and descend into the scrotum  Middle aged and elderly  Can strangulate  Neck is inferior and lateral to pubic tubercle  High risk of obstruction and strangulation Direct: 20%  Commoner in elderly Mx  Acquired: weak posterior wall of canal  50% risk of strangulation w/i 1mo  Emerge through Hesselbach’s triangle  Urgent surgery  Can acquire internal and external spermatic fascia  Rarely descend into scrotum Elective: Lockwood Low Approach  Rarely strangulate  Low incision over hernia ¯c herniotomy and herniorrhaphy (suture ing. ligt. to pectineal ligt.) Clinical Distinction  Cameron, BJS 1994 Emergency: McEvedy High Approach  56% of direct hernias were wrongly classified as indirect on  High approach in inguinal region to allow inspection examination by consultant surgeons. and resection of non-viable bowel.  Then herniotomy and herniorrhaphy

Examination Viva

Inspection Hx  Pt. may be overweight  Previous surgery  Describe scars + drain sites  Post-operative wound infection or other complications  Any evidence of inflammation (e.g. from strangulation)  Co-morbidities → ↑ risk: e.g. chronic cough  Ask pt. to lift head off bed  Discomfort or episodes of obstruction  Ask pt. to cough

Palpation Definition  Any tenderness?  Extrusion of peritoneum and abdominal contents through  Feel for presence of defect a previously acquired defect.  Ask pt. to cough while feeling for an impulse  Is the defect present along the whole length of the scar? . Size of defect relates to risk of strangulation Complications  If a lump is present, can it be reduced?  Intestinal obstruction: often intermittent  Become irreducible Auscultate  Strangulation  For bowel sounds  Pain or discomfort

Risk Factors

Pre-operative  ↑ age  Comorbidities: DM, renal failure  Drugs: steroids, chemo, radio  Obesity or malnutrition  Malignancy

Intra-operative  Surgical technique/skill (major factor)  Too small suture bites  Inappropriate suture material  Incision type (e.g. midline)  Placing drains through wounds

Post-operative  ↑ IAP: chronic cough, straining, post-op ileus  Infection  Haematoma

Mx  Surgery is not appropriate for all patients.  Must balance risk of operation and recurrence ¯c risk of obstruction / strangulation and pt. choice.  Usually broad-necked  low risk of strangulation

Conservative  Manage RFs: e.g. constipation, cough  Weight loss  Elasticated corset or truss

Surgical  Pre-Op  Optimise cardiorespiratory function  Encourage wt. loss  Nylon mesh repair: open or lap

Examination Viva

Inspection Hx  Pt. may be overweight  Predisposing factors: pregnancy, ascites, obesity  Ask pt. to lift head off bed and to cough  Pain  Note any associated skin damage: e.g. ulceration  Reducible  Note any overlying scars: may indicate recurrence  Episodes of obstruction or strangulation  Previous repairs Palpation  Any tenderness?  Feel for presence of defect Paraumbilical  Try to asses size  Ask pt. to cough while feeling for an impulse Pathogenesis  If a lump is present, ask pt. to reduce it.  Acquired defect in the linea alba just above or below the umbilicus  Commoner in obese, middle-aged pts.  Neck is commonly narrow  Prone to becoming irreducible or strangulated  Typically contain omentum ± large or small bowel  May be large → necrosis of the skin

Risk Factors  Obesity  Pregnancy  Ascites  Fibroids  Bowel distension

Mx  Surgery advised due to high risk of strangulation  Rx concurrent medical problems  Mayo Repair . Mobilise sac and reduce contents . Double-breast the linea alba ± sublay mesh

Umbilical

Pathogenesis  Congenital defect in the umbilical scar (cicatrix)  Typically congenital: 3% of live births

Risk Factors  Afro-Caribbean  Trisomy 21  Congenital hypothyroidism

Can recur in adults: pregnancy, ascites

Mx  Usually asymptomatic and resolve by 2-3yrs  Surgical repair advocated if no resolution by 3yrs

Other Congenital Defects

Gastroschisis  Protrusion of abdo contents through defect in abdo wall to the right of the umbilicus.  Not usually assoc. ¯c other abnormalities  Promt surgical repair after fluid resuscitation

Exomphalos  Protrusion of abdominal contents w/i in a 3-layered sac  Commonly assoc. ¯c other defects: cardiac, anencephaly © Alasdair Scott, 2012 109 Epigastric Hernia

Examination Viva

Inspection Hx  Midline lump above the umbilicus when the pt. coughs or  Predisposing factors: pregnancy, obesity lifts head from bed.  Symptoms  Typically small: “pea shaped”  Reducible  Associated scars?  Episodes of obstruction or strangulation . Incisional hernia or previous repairs  Previous repairs

Palpation  Any pain? Features  Feel for cough impulse  Abnormal protrusion of abdominal contents through a  Establish size of the defect defect in the linea alba between the xiphisternum and umbilicus. Differential  Usually contain extraperitoneal fat or omentum  Incisional hernia: ?scar  Commoner in young (20-50yrs)  Divarication of the recti . Widening of gap between recti muscles . Not a hernia Symptoms  May be asymptomatic  May be confused for upper GI pathology  Pain: may ↑ after meals or exercise  Nausea and early satiety  Abdominal bloating

Conservative  Manage RFs: e.g. constipation, cough  Weight loss

Surgical  Reduce hernial contents and excise sac  Suture or mesh repair

Set Up  Best to examine pt. standing: won’t miss a varicocele

Inspection  Skin: scars, erythema, blue tinge, ulcers  Groin lumps or scars  Ask pt. to cough

Palpation: 4 Key Questions

1. Can you get above it?  Can’t get above an inguinoscrotal hernia

2. Is it tender?  Torted testis or hydatid of Morgagni  Epididymo-orchitis  Strangulated hernia

3. Is testis palpable separately?  No . Tumour . Orchitis . Hydrocele  Yes . Varicocele . Spermatocele / epididymal cyst

4. Does it transilluminate?  No . Tumour . Testis . Varicocele  Yes . Hydrocele . Spermatocele

Diagnostic Pathway

Can you get above it?

No Yes

Inguinoscrotal Hernia Is it separately palpable?

No Yes

Does it transilluminate? Does it transilluminate?

No Yes No Yes

Tumour Hydrocele Varicocele Epididymal cyst Orchitis Spermatocele Haematocele Sperm granuloma Epididymitis

Examination Viva

Inspection Hx  Swollen scrotum  Duration  Pain, discomfort or other symptoms Palpation  Previous testicular masses or infections  Can get above it.  Recent trauma  Cannot feel testis separately  Treatment so far  Firm / tense  Co-morbidities: e.g. heart failure  Transilluminates Definition  Accumulation of fluid w/i the tunica vaginalis  Remnant of the processus vaginalis that accompanied the testicle during its descent.  Forms one of the adult coverings of the testis

Anatomical Classification

Vaginal  Accumulation in the tunica vaginalis that doesn’t extend up the cord

Congenital  Proximal part of processus has not obliterated and the sac communicates directly ¯c the peritoneum.

Infantile  Processus is obliterated at the deep ring but still extends up the cord

Hydrocele of the Cord  Fluid accumulates around the ductus deferens.  Can be hard to distinguish from an inguinal hernia as it may extend proximal to the superficial ring.  Testicular traction will pull it inferiorly (cf. inguinal hernia)

Aetiological Classification

Primary  Caused by a patent processus vaginalis  Commonest type  Young men, large, tense

Secondary  Vaginal type can be caused by a variety of pathologies . Testicular tumours . Epididymo-orchitis . Trauma . Torsion

Ix  US to exclude malignancy

Non-Surgical  Watch-and-wait (ensure no Ca)  Aspiration: symptom relief only as will accumulate

Surgical  Lord’s Repair: plication of the tunica vaginalis  Jaboulay’s Repair: eversion of the sac

Examination Examination

Inspection Inspection  Normal appearing scrotum  Normal appearing scrotum

Palpation Palpation  Can get above it  Pt. must be standing  Separate from testis: typically above and behind  Can get above mass  Firm  Separate from testis  Transilluminates  Feels like a bag of worms . Unless it’s a spermatocele  Doesn’t transilluminate  May have palpable cough impulse  Often disappear on lying supine Viva Viva Hx  Duration Hx  Pain, discomfort or other symptoms  Duration  Treatment so far  Pain, discomfort or other symptoms  Treatment so far

Features Pathophysiology  Retention cyst of a tubule of the rete testis or the  Dilated veins of the pampiniform plexus epididymis.  98% left sided, 50% bilateral  Often multiple  1O: occur in up to 15% of young men  May contain sperm: spermatocele . Often around puberty  Generally asymptomatic . Anatomical cause: ? nutcracker syndrome  2O: varicoceles suddenly appearing in older men can be sinister Mx . Retroperitoneal disease affecting the testicular V. . E.g. renal cell carcinoma extending into L renal V. Non-surgical . Don’t disappear when pt. lies supine  If the cyst isn’t troublesome it shouldn’t be removed  There is a risk of operative damage and post-op Symptoms fibrosis → subfertility  Dragging sensation, exacerbated by exertion  Subfertility: commonest surgically correctable cause Surgical  Very large or painful cysts can be removed 98% Occur on the Left  Excision of the entire epididymis may be indicated to  Left testicular vein is more vertical where it joins the left prevent the recurrence of painful cysts. renal vein, cf. to the obliquity of the right testicular V. where it joins the IVC.  Left renal vein can be compressed by the colon  Left testicular vein is longer than the right

 Left testicular vein often lacks a terminal valve to prevent backflow.

Non-surgical  Scrotal support  Transfemoral radiological embolisation of the testicular vein

Surgical  Often advised as the problem usually gets worse ¯c age and can → subfertility  Palomo operation . High approach ¯c transverse incision slightly above and medial to ASIS . Vein exposed and ligated. . Inguinal approach: ligation of veins in the inguinal canal  Laparoscopic approach also possible © Alasdair Scott, 2012 113 Testicular Tumour

Examination Viva

Inspection Hx  Enlarged testis may be visible  Pain, discomfort  SOB: lung mets Palpation  Back pain: para-aortic node involvement  Can get above mass  Haematospermia  Inseparable from testis  Hydrocele  Hard, irregular, nodular  Previous history: tumour, infection

 Non-tender

 Doesn’t transilluminate Presentation Completion  Commonest malignancy in men 15-45yrs  Painless lump or dull ache in one testis in young man  Examine contralateral scrotum  Occasionally a Hx of trauma accompanying discovery of mass.  Abdo exam: hepatomegaly  10% present c acutely painful testis  Chest exam: thoracic mets ¯  Haematospermia  Examine for abdominal lymphadenopathy O  2 hydrocele Differential  Testicular tumour Classification  Chronic infection → scarring: orchitis, TB  95% are germ cell tumours  Chronic, calcified hydrocele  Only 50% are pure cell populations . Pure seminomatous: 50% . Non-seminomatous: teratoma is commonest  Other types include . Yolk sac: commonest testicular tumour in children . Choriocarcinoma . Leydig or Sertoli Cell  May secrete oestrogens → gynaecomastia . Lymphoma: NHL is commonest testicular mass >60yrs

Seminoma: 40% Teratoma Present 30-40yrs 20-30yrs Markers Usually normal ↑AFP + ↑βhCG in 90% Early DXT to para-aortic LNs Observation or 1-2 cycles ± single dose of cisplatin of chemo Late DXT + combi chemo: BEP Combination chemo: BEP

Ix  Tumour markers: AFP, βhCG, placental ALP  CXR: mets  US scrotum: diagnostic  CT abdomen: staging

Mx  All testicular tumours are treated ¯c orchidectomy  Groin incision ¯c early clamping of spermatic cord to prevent seeding

Seminoma  Early: DXT to para-aortic nodes  Late: DXT + combination chemo

Teratoma  Early: observation  Late: combination chemo (Bleomycin, Etoposide, cisPlatin)

Examination Viva

Inspection Definition  Site  Artificial union between conduits or between a conduit  Contents of bag and the outside. . Solid stool . Semi-formed or liquid stool Hx . Urine  Surgery  Appearance  Output . Spout  Pain . Lumens  Complications . Rod  Psychosexual function . Mucosal health  Scars . No scars suggests colonoscopy assisted Indications trephine colostomy  Exteriorisation . Perforated or contaminated bowel: e.g. Hartmann’s Palpate . Permanent: e.g. AP resection  Palpate for parastomal hernia  Diversion . Protection of distal anastomosis Complete Examination  Contamination: e.g. faecal peritonitis  Remove bag to closely inspect and digitate stoma  Anatomical: e.g. ileorectal anastomosis . No. of lumens . Acute Crohn’s . Health of mucosa and surrounding skin . Urinary diversion following cystectomy . Strictures  Decompression: bypass of distal obstructing lesion . Prolapse  Feeding: gastrostomy / jejunostomy  Examine the perineum  Lavage: e.g. appendicostomy

Quick Distinction

Ileostomy Colostomy RIF LIF Spout Flush Watery contents Formed faeces Perm: Proctocolectomy Perm: AP resection Temp: Anterior resection Temp: Hartmann’s

Discussion  Pt. preparation  Complications  Rehabilitation  Classification

Type Features Surgery Indication End Ileostomy Permanent: Panproctocolectomy (no anus) Proctocolectomy UC Temporary: Total colectomy Total colectomy ¯c later IPAA FAP Loop Ileostomy Temporary stoma to defunction distal bowel Anterior resection Colon Ca May be supported by bridge or rod Bowel rest Crohn’s

Colostomy Located in LIF or RUQ (transverse loop colostomy) Flush with skin surface

Type Features Surgery Indication End Colostomy Permanent: AP resection (no anus) AP resection Colon Ca Temporary: Hartmann’s Hartmann’s Diverticulits Loop Colostomy RUQ: Anterior resection Colon Ca Defunctioning transverse colostomy to cover a distal Decompression anastomosis: rarely performed LIF: Apex of sigmoid exteriorised w/o a resection for inoperable Ca rectum which is likely to obstruct.

Patient Preparation Patient Rehabilitation  Explanation of the indications and complications  Aim for a normal diet  Liaison ¯c Stoma Nurse to arrange siting  Good skin care and cleanliness  Psychosexual support Siting  Done ¯c pt. standing up to ensure pt. can see stoma.  Avoid Classification . Bony prominences  Anatomical classification according to location . Skin folds/creases . Tracheostomy . Waistline . Gastroscopy . Old wounds . Jejunostomy . Umbilicus . Ileostomy  Choose . Caecostomy . A site that is accessible to the pt. . Colostomy . Ideally below the belt line for concealment . Urostomy . w/i the rectus: ↓ risk of hernia or prolapse

Complications Urostomy Early  Fashioned following total cystectomy  Haemorrhage  Ischaemia Ileal Conduit: Incontinent  High output (can → ↓K+)  Ureters attached to a portion of resected ileum which is . Loperamide ± codeine to thicken output exteriorised as a spouted stoma.  Parastomal abscess  Bowel continuity maintained by primary anastomosis.  Stoma retraction  Urine collected in a bag.

Delayed Indiana Pouch: Continent  Parastomal hernia (on lateral side)  Pouch created from ~2ft of resected ascending colon and  Obstruction: adhesions or herniation through lateral portion of ileum which includes the ileocaecal valve. space around stoma  Ureters anastomosed to colonic end and ileal end  Dermatitis (esp. ileostomy) exteriorised as spouted stoma.  Stoma prolapse  Ileocaecal valve prevents urinary leak from the pouch.  Stenosis or stricture  Pt. self-catheterises to drain pouch.  Fistulae

 Psychosexual dysfunction

Examination Look For  Give correct technical name where possible  Stoma and drain scars: bowel surgery  Otherwise describe anatomical location and orientation  Vasc. access scars: AAA, graft  Comment on whether it looks well healed or recently formed  Ask pt. to lift head off bed and cough: incisional hernia  Don’t guess the operation unless asked to by the examiner.

Name Appearance Use Features Midline Laparotomy Emergency Good access - Skin - Perforated DU Bloodless line - Camper’s fascia - Trauma Minimal nerve and muscle injury - Scarpa’s fascia - Ruptured AAA - Linea alba - Hartmann’s Long midline scar - Transversalis fascia ↑ pain - Pre-peritoneal fat Elective - Peritoneum - Colectomy Closure: PDS, blunt J shaped suture, en mass - AAA Jenkin’s Rule - Vascular bypass - Length of suture = 4x length of incision - 1cm bite, 1cm apart Right Paramedian Not commonly used ~3cm lateral to the midline now as closure techniques have Rectus sheath opened and rectus displaced improved laterally. - Rectus slips back to cover the defect

Time consuming

Kocher’s (Subcostal) Open cholecystectomy

L Kocher’s used for splenectomy

Rooftop Hepatobiliary Surgery Longer to close than a midline as the incision is - liver Tx closed in 3 layers. - Whipple’s - liver resection May be modified to a Mercedes Benz incision Gastric surgery

Pfannenstiel Gynae surgery Lower Urinary Tract

McBurney’s: Oblique Appendicectomy Lanz incision favoured: hidden in skin crease Lanz: Transverse Both follow Langer’s Lines

Muscle splitting Risk of injury to ilioinguinal and iliohypogastric

- Skin nerves may predispose to inguinal hernia - Camper’s fascia - Scarpa’s fascia - External oblique - Internal oblique - Transversus - Transversalis fascia - Pre-peritoneal fat - Peritoneum © Alasdair Scott, 2012 117

Name Appearance Use Features Thoracoabdominal Oesophagogastrectomy

Transverse Muscle Right Hemicolectomy Limited access cf. midline incision Splitting ↓ damage to rectus - segmental nerve supply means the muscle can be cut transversely w/o weakening

Inguinal Hernia Open Inguinal Hernia Incision over the inguinal ligament Incision Repair Follow’s Langer’s Lines

Orchidectomy High rates of chronic neuropathic pain

McEvedy Emergency Femoral Allows inspection of peritoneal cavity ¯c easy - Modified Hernia conversion to laparotomy if necessary

“Half” a Pfannenstiel

Loin Nephrectomy

Vascular Access Bypass Embolectomy EVAR / TEVAR Stent Insertion Femoral Endarterectomy Angioplasty

Right Hemicolectomy Features

Indication: tumours in the cecum and proximal ascending colon

Scars  Midline laparotomy  Transverse muscle splitting  Laparoscopic ports

Stoma: none

Anastomosis: ileocolic

Differential: midline laparotomy differential

Extended Right Hemicolectomy Features

Indication: tumours in the distal ascending colon or transverse colon

Scars  Midline laparotomy  Laparoscopic ports

Stoma: none

Anastomosis: ileocolic

Differential: midline laparotomy differential

Left Hemicolectomy Features

Indication: tumours in the descending colon

Scars  Midline laparotomy  Laparoscopic ports

Stoma: none

Anastomosis: colocolic

Differential: midline laparotomy differential

Hartmann’s Procedure Features

Indication: obstruction or perforation 2O to sigmoid tumour or diverticulitis

Description  Emergency procedure  Sigmoid colectomy  Proximal bowel exteriorised as an end colostomy  Distal bowel oversewn to form a rectal stump  May be reversed after 3-6mo (>50% of pts. aren’t reversed)

Scars  Midline laparotomy  May have previous stoma scar in LIF if it has been revered

Stoma: single lumen colostomy in the LIF

Differential: APR

Abdomino-Perineal Resection Features

Indication: rectal Ca < 4-5cm from anal verge

Description  Sigmoid, rectum and mesorectal nodes removed via abdominal incision  Anus removed via perineal incision

Scars  Midline laparotomy  No anus

Stoma: single lumen colostomy in the LIF

Differential  Hartmann’s Procedure

Anterior Resection Features

Indication: rectal Ca >4-5cm from anal verge

Description  Excision of part of the rectum and sigmoid colon  May be high or low depending on site of tumour  + Total mesorectal excision for tumours in the middle or lower 1/3  Rectal blood supply is poor  colorectal anastomosis covered by temporary loop ileostomy.

Scars  Midline laparotomy  Laparoscopic port scars  Scar or stoma in RIF

Stoma: double lumen loop ileostomy in RIF

Differential  End Ileostomy . Panproctocolectomy: UC, FAP . Subtotal colectomy: acute severe UC . Cystectomy and ileal conduit  Loop Ileostomy . Temporary diversion: Crohn’s

Subtotal Colectomy Features

Indication: acute severe UC

Description  All colon excised except distal sigmoid and rectum.  Temporary end ileostomy  Rectosigmoid stump may be exteriorised as mucus fistula  Followed after ~3mo by either: . Completion proctectomy + IPAA or permanent end ileostomy . Ileorectal anastomosis (IRA)

Scars  Midline laparotomy  Laparoscopic port sites

Stoma: single lumen end ileostomy in RIF

Differential  End Ileostomy . Panproctocolectomy: UC, FAP . Cystectomy and ileal conduit  Loop Ileostomy . Temporary diversion: anterior resection or Crohn’s

Panproctocolectomy Features

Indication: UC or FAP

Description  All colon, rectum and anus removed  Permanent end ileostomy

Scars  Midline laparotomy  Laparoscopic port sites

Stoma: single lumen end ileostomy in RIF

Differential  End Ileostomy . Subtotal colectomy: acute severe UC . Cystectomy and ileal conduit  Loop Ileostomy . Temporary diversion: anterior resection or Crohn’s

Examination Viva

Inspection Hx  Symptoms Peripheral . Wt. loss, fever, malaise  General . Abdominal pain . Malnutrition or wt. loss . Diarrhoea, blood and/or mucus PR . Cushingoid, evidence of steroids  Peri-anal disease: abscesses, fistulae  Hands  Extra-intestinal: EN, arthritis, iritis, gallstones, PSC . Clubbing  Therapy . Leukonychia . Admissions . Beau’s lines . Medical therapy  Eyes . Operations . Pale conjunctivae . Iritis, episcleritis Ix  Mouth . Aphthous ulcers Bloods . Gingival hypertrophy  FBC: ↓Hb, ↑WCC  Legs  U+E: dehydration, ↓K . Erythema nodosum  LFTs: ↓ albumin, deranged LFTs . Pyoderma gangrenosum  Clotting: ↑INR  ↑ ESR, ↑ CRP: used to monitor activity Abdominal  Scars Stool . May be multiple and atypical in Crohn’s  Culture + CDT: exclude infective causes . Healed stoma sites . Campy, Yersinia, Shigella, C. diff, TB . Healed drain sites

 Stomas or healed stoma sites Imaging  Enterocutaneous fistulae  AXR . Toxic megacolon in UC Palpation . Bowel obstruction 2O to strictures in Crohn’s  Tenderness  Contrast studies  RIF mass . Ba or Gastrograffin enema in UC  ± hepatomegaly . Small bowel follow–through in Crohn’s  MRI: perianal disease in Crohn’s Completion  Inspect perineum for perianal disease Endoscopy  Examine for extra-intestinal features  Ileocolonoscopy + regional biopsy . Large joint monoarthritis . Ix of choice . Sacroileitis . Safe in acute disease . Bronchiectasis . Distinguish UC from Crohn’s . Assess disease severity  Wireless capsule endoscopy

Discussion  Clinicopathological distinction between UC and CD  Main complications of IBD  Extra-intestinal manifestations  Definition of severe exacerbation  Indications for surgery in UC and CD  Surgical options for UC and CD

Pathology Complications

UC Crohn’s UC Crohn’s

Macroscopic Toxic megacolon Fistulae Location Rectum + colon Mouth to anus - esp. perianal ± backwash ileitis esp. terminal ileum Haemorrhage Perianal abscess Distribution Contiguous Skip lesions Malignancy Strictures Strictures No Yes - CRC Malabsorption - Cholangiocarcinoma Microscopic VTE Toxic dilatation Inflammation Mucosal Transmural Ulceration Shallow, broad Deep, thin, serpiginous Hepatobiliary → cobblestone mucosa  Fatty liver Fibrosis None Marked  Chronic hepatitis → cirrhosis Granulomas None Present  Gallstones Pseudoplyps Marked Minimal  PSC (3% of UC) and cholangiocarcinoma Fistulae No Yes

Definition of Severe Exacerbation Surgical Options for UC

Truelove and Witts Criteria Principles  Symptoms  Curative intent . BMs >6 x /d  IPAA or IRA offer continence but suffer from ↑ BMs, pouchitis . Large PR bleed and risk of malignancy.  Systemic Signs . ↑ HR >90 Subtotal colectomy ¯c end ileostomy ± mucus fistula . Pyrexia >37.8  Operation of choice for acute severe colitis  Laboratory Values . ↓ Hb <10.5g/dL  All colon excised except distal sigmoid and rectum. . ESR >30mm/Hr  Rectosigmoid stump may be exteriorised as mucus fistula  Followed after ~3mo by either: . Completion proctectomy + IPAA or end ileostomy . Ileorectal anastomosis (IRA) Indications for Surgery

Proctocolectomy and permanent ileostomy UC  Rectum and anus excised c all of colon ¯ Acute Severe  Only performed for pt. choice or when pt. is not suitable for  Megacolon: ≥6cm on AXR restorative procedure . ↑ age  Perforation: 30-40% mortality . Impaired sphincter function  Severe GI bleeding

Chronic Restorative Proctocolectomy  Medical Mx failure  Proctocolectomy or completion proctectomy  Malignancy  Construction of ileal reservoir which is anastomosed to anus  Maturation failure in children . Ileal pouch anal anastomosis (IPAA)  Usually covered by a diverting loop ileostomy  May check pouch anastomosis ¯c water soluble contrast

Crohn’s

Acute Severe Surgical Options for Crohn’s  Obstruction 2O to stenosis  Perforation Principles  Severe GI bleeding  80% need ≥1 operation in their life  Never curative Chronic  Must be as conservative as possible: avoid short gut syndrome  Peri-anal disease: fistulae and abscesses  Intra-abdominal abscesses Procedures  Medical Mx failure: temporary defunction  Ileocaecectomy  Entero-cutaneous fistulae  Drainage of intra-abdominal abscesses  Stricturoplasty  Colonic defunctioning for failed medical therapy  Occasionally a subtotal colectomy + permanent end ileostomy may be needed. © Alasdair Scott, 2012 123 Surgical Jaundice

Examination Viva

Inspection Hx

Peripheral Post-hepatic: most likely in surgery exam  Cachexia  Dark urine, pale stools  Signs of chronic liver disease  Itching  Look in sclera and at frenulum (of tongue): jaundice  Stones: RUQ pain or biliary colic  Palpate for Virchow’s node  Malignancy . Wt. ↓ and ↓ appetite Abdominal . Change in bowel habit: esp. steatorrhoea  Ascites . Back pain  Dilated abdominal veins Hepatic  Umbilical / para-umbilical hernia  EtOH intake  Foreign travel: Hep A  Blood transfusions, IVDU, Sex: Hep B and C Palpation  Sore throat: EBV  Hepatomegaly  Drug Hx: OCP, Abx, neuroleptics, OTCs  Splenomegaly  Palpable gallbladder Pre-hepatic  Anaemia: tired, SOB, palpitations, ankle swelling  FH Completion  Check temp: obstruction complicated by infection Definition  Dipstick urine: bilirubin, urobilinogen, Hb  Yellow discoloration of the skin and mucus membranes caused by the accumulation of bile pigments. Commonest Differentials  Normal BR = 3-17uM  Visible jaundice = 50uM (3 x ULN) Pre-hepatic Hepatic Post-hepatic  Very high levels usually have a hepatic cause Unconjugated Un- / Conjugated Conjugated Haemolysis Hepatitis Gallstones Ix of Post-Hepatic Jaundice - SCD - EtOH - HS - Viral Ca Head Panc Urine - AIHA Decompensated CLD  ↑↑BR, no urobilinogen Drugs LNs @ porta hepatis - Paracetamol - Ca Bloods - Statins - TB  LFTs: ↑cBR ↑↑↑ALP, ↑AST/ALT, ↑GGT - Anti-TB  Clotting: ↑ INR  Auto-Abs: AMA, pANCA, ANA

Imaging  US . Underlying hepatic disease . Dilated ducts: >6mm . Gallstones . Pancreatic mass or lymphadenopathy  MRCP  ERCP  CT: staging tumour

Causes of Post-Op Jaundice

Pre-hepatic: haemolysis after a transfusion

Hepatic  Halogenated anaesthetics  Sepsis  Intra- / post-operative hypotension

Post-hepatic  Biliary injury: e.g. in Lap Chole

Examination Viva

Inspection Hx  Duration of mass and how it has changed Peripheral  Abdominal symptoms  Hands and Arms  Gynae symptoms . Clubbing  Systemic symptoms . AV fistula  Co-morbidities and previous operations  Eyes . Pallor . Jaundice Differential of RIF Mass  Neck  LNs: e.g. Virchow’s node Commonest  Transplanted kidney Abdominal  Caecal Ca  Asymmetry  Crohn’s or Appendix mass or abscess  Scars: esp. Rutherford Morrison  Incisional hernia (mass ¯c scar)

Skin and Soft Tissues Palpation  Sebaceous cyst  Differentiate mass before continuing ¯c rest of exam  Lipoma  Site, size, shape  Sarcoma  Consistency: firm, soft  Edge: well or poorly defined Gynaecological  Surface: smooth, irregular, nodular  Ovarian tumour  Relations  Fibroid uterus  Can you get above and below it?  Does it move ¯c respiration? Male Reproductive System  Attachment to skin  Undescended or ectopic testis ± tumour

 Attachment to abdominal muscles Urological System  Ask pt. to lift head while palpating  Ectopic kidney  Cough impulse  Bladder diverticulum  Inguinal nodes

Blood Vessels

 External iliac or common iliac artery aneurysm Percussion  LNs  Resonant: e.g. bowel or retroperitoneal  Dull Radiological Ix

Auscultation US  Bruits  1st line  Bowel sounds  Distinguish bowel mass from pelvic mass  ID any LNs and abnormal blood vessels

CT  Best to view abdominal wall masses  Good to assess extent of intra-abdominal malignancy

MRI  Good for pelvic masses

Other Ix  Bloods  FBC, U+E, LFT  Mantoux  CXR, AXR  US / CT guided biopsy

Epigastric

Abdominal Wall and Soft Tissue

 Sebaceous cyst

 Lipoma  Epigastric hernia  Sarcoma RUQ LUQ GIT Abdominal Wall and Soft Tissue  Gastric Ca Abdominal Wall and Soft Tissue  Sebaceous cyst  Hepatomegaly  Sebaceous cyst  Lipoma  Ca pancreas  Lipoma  Sarcoma  Pancreatic pseudocyst  Sarcoma

Intra-abdominal Vascular Intra-abdominal  Hepatomegaly  AAA  Splenomegaly  Hepatic mass: cyst, abscess,  Left kidney hepatoma  Gastric Ca  Gallbladder  Right kidney

RIF LIF

Commonest Commonest  Transplanted kidney  Faecal mass  Caecal Ca  Colon Ca  Crohn’s or Appendix mass or  Diverticular Mass abscess  Transplanted Kidney  Incisional hernia (mass ¯c scar) Abdominal Wall and Soft Tissue Abdominal Wall and Soft Tissue  Sebaceous cyst  Sebaceous cyst  Lipoma  Lipoma  Sarcoma  Sarcoma

Gynaecological Gynaecological  Ovarian tumour  Ovarian tumour  Fibroid uterus  Fibroid uterus Male Reproductive System Male Reproductive System  Undescended or ectopic testis  Undescended or ectopic testis  ± tumour  ± tumour Urological System Urological System Suprapubic  Ectopic kidney  Ectopic kidney  Bladder diverticulum  Bladder diverticulum Abdominal Wall and Soft Tissue  Sebaceous cyst Blood Vessels Blood Vessels  Lipoma  External iliac or common iliac  External iliac or common iliac artery  Sarcoma artery aneurysm aneurysm  LNs  LNs Urological  Bladder  Bladder mass  Bladder diverticulum

Gynae  Gravid uterus  Fibroid uterus  Ovarian Tumour

Contents Breast Examination ...... 128 Breast Lumps ...... 129 Post-Mastectomy Breast ...... 130 Breast Reconstruction ...... 131 Gynaecomastia ...... 132

Set Up  Request a chaperone  Expose pt. from waist up and start ¯c her sitting up  Ask pt. if they have noticed lump in breast: which breast?

Inspection

Breast  Positions . Hands relaxed by sides . Leaning forwards . Hands behind head . Hands pressing hips  Shape: asymmetry, masses  Skin . Scars: periareolar, submammary . Radiotherapy tattoos . Eczema, erythema, ulceration . Peau d’orange, dimpling . Accessory nipples: look along the milk line  Nipple: inversion, discharge, discolouration, destruction

Peripheral  Axillae: LN dissection  Arm: lymphoedema  Abdomen / Suprapubic: DIEP or TRAM flap harvest  Back: lat-dorsi flap harvest

Palpation

Breast  Pt. @ 45O with hand behind head, start ¯c normal breast  Any pain or discharge?  Palpate each breast quadrant, subareolar area and the axillary tail  If lump found: SSS CCC TTTT FS  Ask pt. to push inwards on her hip to assess tethering

Axillae  Right axilla: hold pts. right arm with your right hand (and vice versa)  Gently palpate axillary node: . Apical . Anterior . Posterior . Medial . Lateral

Supraclavicular and cervical nodes

Lateral Chest Wall  Inflatable port sites for implants

Completion  Palpate / percuss spine for tenderness, masses  Examine abdomen for hepatomegaly  Percuss and auscultate lungs for signs of mets: e.g. effusion

Ix of a Lump: Triple Assessment Classification of Breast Disease

Hx and Examination Malignant  Ductal carcinoma NOS: ~70% of cancers Presentation  Lobular carcinoma: ~20% of cancers  Lump  Other: mucinous, medullary, papillary  Breast pain  Phylloides tumours  Skin or nipple changes  Mets Benign . Bones: bone pain, #s . Lungs: dyspnoea Congenital . Liver: abdo pain  Supernumerary nipples . Brain: headache, seizures  Hypoplasia

Risk Factors: BOOBYS Stromal Tumour: fibroadenomas  Bleeding: early menarche (<13), late menopause (>55)  Oestrogen: OCP, HRT Epithelial Lesions  Other breast disease: previous Ca, DCIS, atypia  ANDI: fibroadenosis, cysts  Breast feeding: protective  Papillomas  Young ‘un: first child >35yrs (↑ risk)  Cystic disease  Sister: FH of Ca breast Inflammatory Lesions  Mastitis Radiology  Abscess  <35yrs: US  Fat necrosis  >35yrs: US + mammography  Duct ectasia and periductal mastitis . Oblique and craniocaudal  MRI . Multifocal disease Commonest Single Breast Lumps . Cosmetic implants  Fibroadenoma  Cyst  Fat necrosis Pathology  Cancer  Solid lump: Tru-Cut biopsy  Cystic lump: FNAC . Reassure if clear fluid Features of a Malignant Lump . Send cytology if bloody fluid  Irregular, nodular surface . Core biopsy residual mass  Poorly defined edge . Core biopsy if +ve cytology  Hard / scirrhous consistency  Painless Other Ix  Fixation to skin or chest wall  Bloods: FBC, LFTs, ESR, bone profile  Nipple involvement  Imaging: help staging . CXR . Liver US . CT scan . Breast MRI . Bone scan and PET-CT  May need wire-guided excision biopsy

Examination Viva

Inspection Hx  Note asymmetry  What happened?  Describe scar . Presentation  Look at surrounding skin and axilla . Risk factors  Evidence of radiotherapy . Surgery  Ask pt. to press her hips: pec major present  How are things now?  Arm lymphoedema . Post-op pain, anaesthetised skin (@ T1) . Arm swelling . Psych Palpate . Symptoms of mets  What will happen in the future?  Remaining breast . Chemo and radiotherapy  Axilla . Reconstruction  Supraclavicular fossa

Indications for Mastectomy

 Modern oncological breast surgery involves breast Completion conservation wherever possible.  Palpate / percuss spine for tenderness, masses . Typically WLE and SNB  Examine abdomen for hepatomegaly  Mastectomy may be considered if  Percuss and auscultate lungs for signs of mets . Pt. preference . Multifocal disease . Large lump in small breast: e.g. >4cm . Large area DCIS: e.g. >4cm . Nipple involvement

Types of Mastectomy  Simple mastectomy . Removal of breast alone: commonest type . Still need to Mx the axilla  Other types not performed as no survival benefit . Modified radical: breast, pec minor, axilla . Radical: breast, pec minor and major, axilla . Extended radical: radical + internal mammary LNs

Pt. Preparation

Physical  Mark side prior to anaesthetic  Explanation including use of suction drain to close cavity and ↓ risk of haematoma or seroma formation.  There will be an anaesthetised patch of skin in the upper medial part of the arm  Division of intercostobrachial nerve (T1)

Psychological  Pts. should see breast care nurse pre-op  Options for reconstruction should be discussed

Drain Removal Post-op  Typically 2 drains: axilla and site of surgery  Left for 3-5d or until draining <50ml/d  Pts. can go home ¯c drains and district nurse support.

Examination Viva

Inspection Hx  As for mastectomy General  Note asymmetry Timing  Arm lymphoedema  Immediate: single operation  Evidence of radiotherapy  Delayed  Evidence of axillary clearance / radiotherapy  ↑ pt. decision time  Avoidance of detrimental effects of adjuvant therapy Flap Reconstruction  Scars extend over back or abdominal wall Techniques  Recess on back where lat dorsi has been removed  Tissue expansion reconstruction ¯c implants  Ask pt. to lift head of bead (when lying supine) to see  Autologous tissue reconstruction c myocutaneous flaps recess in the rectus muscle ¯

Implant Reconstruction Implants

 Rounder shape than normal breast Advantages Disadvantages  Breast usually lies higher Simpler technique Cosmetic result not as good  Becker implant may have palpable SC filling port in the Primary or delayed Requires plenty of available skin axilla Lies higher than other breast

Late Complications - Capsular contracture - Implant leakage - Infection requiring removal

Myocutaneous Flaps

Advantages Disadvantages Useful when little remaining ↑ blood loss skin or muscle Good cosmetic result ↑ op time and complications Primary or delayed Use of rectus impossible if pt. has had abdo surgery Late complications - flap necrosis and infection

Types of Myocutaneous Flap

Latissimus Dorsi myocutaneous flap  Pedicled: skin, fat, muscle and blood supply  LD mobilised and tunnelled medially to form neo-breast  Supplied by thoracodorsal A. via subscapular A.  Often augmented ¯c an implant

Transverse Rectus Abdominis Myocutaneous (TRAM) Flap  Pedicled: inf. epigastric A.  Or free: attached to internal thoracic A  No implant necessary and combined tummy tuck  CI if poor circulation: smokers, obese, PVD, DM  Risk of abdominal hernia

Deep Inferior Epigastric Perforator (DIEP) Flap  Evolution of the TRAM flap  Free: skin and fat only, no muscle  Spares the rectus: ↓ pain and ↓ risk of hernia  May not be possible if small perforators

Examination Viva

Inspect Causes of Gynaecomastia: 3Ps  Unilateral or bilateral breast swelling Potions Palpation  Recreational  Must feel glandular tissue to differentiate from pseudo- . Marijuana gynaecomastia (fat). . Diazepam . Anabolic steroids Completion  Prescription . Spiro  Look for cause . Digoxin . External genitalia . Captopril . Thyroid examination . Verapamil . Evidence of CLD . Ranitidine . Visual fields

 Take Hx Physiological  Prescription and recreational drugs  Especially at puberty where breast tissue may be

unilaterally or bilaterally enlarged.  Usually resolves by adulthood

Pathological  ↓ androgen production: hypogonadism . Hyperprolactinaemia . Renal failure . Testicular atrophy . Post-orchitis . Bilat torsion . Klinefelter’s: XXY  ↑ oestrogens . ↑ production  Sex-cord stromal tumours  Lung Ca . ↑ peripheral aromatisation  Chronic liver disease  Thyrotoxicosis

Ix  Testicular Ca: AFP, βhCG  Hypogonadism: testosterone and LH levels  Prolactinoma: PRL level  TFTs

Suggestions of Breast Ca  1% of breast Ca occurs in men  Older age  FH  Unilateral gynaecomastia  Firm or hard nodules w/i breast tissue  Axillary LNs

Contents Venous Examination ...... 134 Varicose Veins ...... 135 Post-Phlebitic Limb: Chronic Venous Insufficiency ...... 136 Arterial Examination ...... 137 Chronic Limb Ischaemia ...... 138 Abdominal Aortic Aneurysm ...... 139 Popliteal Aneurysm ...... 140 Aneurysms: Key Facts ...... 140 False Aneurysm ...... 141 Amputations ...... 141 Carotid Artery Disease ...... 142 Vascular Effects of the Diabetic Foot...... 143 Gangrene ...... 143 Raynaud’s Phenomenon ...... 144 Thoracic Outlet Obstruction ...... 144 Peripheral Ulcer Examination ...... 145 Venous Ulcer ...... 146 Ischaemic Ulcer ...... 146 Neuropathic Ulcer ...... 147 Lymphoedema ...... 148

Set-Up Great Saphenous Vein Anatomy  Expose pt. from groin to toes  Examine ¯c pt. standing

Inspection SFJ - 2 finger breaths below and Skin Changes and Scars lat. to pubic tubercle  Scars: esp. in groin creases  Chronic Venous Insufficiency: HAS LEGS Mid-thigh perforator of . Haemosiderosis Hunter . Atrophie blanche . Swelling . Lipodermatosclerosis . Eczema . Gaiter ulcers . Stars, venous Calf perforators of Cockett Site and Size of Varicosities - draining into post. ach vein  Medial and above knee: great saphenous  Posterior and below knee: short saphenous  Few varicosities + prominent skin changes: calf perforators Great Saphenous - Passing anterior to medial malleolus Palpation  Pitting oedema  Palpate varicosities . Tenderness: thrombophlebitis . Induration: thrombosis  Saphena varix @ SFJ . Two finger breaths below and lateral to pubic tubercle . Bluish tinge, disappears on lying flat . May have cough impulse (Cruveihier’s Sign)  Tap test (Chevrier’s Test) . Tap proximally and feel for impulse distally . Distal pulses: PTA, DPA

Auscultation  Bruit over varicosity: AVM

Doppler  Place probe @ SFJ/SPJ and squeeze calf  Normally hear only half second whoosh when pressure released.  Long whoosh suggests valve incompetence.

Completion  Trendelenberg or Tourniquet Test  Examine abdomen + PR  Pelvis in females

Tourniquet / Trendelenberg’s Test  Position pt. supine, elevate leg and milk veins.  Apply tourniquet as high up thigh as possible or compress SFJ  Stand pt. . Controlled: incompetence above tourniquet  Release tourniquet to confirm filling . Uncontrolled: incompetence below tourniquet  e.g. SPJ or calf perforators  Repeat test with tourniquet just below knee

Pathophysiology Definition  One-way flow from sup → deep maintained by valves  Tortuous, dilated veins of the superficial venous  Valve failure → ↑ pressure in sup veins → varicosity system . Fibrous tissue invades tunica intima and media, breaking up the SM CEAP Classification . Prevents maintenance of vascular tone → dilatation  Classification of Chronic Venous Disease  3 main sites where valve incompetence occurs  Clinical signs (1-6 + sympto or asympto) . SFJ: 3cm below and 3cm lateral to pubic tubercle  Etiology . SPJ: popliteal fossa . Perforators: draining GSV  Anatomy  Chronic venous insufficiency is distinct and results from  Pathophysiology incompetency in the deep system itself. . May co-exist ¯c varicose veins Mx

Causes Conservative  Lose wt. and regular exercise

 Avoid prolonged standing Primary / Idiopathic: 95%  Class II graduated Compression Stockings  Prolonged standing . 18-24mmHg  Pregnancy  Skin care: emollients  Obesity  OCP Minimally Invasive Therapies

Secondary: 5% Indications  Valve destruction: DVT, thrombophlebitis  Small below knee varicosities not involving GSV or  Obstruction: pelvic mass, DVT SSV  AVM  Syndromes Techniques  Local or GA Syndromes  Injection sclerotherapy: 1% Na tetradecyl sulphate  Endovenous laser or radiofrequency ablation Klippel-Trenaunay-Weber  Abnormality of the deep venous system Post-Operatively  Varicose veins  Compression bandage for 24hrs  Port wine stain  Compression stockings for 1mo  Bony and soft tissue hypertrophy of the limbs Surgery Parkes-Weber Syndrome  Multiple AVMs ¯c limb hypertrophy Indications  AVMs can → high-output HF  SFJ incompetence  Major perforator incompetence Symptoms  Symptomatic: ulceration, skin changes, pain  Cosmetic defect  Pain, cramping, heaviness Procedures Trendelenberg: saphenofemoral ligation  Tingling  SSV ligation: in the popliteal fossa  Bleeding: may be severe  LSV stripping: no longer performed due to potential  Swelling  for saphenous nerve damage.  Multiple Avulsions Ix  Cockett’s Operation: perforator ligation

 SEPS: Subfascial Endoscopic Perforator Surgery Duplex US Post-op Indications  Bandage tightly and elevate for 24h  Previous Hx of DVT  D/C ¯c compression stockings and told to walk daily.  Signs of chronic venous insufficiency . Suggests deep venous disease for which the Complications varicosity may be the collateral.  Early  Recurrent varicose veins . Haematoma: esp. groin  Difficulty in deciding whether GSV or SSV is incompetent . Wound sepsis . Nerve damage: e.g. long saphenous Preparation for Surgery  Late  FBC, U+E, clotting, G+S . Superficial thrombophlebitis  CXR . DVT  ECG . Recurrence: 10% @ 5yrs © Alasdair Scott, 2012 135 Post-Phlebitic Limb: Chronic Venous Insufficiency

Examination Viva

Inspection Hx  Previous DVT HAS LEGS . Orthopaedic surgery  Haemosiderosis . Complicated obstetric course  Atrophie blanche  Venous Claudication  Swelling . “Bursting” pain in the leg after exercise  Lipodermatosclerosis . Relieved by rest and elevation of limb (cf. arterial)  Eczema  Gaiter ulcers Causes  Stars, venous  Reflux following DVT: 90%  Obstruction following DVT: 10% Varicose Veins  Often present as collaterals bypassing the obstruction Venous Gangrene

 Rare complication of DVT in the iliofemoral segment  3 phases Palpation . Phlegmasia alba dolens: white leg  Pitting oedema . Phlegmasia cerulea dolens: blue leg . Gangrene 2O to acute ischaemia

Completion Lipodermatosclerosis  Perthes’ Test  Panniculitis  Abdominal exam + PR  Venous HTN → extravasation of fibrin and red cells  Pelvic exam in women  Poor tissue oxygenation → ulceration and fat necrosis  Inverted champagne bottle appearance Perthes’ Test . Chronic inflam → fibrosis → distal shrinkage  Tests for deep venous occlusion . Venous obstruction → proximal leg swelling  High tourniquet around pts. leg + walking for 5min  Deep obstruction → swelling and pain Ix of Deep Venous Disease  Duplex: reflux and occlusion  Venography . Ascending: patency and perforator incompetence . Descending: reflux  Ambulatory venous pressures

Surgical Options

Reflux  Trahere Transplantation . Transplant segment of axillary vein ¯c valve into deep venous system of leg . Wrap ¯c PTFE cuff  Kistner Operation . Valvuloplasty of damaged valves

Obstruction  Palma operation . Use contralateral GSV and anastomose to femoral vein to bypass iliofemoral obstruction

Lower Limb Upper Limb

Set-Up Inspection  Expose pt. from groin to toes  Start @ the toes unless told otherwise Hands and Arms  Tobacco staining  Colour Inspection  Trophic changes  Colour: pallor or cyanosis  Ulcers and gangrene  Trophic changes  Scars . Muscle atrophy, . Shiny dry skin Face and Neck . Nail dystrophy and loss of hair  Corneal arcus, xanthelasma  Ulcers  High arched palate . Between toes  Scar over carotids . Base of 1st and 5th metatarsals . Heel (ask re. pain before lifting…) Chest  Gangrene  Mid-line sternotomy scar  Scars . Medial thigh and leg . Vascular access (vertical groin) Palpation . Midline sternotomy or laparotomy  Temperature . Axilla  Pulses: rate and rhythm . Radial: lat. to FCR tendon @ wrist . Ulna: lat. to FCU Palpation . Brachial: medial to biceps tendon  Temperature: feel ¯c backs of both hands . Carotid: ant. to SCM at the thyroid cartilage  Pulses: as present, reduced or absent  Radio-radial delay . Feel pulses bilaterally if possible for comparison  Radio-femoral delay . Aorta: just above the umbilicus . Stenosis, coarctation, dissection . Femoral: mid-inguinal point . Popliteal: between the heads of gastrocnemius . Dorsalis pedis: lat. to extensor hallux longus Auscultate for Bruits tendon (absent in ~5% of people)  Carotids . Post tib: postero-inferior to medial malleolus  Graft . Graft + distal pulses: is the graft patent?

 Capillary refill: <2s

Completion Auscultate for Bruits  Examine the rest of the vascular system  Assess the pulses with a hand-held doppler  Aorta and renal vessels  Cardiovascular and neurological examination  Iliac: midway from umbilicus to inguinal ligament  BP of both arms  Femoral  Difference >20mmHg suggests stenosis, CoA or  Course of SFA if popliteal can’t be palpated dissection.  Grafts

Buerger’s Angle and Test  Lift leg to 45O and observe for pallor and venous guttering . <20O = severe ischaemia  Buerger’s Test: reactive hyperaemia on lowering the leg . 2O to vasodilatation of the microcirculation in response to ischaemia

Completion  Examine the rest of the vascular system  Assess the pulses with a hand-held doppler  Measure the ABPI  Cardiovascular and neurological examination . DM neuropathy . Valve disease

Presentation Ix

Intermittent Claudication Bedside  Cramping pain after walking a fixed distance  ABPI ± exercise ABPI (↓ by 0.2 in PVD)  Pain rapidly relieved by rest  ECG  Calf pain = superficial femoral disease (commonest)  Buttock pain = iliac disease: internal or common Blood  FBC: anaemia may worsen symptoms Critical Limb Ischaemia: Fontaine 3 or 4  U+E: renovascular disease  Ankle artery pressure <50mmHg (toe <30mmHg)  Glucose: DM  And either:  Lipids: hypercholesterolaemia . Persistent rest pain requiring analgesia for ≥2wks . Ulceration or gangrene Imaging: assess site, extent and distal run-off  Rest pain  Colour duplex US . Especially @ night  CT / MR angiogram: gadolinium contrast . Usually felt in the foot  Digital subtraction angiography . Pt. hangs foot out of bed . Invasive  not commonly used for Dx only. . Due to ↓ CO and loss of gravity help . Used for therapeutic angioplasty or stenting  Tissue loss: ulceration, gangrene

Leriche’s Syndrome: Aortoiliac Occlusive Disease Non-Surgical Mx  Atherosclerotic occlusion of abdominal aorta and iliacs  Walk through pain: may use exercise programs  Triad of:  Optimise risk factor profile . Buttock claudication and wasting . Smoking cessation . Erectile dysfunction . Control HTN, lipids and BP . Absent femoral pulses . Lose wt.  Antiplatelet and statin for all pts.  Foot care Intermittent Claudication vs. Spinal Claudication Prognosis Arterial Spinal  ~80% improve or stay the same Path Vascular insufficiency Nerve compression  20% deteriorate, 1% lose their limb Site Usually calf or buttock Ill-defined / whole leg  60% mortality @ 5yrs: cardiovascular disease Pain Set distance: reproducible Positional onset Worse up stairs Better up stairs Interventional Cramping Burning pain  Angioplasty ± stenting Eased by standing rest Eased sitting forward  Chemical sympathectomy Exam Evidence of PVD Normal Surgical Mx

 Endarterectomy Risk Factors  Bypass grafting

 Amputation Modifiable Non-modifiable

 Smoking  FHx Bypass Grafting  BP  PMH

 DM control  Male Indications  Hyperlipidaemia  ↑ age  V. short claudication distance (e.g. <100m)  ↓ exercise  Ethnicity  Symptoms greatly affecting pts. QoL

 Development of rest pain

Classification Pre-op Assessment  Need good optimisation as likely to have Clinical Fontaine ABPI cardiorespiratory co-morbidities. Calcification: CRF, DM >1.4 Normal >1 Practicalities Asymptomatic Fontaine 1 0.8-1  Need good proximal supply and distal run-off Claudication Fontaine 2 0.6-0.8  Saphenous vein grafts preferred below the IL Rest pain Fontaine 3 0.3-0.6  More distal grafts have ↑ rates of thrombosis Ulceration and gangrene Fontaine 4 <0.3 Classification  Anatomical: fem-pop, fem-distal, aortobifemoral  Extra-anatomical: axillo-fem / -bifem, fem-fem crossover

Examination Viva

Inspection Hx  Midline pulsating mass: esp. on deep inspiration  Presentation: usually incidental finding  Abdominal scars  Symptoms . Abdominal or back pain . Tenderness over aneurysm Palpation  Distal embolic events  Pulsatile and expasile mass on deep palpation in the  Leak epigastrium.  Other peripheral or cardio-vascular disease . Expansile: moves fingers laterally ¯c each pulse  CV risk factors  Estimate size using lateral margins of index fingers  Palpate for other aneurysms Definition . Course of common iliacs  Abnormal dilatation of the abdominal aorta to >50% of . Femorals its normal diameter = ≥3cm . Popliteals Risk Factors  Male Auscultation for Bruits  Age >60yrs (prevalence: ~5%)  Aortic  Smoking  Renal  HTN  Iliac  FHx

Ix Completion  Abdo US: used for surveillance and screening  Cardiovascular system  CT/MRI: Ix of choice  Peripheral vascular system  Angio: useful to delineate relationship of renal arteries

When to Operate  Repair aims to avoid complications  Operate when risk of complications, esp. rupture, > risk of surgery.

Indications  Symptomatic aneurysms  Asymptomatic . ≥5.5cm . Expanding >1cm/yr

Complications  Death  MI  Renal failure  Spinal or mesenteric ischaemia  Distal trash from thromboembolism  Anastomotic leak  Graft infection  Aortoenteric fistula

Operative Mortality  Open . Emergency: 50%  But only 50% reach hospital alive . Elective: 5% (lower in specialist centres) . ↑ if IHD, LVF, CRF, COPD  EVAR: 1%

EVAR  ↓ perioperative mortality (1% vs. 5%)  No mortality benefit after 5yrs  Significant late complications: e.g. endoleaks  EVAR not better cf. medical care in unfit pts.

Examination Definition  Abnormal dilatation of a blood vessel > 50% of its Inspection normal diameter.  Pulsatile popliteal swelling  Ischaemic patches on foot: emboli Classification

Palpation True Aneurysm  If asked just to examine the pulses, start ¯c femorals  Dilatation of a blood vessel involving all layers of the . Comment on presence and character wall and is >50% of its normal diameter  Aneurysmal popliteals are very easily palpable  Two different morphologies . Popliteal aneurysm ≥2cm in diameter . Fusiform: e.g AAA  50% bilateral: examine the other knee . Saccular: e.g Berry aneurysm  Distal pulses may not be palpable False Aneurysm Completion  Collection of blood around a vessel wall that communicates ¯c the vessel lumen.  Complete peripheral vascular examination  Usually iatrogenic: puncture, cannulation  Abdominal examination for AAA

. Present in 50% Dissection

 Vessel dilatation caused by blood splaying apart the media to form a channel w/i the vessel wall. Viva  Used to be classified as “dissecting aneurysms” but not technically correct as represents a different pathology. Presentation  Popliteal aneurysms represent 80% of all non-aortic Causes aneurysms  Lump behind the knee Congenital  50% present ¯c distal limb ischaemia: thromboembolism  ADPKD → Berry aneurysms  <10% rupture  Marfan’s, Ehlers Danlos

Mx Acquired  Atherosclerosis Surgical Indications  Trauma: e.g penetrating trauma  Symptomatic aneurysms  Inflammatory: Takayasu’s aortitis, HSP  Aneurysms containing thrombus  Infection  Aneurysms >2cm . Mycotic: SBE . Tertiary syphilis (esp. thoracic) Mx . Salmonella typhi: assoc. ¯c AAA

 Acute: embolectomy or fem-distal bypass  Stable: excision bypass Complications  Rupture  Thrombosis  Distal embolisation  Pressure: DVT, oesophagus, nutcracker syndrome  Fistula: IVC, intestine

UK Small Aneurysms Trial  Powell, Greenhalgh et al., Lancet 1996  Asymptomatic aneurysms between 4-5.5cm should be monitored.  Aneurysms ≥ 5.5cm should undergo repair.  Risk of rupture . <5.5cm: 1% /yr . ≥5.5cm: 10% /yr

Screening  MASS trial revealed 50% ↓ aneurysm-related mortality in males aged 65-74 screened ¯c US.  UK men offered one-time US screen @ 65yrs

Examination Examination

Inspection Inspection  Pulsatile mass in the groin  Stump anatomical level  Surgical scars or puncture sites  Stump health  Evidence of chronic vascular disease Palpation  Pulsatile, expansile swelling Palpation  Define the anatomical location  Soft tissue under skin should move freely over the bone . Usually mid-inguinal point  Proximal pulses  Palpate distal pulses Move Auscultate for a Bruit  Ask pt. to actively flex and extend the knee joint above the amputation . Many pts. have a fixed flexion deformity after Viva BKA  Ask to look @ prosthesis and see pt. walk ¯c it. True vs. False Aneurysm  Often useful to draw this Completion  Aneurysm is an abnormal dilatation of a blood vessel  Examine other limb for signs of PVD

True: involves all layers of arterial wall

False Viva  Collection of blood around a vessel wall that communicates ¯c the lumen Indications: 4D’s  i.e. a pulsating haematoma  Dead: PVD (90%), thrombangiitis obliterans  Fibrous tissue forms around haematoma → false sac  Dangerous: sepsis, malignancy which communicated ¯c vessel lumen  Damaged: trauma, burns, frostbite  Damned nuisance: pain, neurological damage Aetiology  Occurs after vessel a laceration / puncture Considerations . Traumatic or iatrogenic  Psychosocial implications . Usually in the common femoral A. following  Future mobility: 200% more effort to walk after AKA puncture for a radiological procedure.  OT involvement  Level of amputation must be high enough to ensure Mx healing of the stump.  Ultrasound compression  But ↑ mortality ¯c AKA vs. BKA  Thrombin injection  Surgical repair Procedures  Toe: with the metatarsal head  Ray Amputation . Incision on either side of affected digit to the base of the metatarsal . Creates a V shape and narrows foot . Heals by 2O intention . Used if necrosis of digit and muscles of the foot.  Forefoot: transmetatarsal  Below knee: aids rehabilitation  Above knee  Hindquarter / hemipelvicotomy

Complications  Pts. often have co-morbidities → ↑ risk  Esp. CVD

Early  Mortality: ~20% for AK  Haemorrhage  Infection: cellulitis, gangrene, osteomyelitis  Scar contractures → fixed flexion  Phantom limb pain: try gabapentin  Poor stump shape inhibiting prosthesis © Alasdair Scott, 2012 141 Carotid Artery Disease

Examination Viva

Two Possible Options Hx  Previous TIA: esp. amaurosis fugax Carotid Endarterectomy Scar . Amaurosis fugax will be ipsilateral to stenosis  Beneath the angle of the mandible  Previous stroke  Parallel to SCM  Other CV and PV disease  CV risk factors Carotid Bruit  Along course of common carotid: medial to SCM in the Ix anterior triangle  Best heard in expiration Bedside  Urine dip: proteinuria in renovascular disease  ECG: ischaemic changes, AF Completion  If heard bilaterally, listen over precordium to exclude AS Blood  Full peripheral vascular examination  FBC: anaemia may worsen symptoms  Neurological examination: cerebrovascular event  U+E: renovascular disease  Glucose: DM  Lipids: hypercholesterolaemia

Imaging  Carotid Duplex US: site and size of stenosis  MRA: more detailed carotid anatomy  Echo: CVD  CT or MRI brain: infarcts

Complications of Carotid Stenosis

TIA  Sudden neurological deficit of vascular origin lasting <24h (usually lasts <1h) ¯c complete recovery  Microemboli from the plaque

Stroke  Sudden neuro deficit of vascular origin lasting >24h . 3rd leading cause of death in the West  Carotid atheroembolism is the commonest cause

Mx  Pts ¯c severe symptomatic stenosis should have CE ASAP after the neurological event.

Conservative  Aspirin or clopidogrel  Control risk factors

Surgical: Endarterectomy  Symptomatic (ECST, NASCET) . ≥70% (5% stroke risk per yr) . ≥50% if low risk (<3%, typically <75yrs) . 6 fold reduction in stroke rate @ 3yrs  Asymptomatic (ACAS, ACST) . ≥60% benefit if low risk

Complications  3% risk of stroke or death  Haematoma  MI  Nerve injury . Hypoglossal: ipsilateral tongue deviation . Great auricular: numb ear lobe . Recurrent laryngeal: hoarse voice, bovine cough

Examination Examination

Inspection Inspection  Bilateral signs of chronic arterial disease  Wet  Amputations: esp. digits . Putrefaction  Charcot joints . Ill-defined, spreading edge  Ulceration  Dry . Dry and shrunken . Well demarcated Palpation . Features of PVD  Pulses may be preserved due to calcification  ↓ sensation in stocking distribution Palpation  Temperature  Distal pulses Completion  Examine the peripheral nervous system  Urinalysis: proteinuria Viva  Fundoscopy: retinopathy Definition  Irreversible tissue death from poor vascular supply. Viva Classification Hx  Wet: tissue death + infection  Control  Dry: tissue death only  Complications  Pregangrene: tissue on the brink of gangrene  Claudication  Previous operations Causes of Gangrene  Other vascular disease  DM: commonest  Other vascular risk factors  Embolism and thrombosis . E.g. foot trash in AAA repair  Raynaud’s Diabetic Foot Syndrome  Thrombangiitis obliterans  Microvascular disease  Injury: extreme cold, heat, trauma or pressure

 Macrovascular disease . Predominantly below knee cf. non-DM occlusive Mx disease.  Take cultures  Neuropathy  Debridement (including amputation)  Infection and osteomyelitis  Benzylpenicillin ± clindamycin

Aetiology of Diabetic Ulcers Synergistic Gangrene  Neuropathic: 45-60%  Involves aerobes + anaerobes  Ischaemic: 10%  Fournier’s: perineum  Mixed neuroischaemic: 25-45%  Meleney’s: post-op ulceration  Both progress rapidly to necrotizing fasciitis and myositis Preservation of Pulses  Calcification in the walls of the vessels: mediasclerosis  Preserves the pulses until late Gas Gangrene  → abnormally high ABPI  Clostridium perfringes myositis . Use toe pressure instead: <30mmHg  RFs: DM, trauma, malignancy  Similar effect is seen in CRF Presentation  Toxaemia Problems ¯c Diabetics Undergoing Angiography  Crepitus from surgical emphysema  Often have a degree of renal impairment which can be  Bubbly brown pus dramatically worsened ¯c contrast agents.  Metformin must be stopped prior to the procedure to Rx prevent lactic acidosis  Debridement (may need amputation)  Benzylpenicillin + metronidazole  Hyperbaric O2

Examination Examination

Key Questions Inspection  What is the main problem you have ¯c your hands?  Arm: ↓ venous outflow  When do symptoms occur? . Oedema: pitting  Is it precipitated by any specific weather conditions? . Cyanosis  Can you describe the colour changes your fingers go . Pallor through?  Hand: ↓ arterial inflow . Raynaud’s Inspection . Patchy gangrene . Fingertip necrosis  Usually bilateral  Hand and Arm: neurological complications  Dry, red skin . Complete claw hand  Brittle nails . T1 sensory loss  Ulceration or gangrene on the pulps . Radicular pain

Palpation Palpation  Normal radial pulse  Palpate for cervical rib above the supraclavicular fossa

 Disappearance of radial pulse on abduction and Completion external rotation of arm  Ask about symptoms and look for signs of secondary causes of Raynaud’s phenomenon Viva

Viva Differential of Thoracic Outlet Obstruction

 Arterial: Raynaud’s Definitions  Venous: axillary vein thrombosis or trauma  Phenomenon: characteristic cold-induced changes  Neurological: cervical spondylosis, Pancoast’s tumour assoc. ¯c vasospasm  Disease: primary Raynaud’s phenomenon occurring in Ix isolation  X-Ray: cervical rib  Syndrome: secondary Raynaud’s phenomenon assoc.  Duplex in abduction c other disease ¯  Arteriograms of subclavian artery may show kinking

 Nerve conduction studies Colour Changes  Cold- or emotion-induced Aetiology  White → Blue → Crimson  Congenital: cervical rib st  Acquired: clavicle #, pathological enlargement of 1 rib Pathogenesis  Overactive α sympathetic receptors  Or, fixed obstruction in vessel wall

Secondary Causes: BADCAT  Blood: polycythaemia, cryoglobulinemia, cold agglutinin  Arterial: atherosclerosis, thrombangiitis obliterans  Drugs: β-B, OCP, ergotamine  Cervical rib: → thoracic outlet obstruction  Autoimmune: SLE, RA, SS  Trauma: vibration injury

Conservative  Wear gloves and avoid cold  Stop smoking

Medical  CCBs: e.g. nifedipine  IV prostacyclin

Surgical  Cervical sympathectomy  Amputate gangrenous digits

Inspection: BEDS Ulcer Edges

3s  Site  Size  Shape

Base  Granulation tissue  Slough  Floor: bone, tendon, fascia

Edge  Sloping: healing – usually venous  Punched-out: ischaemic or neuropathic  Undermined: pressure necrosis or TB  Rolled: BCC  Everted: SCC

Discharge  Serous  Purulent  Sanguinous

Surroundings  Cellulitis  Excoriations  Sensate  LNs

Palpation

 Limb pulses  Sensation around the ulcer

Completion  Examine contralateral side  Distal neurovascular examination  ABPI: must be >0.8 for compression bandaging

Causes  Venous: 75%  Arterial: 2%  Mixed arteriovenous: 15%  Neuropathic  Pressure  Vasculitis: e.g. PAN  Malignancy: SCC, Marjolin’s  Systemic: pyoderma gangrenosum

Examination Examination

Inspection Inspection  Site: medial malleolus  Site  Size: variable, can be v. large . Tips of and between toes st th  Base . Base of 1 and 5 metatarsals . Shallow . Heel . Pink granulation tissue  Size: mm-cm  Edge: sloping edge  Base  Discharge: seropurulent . Deep: may be down to bone  Surroundings . May be slough but no granulation tissue . Signs of chronic venous insufficiency: HAS LEGS  Edge: punched-out . Varicose veins  Surroundings . Pale Palpation . Trophic changes  Painless  Warm surroundings Palpation  Sensate  Painful  Cold surroundings  Sensate  Reduced or absent distal pulses Viva

Causes Viva  Valvular disease

 Varicose veins Causes  Deep vein reflux: e.g. post DVT

 Outflow obstruction Large Vessel . Often post DVT  Atherosclerosis  Muscle pump failure  Thombangiitis obliterans (Buerger’s Disease)  Stroke

 Neuromuscular disease Small Vessel

 DM Ix  PAN  ABPI if possible  RA  Duplex ultrasonography  Biopsy may be necessary: esp. if persistent ulcer  Look for malignant change: Marjolin’s ulcer Mx

Mx Analgesia  Refer to leg ulcer community clinic  Can be extremely painful  Combination of drugs administered regularly General Measures  Based on the analgesic ladder: titrate to pain  Optimise risk factors: nutrition, smoking . Paracetamol + NSAIDs  Analgesia . Weak opioids: e.g. codeine  Bed rest + elevate leg . Strong opioids: e.g. morphine

4 layer compression bandaging if ABPI >0.8 Risk Factor Modification  Construction  Stop smoking . Non-adherent dressing + wool bandage  Control DM and HTN . Crepe bandage  Optimise lipids . Blue line bandage: light compression . Cohesive compression bandage Medical  Change bandages 1-2 x/wk  Avoid drugs which may worsen symptoms: e.g. β-B  Once healed use grade 2 compression stockings for life  Low-dose aspirin  IV prostaglandins Other Options  Chemical lumbar sympathectomy  Pentoxyfylline PO: ↑ microcirculatory blood flow . Chemical ablation of L1-L4 paravertebral ganglia  Desloughing ¯c larval therapy . Inhibit sympathetic-mediated vasoconstriction  Topical antiseptics: Manuka honey . Relief of pain  Surgical: split-thickness skin grafts . Often unsuccessful in DM: neuropathy

Examination

Inspection  Site: pressure areas . Tips of and between toes . Base of 1st and 5th metatarsals . Heel  Size: variable  Shape: corresponds to shape of pressure point  Base: may be deep ¯c bone exposure  Edge: punched-out  Surroundings . Skin looks normal . Charcot’s joints . May be signs of PVD if co-existent arterial disease

Extras  Blood sugar testing marks on fingers  Insulin injection marks on the abdomen

Palpation  Normal temperature  Normal peripheral pulses  Absent sensation around ulcer  Absent ankle jerks

Completion  Full peripheral vascular exam  Cranial and peripheral neuro exam

Viva

Causes

Any cause of peripheral neuropathy  DM  Alcohol  B12  CRF  Drugs: e.g. isoniazid, vincristine  Every vasculitis

Pathophysiology  Sensory neuropathy: distal limb damage not felt by pt.  Motor neuropathy: wasting of intrinsic foot muscles and an altered foot shape . Claw toes + prominent metatarsal heads  Autonomic neuropathy: ↓ sweating → cracked, dry foot

Examination Viva

Inspection Limb Swelling Differential  Gross leg swelling  Bilateral or unilateral Bilateral  Thick, indurated skin  ↑ Venous Pressure . RHF  Lichenification . Venous insufficiency  Yellow nail discoloration . Drugs: e.g. nifedipine

 ↓ Oncotic Pressure Palpation . Nephrotic syndrome  Initially: pitting . Hepatic failure  Later: non-pitting . Protein losing enteropathy  Palpate for inguinal nodes  Lymphoedema  Myxoedema Completion . Hyper- / hypo-thyroidism  Exclude RHF . ↑ JVP Unilateral . Hepatomegaly  Venous insufficiency  Take a Hx: esp. re hereditary conditions  DVT  Infection or inflammation  Lymphoedema

Lymphoedema  Collection of interstitial fluid due to blockage or absence of lymphatics.

Primary  Congenital absence of lymphatics  May or may not be familial  Presentation . Congenital: evident from birth . Praecox: after birth but <35yrs . Tarda: >35yrs

Milroy’s Syndrome: 2% of primary lymphoedema  Familial AD subtype of congenital lymphoedema  F>M

Secondary: FIIT  Fibrosis: e.g. post-radiotherapy  Infiltration . Ca: prostate, lymphoma . Filariasis: Wuchereria bancrofti  Infection: TB  Trauma: block dissection of lymphatics

Mx  Conservative . Skin care . Grade 3 compression stockings . Treat or prevent cellulitis  Physio . Raise leg as much as possible  Surgical . Debulking operation . Bypass procedures

Contents Hip Examination ...... 150 Knee Examination ...... 151 Osteoarthritis: Key Facts ...... 152 Hip Arthroplasty ...... 153 Knee Arthroplasty ...... 154 Knee Ligament Damage ...... 154 Hallux Valgus ...... 155 Lesser Toe Deformities ...... 155 Charcot Joints ...... 156 Gait ...... 157 Popliteal Swellings ...... 157 Shoulder Examination ...... 158 Hand Examination ...... 159 Dupuytren’s Contracture ...... 160 Carpal Tunnel Syndrome ...... 161 Rheumatoid Hands ...... 162 OA Hands ...... 163 Ulnar Nerve Palsy ...... 164 Radial Nerve Palsy ...... 164 Mallet Finger ...... 165 Trigger Finger ...... 165 Back Examination ...... 166 Lumbar Disc Herniation ...... 167

Look

Gait  Antalgic: ↓ stance-phase on affected side  Trendelenberg: sideways lurch of trunk to bring body wt. over limb

Examine Pt. Standing  Skin . Scars: esp. lateral and posterior . Bruising, erythema  Shape +ve Trendelenberg Test . Soft tissue or bony swelling O . Muscle wasting: esp. gluteals  Abductor wasting 2 chronic pain  Deformity: coxa vara or valga  Sup. gluteal N. injury: surgery  Structural: DDH Trendelenberg Test  Negative: pelvis tilts slightly up on unsupported side.  Positive: pelvis drops on the unsupported side . Pathology of contralateral abductor mechanism True Shortening Examine Pt. Supine  #: e.g. NOF  Square the pelvis and measure leg lengths  Hip dislocation . True length: ASIS to medial malleolus  Growth disturbance of tibia/fibula . Apparent length: xiphisternum to medial malleolus . Osteomyelitis, #s . Galeazzi Test: tibial vs. femoral shortening.  Surgery: e.g. THR  SUFE  Perthes’ disease Feel  Palpate for tenderness: Apparent Shortening  ASIS, iliac crests and pubic rami  Scoliosis of the spine  Greater trochanter

Move Hip pain  Abduction: 45  Pain from hip joint usually felt in  Adduction: 30 groin or ant. thigh.  Flexion: 130  Pain @ back of hip is usually  Internal rotation: 20 referred from lumbar spine.  External rotation: 45

Fixed Flexion Deformity Thomas’ Test  Osteoarthritis  Caution if hip arthroplasty on non-test side  # NOF . Forced flexion can → dislocation  Assesses for fixed flexion deformity . Masked by compensatory movement in pelvis or lumbar spine . Obliterate lumbar lordosis . Angle between thigh and bed = fixed flexion deformity Features in OA of the Hip  ± Trendelenberg gait or +ve Test  Pain Completion  Stiffness  ↓ ROM: esp. internal rotation  Examine the knee and spine  Fixed flexion deformity  Perform a neurovascular assessment (esp. pulses).  AP and lateral radiographs of the pelvis

Set-Up  Pt. should be in their underwear  Note presence of walking aids  Start ¯c pt. standing

Look

Gait  Antalgic  Stiff: pelvis rises during swing phase  Varus thrust: medial collateral  Valgus thrust: lateral collateral

Examine Pt. Standing  Skin . Scars: arthroscopic ports, KR (midline longitudinal), menisectomy . Bruising, erythema  Shape . Swelling: knee and popliteal fossa (Baker’s Cyst) . Muscle wasting: quads, hamstrings  Measure quads circumference @ 15cm from tib tuberosity  Deformity . Genu vara (bow legged): OA . Genu valga (knock-knee): RA

Examine Pt. Supine

Feel Knee Effusion  Temperature  Synovial fluid: synovitis  Effusion: sweep test and ballot  Blood  Palpate O . 90% = ACL rupture . Position knees @ 90 . PCL rupture, intra-articular #, meniscal tear . Joint line for tenderness: meniscal pathology . Bleeding diathesis . Patella, tendon and tibial tuberosity  Pus: septic arthritis . Popliteal fossa

Move  Straight leg raise . Extensor lag . Hyperextension . Fixed flexion deformity  Passive flexion of knee while palpating joint for crepitus  Normal range = 0-140

Special Tests  Cruciate Ligaments . Ant + Post drawer tests: observe for posterior sag first = PCL tear . Lachman’s: ACL, more sensitive cf. drawer test . (Pivot shift test: only do in theatre under anaesthetic)

 Collateral Ligaments . In partial flexion ~30O (relax the joint capsule) and full extension . Valgus stress (medial lig.) and varus stress (lateral lig.)

 Menisci . (McMurray test) . (Apley grind test)

Completion  Examine the hip and ankle.  Perform a neurovascular assessment: esp. pulses  Standing AP and lateral and skyline radiographs of the knee

Definition Mx  Degenerative joint disorder in which there is progressive loss of hyaline cartilage and new bone MDT formation at the joint surface and its margin.  GP, physio, OT, dietician, orthopod

Conservative Aetiology / Risk Factors  Lifestyle: ↓ wt., ↑ exercise  Age (80% >75yrs)  Physio: muscle strengthening  Obesity  OT: walking aids, supportive footwear, home mods  Joint abnormality Medical  Analgesia . Paracetamol Classification . NSAIDs: e.g. arthrotec (diclofenac + misoprostol)  Primary: no underlying cause . Tramol  Secondary: obesity, joint abnormality  Joint injection: local anaesthetic and steroids

Surgical Symptoms  Arthroscopic Washout  Affects: knees, hips, DIPs, PIPs, thumb CMC . Mainly knees  Pain . Trim cartilage . Worse ¯c movement . Remove loose bodies. . Background rest/night pain  Realignment Osteotomy . Worse @ end of day . Small area of bone cut out  Stiffness . Useful in younger (<50yrs) pts. ¯c medial knee OA . Especially after rest: joint “gelling” . High tibial valgus osteotomy redistributes wt. to . Lasts ~30min (e.g. AM) lateral part of joint.  Deformity: e.g. genu varus  Arthroplasty: replacement (or excision)  ↓ ROM  Arthrodesis: last resort for pain management  Novel Techniques . Microfracture: stem cell release → fibro-cartilage formation Pathophysiology . Autologous chondrocyte implantation  Softening of articular cartilage → fraying and fissuring of smooth surface → underlying bone exposure.  Subchondral bone becomes sclerotic c cysts. ¯ OA vs. RA  Proliferation and ossification of cartilage in unstressed

areas → osteophytes. OA RA  Capsular fibrosis → stiff joints. Pathology Pathology - Degenerative - Inflammatory - Negative serology - Positive serology Ix Clinical Clinical Exclude Rheumatological Disease - Asymmetric - Symmetric  FBC - Large joints - Small joints  ESR - Early AM stiffness <30min - Early AM stiffness >1hr  RF, ANA - Worse PM - Worse AM - Hands: DIPJs and PIPJs - Hands: PIPJs and MCPJs Check Renal Function - No extra-articular features - Extra-articular features  Important before prescribing NSAIDs: esp. in elderly  U+E Radiology Radiology - Osteophytes - Soft tissue swelling X-ray Changes - Subchondral sclerosis - Periarticular osteopenia  Loss of joint space - Subchondral cysts - Periarticular erosions  Osteophytes - Mild deformity - Severe deformity

Subchondral cysts   Subchondral sclerosis  Deformity

History Complications  Pioneered in 60s by Sir John Charnley Immediate  Nerve injury Types  Fracture  Cement reaction THR  Replace femoral head, neck and acetabulum Early  Usually elective joint arthroplasty  DVT: up to 50% w/o prophylaxis  Deep infection: 0.5-1.5% Hemi-arthroplasty . Must remove metalwork before revision.  Replace femoral head and neck only  Dislocation (3%): squatting and adduction  May be uni- or bi-polar Late Resurfacing  Loosening: septic or aseptic  Replacement of surface of femoral head  Leg length discrepancy  Metalosis  Revision: most replacements last 10-15yrs Prostheses

Cemented: e.g. Thompson Preventing DVT  Recommended by NICE  DVT is commonest complication of THR  Peak incidence @ 5-10d post-op Uncemented: e.g. Austin-Moore  Easier to revise (may be useful in younger pts.) Pre-Op  TED stocking  Aggressive optimisation: esp. hydration Techniques  Stop OCP

Posterior Approach Intra-Op  Access joint and capsule posteriorly, reflecting of the  Minimise length of surgery short external rotators.  Using pneumatic compression boots  Gives good access  May have higher dislocation rate Post-Op  Sciatic N. may be injured → foot drop  LMWH: also rivaroxaban and dabigatran  Early mobilisation Anterolateral Approach  Good analgesia  Incision over greater trochanter, dividing fascia lata.  Physio  Abductors are reflected to access joint capsule.  Adequate hydration  May have lower dislocation risk  Sup. Gluteal N. may be injured → Trendelenberg gait Hip Resurfacing

Advantages  Metal-on-metal bearings wear less  Larger head → ↓ dislocation / ↑ stability  Preserve bone stock making revision easier

Disadvantages  Cobalt and chromium metal ion release may cause pathology (e.g. leukaemia)  Risk of NOF # if mal-positioned

Indications  May be used in young (<65), active people who are expected to outlive the replacement.

Types Haemarthrosis Differential  Can be uni- or bi-compartmental  Cemented: UK Primary Spontaneous  Uncemented: Europe  w/o trauma  May be 2O to coagulopathy

Aim Secondary to Trauma  Immediate knee swelling  Primary goal is to reduce pain  80% ACL injury O  10% 2 to patellar dislocation The Surgery  10% . Meniscal tear  Performed under tourniquet . Capsular tear  PCL is usually preserved . Osteochondral #  ACL is usually sacrificed . Prosthesis is specifically designed to provide some compensation for this  Metal prosthesis and an ethylene articular disc. Knee Locking Differential  Patella surface can be re-surfaced.  Meniscal tear  Knee bending after 2-3 days.  Cruciate ligament injury  10 days hospital stay  Osteochondritis dissecans: adolescents  Loose body

Complications Presentation of ACL Injury Immediate  Assoc. ¯c deceleration and rotational movements  Fracture  Hears a pop or feels something tear  Cement reaction  Inability to continue sport or activity  Vascular injury  Haemarthrosis w/i 4-6h . SFA  Instability / giving way following injury . Popliteal and genicular vessels  Nerve injury . Peroneal nerve → foot drop (1%) Unhappy Triad of O’Donoghue  ACL Early  MCL  DVT  Medial Meniscus . Up to 50-70% w/o prophylaxis . 25% ¯c prophylaxis  Deep infection: 0.5-15% . Must remove metalwork before revision. Mx of Meniscal Tear  Depends on Late . Age  Loosening: septic or aseptic . Chronicity of injury  Periprosthetic #s . Location and type of tear  ↓ ROM and instability . Loss of ACL Non-Surgical  Symptomatic Rx: e.g. analgesia

Surgical Mx of RA in the Knee Surgical  Indicated in failed medical Mx  Arthroscopic or open . Partial meniscectomy  Synovectomy and debridement . Meniscal repair . Can be done arthroscopically

 Removal of pannus and cartilage  Supracondylar osteotomy  Total knee arthroplasty Mx of ACL Rupture

Non-Surgical  Rest and phyio to strengthen quads and hamstrings  Not enough stability for many sports

Surgical  Gold-standard is autograft repair  Usually semitendinosus ± gracilis (can use patella)  Tendon threaded through heads of tibia and femur and held using screws.

Examination

Look  Hallux . Unilateral or bilateral . Estimate degree of valgus . Rotation: nail faces medially  Bunion . Prominence of 1st metatarsal head ± bursa . Evidence of inflammation: bursitis  Extras . Hammer toes . Callosities on heel Aetiology  Imbalance between intrinsic and extrinsic toe muscles Feel . Intrinsic: lumbricals  Inflammation of bunion . Extrinsic: long flexors and extensors  Localised tenderness  F>M . e.g. OA of MTPJs  Commoner in pts. ¯c RA  ↑ ¯c age Move  Assess ROM of toe joints Mx  Non-surgical: appropriate footwear Completion  Surgical correction  Assess ROM of other toe joints . Flexor-to-extensor tendon transfer  Assess gait . Arthrodesis  Examine shoes: abnormal weight-bearing . Resection of proximal phalangeal head

Viva

Aetiology  Familial tendency  ↑ enclosed / pointed shoes  Assoc. ¯c RA

Ix  Wt. bearing x-rays . Degree of valgus . OA of MTPJ

Non-surgical  Appropriate footwear: wide, soft  Physio

Surgical  Bunionectomy  1st metatarsal realignment osteotomy  Excision arthroplasty

Examination

Look  Swelling  Deformity  Pressure necrosis

Feel  Joint is not tender or warm  May feel crepitus  Subluxation or dislocation of the joint

Move  Abnormal

Completion  Neurological examination of the limb . Esp. pain and proprioception  Dip urine for glucose

Viva

Definition  Progressive destructive joint arthropathy  2O to disturbance of sensory innervation to the joint  Painless deformed joint resulting from repetitive minor trauma.

Causes

Peripheral  DM  Peripheral N. injury  Leprosy

Central  Syringomyelia  Tabes dorsalis

Phases Examination 1. Initial contact / heel strike 2. Stance Describe the Lump 3. Toe off  Visible popliteal swelling 4. Swing  Describe as for lump . SSS CCC TTTT FPS Abnormalities  Pulsatile: swelling overlying popliteal A.  Expansile: popliteal aneurysm Gait Description Cause  Fluctuant and transilluminable: cystic Antalgic ↓ stance Pain ↑ swing Completion Trendelenberg Hips dip Weak abductors  Continue ¯c knee exam: signs of OA Shoulders lurch to  Neurovascular assessment contralateral side

Parkinsonian Slow initiation Parkinsonism Shuffling steps Poor arm swing Viva Slow turn Broad-based Lurches to one side Cerebellar lesions Differential High stepping Foot strikes ¯c ball and Common peroneal  Skin + s/c tissue: lipoma slaps the ground L5 disc  Artery: popliteal aneurysm Spastic Internal rotation UMN  Vein: saphena varix @ SPJ Hips adducted  Nerve: tibial nerve neuroma  Enlarged bursae . Above knee joint line . Assoc. ¯c semimembranosus  Baker’s Cyst

Baker’s Cyst  Posterior herniation of knee joint capsule  Assoc. ¯c degenerative knee joint disease  Located below knee joint line

Dx: US

Mx  Aspiration possible: high recurrence

Look

Inspect shoulder girdle and axilla  Skin: scars, bruising, erythema  Shape . Wasting: deltoid, supra- and infra-spinatous Winging: Seratus Anterior Weakness . Clavicular deformity  Long-thoracic nerve damage: e.g. . Joint swelling axillary surgery  Deformity  Upper brachial plexus injury . Joint dislocation  Muscular dystrophy: e.g. FSH . Scapula location . Winging of the scapula

Feel Shoulder Differential: Pain ± ↓ROM  Temperature  Rotator cuff: tear, tendonitis  Along clavicle from SCJ to ACJ  Subacromial bursitis  Acromion and coracoid (2cm inf. + med. to clavicle tip)  Adhesive capsulitis (frozen shoulder)  Biceps tendon in bicipital groove  Joints: synovitis, OA, dislocation  Scapular spine  Humeral head: #, dislocation  Humoral head and greater and lesser tuberosities.  Referred pain from diaphragm

Move: active then passive Functional screen  Ask pt. to put both hands behind the head  Ask pt. to reach behind back and touch shoulder blades

Abduction and adduction  First 25O of abduction is supraspinatous, rest is deltoid  Palpate acromion tip during abduction to determine GHJ movement . Abduction at GHJ is ~80O, rest is scapula rotation.  Pain . 60-120O = impingement or rotator cuff tendonitis . 140-180 = AC osteoarthritis

Flexion and Extension Internal and external rotation  External rotation most commonly ↓d in frozen shoulder

Special Tests  Jobe’s Empty Can Test: Supraspinatus . Shoulder flexed @ 90O, thumb pointing down, forced flexion of shoulder

 Infraspinatus + Teres Minor . Elbow flexed @ 90O, forced external rotation of shoulder

 Gerber’s Lift Off: Subscapularis . Dorsum of hand placed against lumbar spine, pt. attempts to lift hand off against resistance

 Scarf Test: AC Joint Dysfunction . Place pt’s. hand on contralateral shoulder . Examiner pushes pt’s. flexed elbow posteriorly, eliciting discomfort

 Hawkin’s Test Shoulder: Impingement . Shoulder and elbow flexed @ 90O. . Examiner pushes hand down

 Apprehension Test: GHJ Instability . Shoulder is abducted and externally rotated to 90O . Apprehension occurs as shoulder is slowly externally rotated

Completion  Examine the cervical spine and elbow  Perform a neurovascular assessment © Alasdair Scott, 2012 158 Hand Examination

Set-Up  Expose pts. arms up to elbow  Lay hands on a pillow

Look Deformities  Dorsum and palms  RA . Boutonniere’s Skin . Swan neck  Scars: palm and carpal tunnel . Z-thumb  Erythema . Ulnar deviation @ the MCPs  Calcinosis and tophi . MCP volar subluxation  Ulceration  Dupuytron’s  Ganglia  Trigger Finger  Mallet Finger Muscle Wasting  Claw Hand  Median nerve: thenar eminence  Ulnar nerve: 1st dorsal interroseus Nails  Onycholysis Joints Swellings  Pitting  Heberden’s: distal  Subungual hyperkeratosis  Bouchard’s: proximal Extras  Elbows: rheumatoid nodules, psoriatic plaques  Scalp and behind ears: psoriatic plaques

Feel  Temperature  Joints: pain and swelling Autonomous Sensory Areas  Tendons: palm for nodules or thickening.  Median: pulps of index and middle fingers  Muscles  Ulnar: pulp of little finger . Median nerve: thenar eminence  Radial: 1st dorsal web space . Ulnar nerve: 1st dorsal interroseus

Move  Wrist . Prayer and reverse prayer positions Autonomous Motor Supply . Check that fingers are opposed in prayer position  Median: abductor pollicis brevis st  Thumb  Ulnar: 1 dorsal interosseous . Abduction  Radial: MCP extension  Fingers . Abduction and adduction (cross fingers for luck) . Opposition . Grip

Function  Fasten and unfasten button.  Pick up coin from flat surface  Write name

Special Tests

Median Nerve  Tinel’s  Phalen’s

Ulnar Nerve  Froment’s: flexion of thumb @ IPJ = weak ADductor policis de Quervain’s tenosynovitis (APL + EPB tendonitis)  Finkelstein’s

Completion  Neurovascular status of the upper limb.  AP and lateral radiographs © Alasdair Scott, 2012 159 Dupuytren’s Contracture

Examination Viva

Look Hx  Often bilateral and symmetrical  Associations  Tethering or pitting of palmar skin  Function  Visible tendon cords  Previous therapy  Surgical scars: Z plasties  Other features of diffuse fibromatosis  Fixed flexion of MCP and PIP joints . Usually little and ring fingers  Garrods Pads Associations: BAD FIBERS . Thickening of dorsal skin over PIPJ  Bent penis: Peyronie’s (3%)  AIDS Feel  DM  Palpate thickened tendons  FH: AD  Note fixation to skin  Idiopathic : commonest  Booze: ALD Move  Epilepsy meds and epilepsy: phenytoin  Assess ROM  Reidel’s thyroiditis and other fibromatoses  Note fixed deformities by loss of passive ROM . Ledderhose disease  Ask pt. to lay hand flat on table  Fibrosis of plantar aponeurosis  5% ¯c dupuytren’s Function . Retroperitoneal fibrosis  Ask pt. to pick up a coin and do up a button  Smoking

Completion  Abdominal exam for signs of CLD Pathophysiology  Hx and Drug chart  Local microvessel ischaemia → ↑ xanthine oxidase  Other features of diffuse fibromatosis activity → ROS production.  ROS → myofibroblast proliferation → collagen 3 formation  Chronic inflammation → continued fibrosis Differential  Skin contracture: look for scar from previous wound  Congenital contracture of little finger Non-Surgical Mx  Ulnar nerve palsy: ↓ sensation, +ve Froment’s sign  Physiotherapy  Allopurinol may help

Surgical Mx

Indication  MCP or PIP contracture >30O

Procedures  Fasciotomy  Partial fasciectomy . Z-plasty to lengthen wound . Post-op physio . Can damage ulnar nerve . Often recurs  Dermofasciectomy + full-thickness skin grafting . Lowest risk of recurrence  Arthrodesis and amputation

Examination Viva

Look Hx  Wasting of thenar eminence  Symptoms  Scars from previous surgery over flexor retinaculum . Tingling / pain in thumb, index and middle fingers . Pain worse @ night or after repetitive actions Feel . Relieved by shaking / flicking hand  Test light touch over finger pulps  Causes  Test light touch over the thenar eminence . Hypothyroidism . Pregnancy Move . RA  Previous treatments  Opponens pollicis

 Abductor pollicis brevis

Causes: I WRIST Special Tests  Idiopathic: commonest  Tinel’s  Water: pregnancy, hypothyroidism  Phalen’s  Radial #

 Inflammation: RA, gout Completion  Soft tissue swelling: lipomas, acromegaly, amyloidosis  Hx  Toxic: DM, EtOH  Look for underlying cause and associations

Ix Differential  Not typically necessary  More proximal median nerve lesion  Nerve conduction studies  Cervical root lesion . Determine lesion location . E.g. cervical disc herniation . Determine lesion severity  US

Non-surgical Mx  Mx of underlying cause  Wrist splints . Neutral position . Esp. @ night  Local steroid injections

Surgical Mx  Carpal tunnel decompression by division of the flexor retinaculum

Complications  Scar formation: high risk for hypertrophic or keloid  Scar tenderness: up to 40%  Nerve injury . Palmar cutaneous branch of the median nerve . Motor branch to the thenar muscles  Failure to relieve symptoms

Other Locations of Median Nerve Entrapment  Pronator syndrome . Entrapment between two heads of pronator teres  Anterior interroseous syndrome . Compression of the anterior interosseous branch by the deep head of pronator teres . Muscle weakness only  Pronator quadratus  FPL  Radial half of FDP

Examination Viva

Look Hx  Symptoms Hands . Early morning stiffness  Skin: joint erythema, palmar erythema . Pain  Joint Swelling: MCPs and PIPs . Swelling  Muscle wasting: interossei, thenar eminence  Affect on life  Deformity  Extra-articular features: aNTI CCP Or RF 1. Ulnar deviation @ the MCPs  Treatments tried so far + any complications 2. Boutonniere deformity 3. Swan neck deformity Extra-Articular Features: aNTI CCP Or RF 4. Z thumb  Nodules 5. MCP volar subluxation  Tenosynovitis: de Quervains and atlanto-axial subluxation  Immune: vasculitis, amyloidosis Surgical Scars  Cardiac: pericarditis ± effusion Wrist: carpal tunnel release   Carpal tunnel Thumb: joint replacement   Pulmonary: fibrosis, effusions Dorsum: tendon transfer   Ophthalmic: episcleritis, scleritis, Sjogren’s Ulna stylectomy   Raynaud’s

 Felty’s: RA + ↓PMN + splenomegaly Wrist

 Radial deviation Ix  Volar subluxation of the ulnar styloid

Elbow Bloods FBC: ↓Hb, ↓PMN  Rheumatoid nodules   ↑ESR and ↑CRP Feel  Immune: RF, anti-CCP, ANA, HLA-DR3/4

 ↑ temperature of swollen joints = active synovitis X-Ray Joint tenderness   Soft tissue swelling Median nerve sensation   Periarticular osteopenia

 Loss of joint space Move  Periarticular erosions  Fixed flexion on prayer position  Deformity  ↓ ROM Mx Special  Finkelstein’s MDT  Tinel’s and Phalen’s  GP, physio, OT, rheumatologist, orthopod

Function Conservative  Precision: unbutton shirt, pick up coin from table  Physio  Power: squeeze fingers  OT: aids and splints  Writing  Walking aids, splints, wheelchair Medical  Analgesia Completion  Steroids: IM, PO or intra-articular  Hx  DMARDS  Examine for other features of RA  Biologicals  Other: CV risk, prevention of PUD and osteoporosis Presentation  Symmetrical deforming polyarthropathy Surgical  Signs of active synovitis  Carpal tunnel decompression  Signs of cause  Tendon repairs and transfers . Rheumatoid nodules  Ulna stylectomy . Psoriatic plaques  Arthroplasty

Differential Anatomy of Rheumatoid Hands  Psoriatic arthritis  Boutonierre’s: rupture of central slip of extensor  Jacoud’s arthropathy expansion → PIPJ prolapse through “button-hole” created by the two lateral slips.  Swan: rupture of lateral slips → PIPJ hyper-extension

Examination Viva

Look Hx  Heberden’s nodes: swelling of DIPJs  Symptoms  Bouchard’s nodes: swelling of PIPJs . Pain  Squaring of the thumb CMC . Stiffness  Affect on life Move  Other joint disease  ↓ ROM of passive and active motion  Treatments so far

Function  Unbutton shirt OA of the Hands  Pick up coin from table  Typically affects  Writing . Thumb CMC . PIPJs Completion . DIPJs  Bouchard’s Nodes are strongly assoc. c polyarticular OA  Hx ¯

 Examine other joints for OA

 Hips, lumbar spine, knees Mx of OA Hands

Differential Non-Surgical  Physiotherapy  RA hands  Analgesia  Tophi

Surgical  Joint arthrodesis

Examination Examination

Look Look  Partial claw hand: little and ring fingers  Wrist drop: holds hands out in front, palms down  Wasting . Hypothenar eminence Feel . Dorsal interossei  Loss of sensation over the first dorsal interosseous  May be sensory loss over dorsal forearm Feel  Loss of sensation in ulnar distribution Move  Low Move . Loss of MCP extension  Weak abduction and adduction of fingers . Preserved PIPJ extension: lumbricals  Weak flexion of DIPJ in little and ring fingers  High: + wrist weakness  Very high: + triceps weakness Special  Froment’s Completion . Weak adductor pollicis → flexion of thumb IPJ  Examine neck: brachial plexus injury . Compensation by FPL  Examine PNS of affected limb  Elbow flex test . Full elbow flexion for 1min . → paraesthesia in little and ring fingers Viva

Completion Causes  Examine neck: brachial plexus injury  Examine PNS of affected limb Very High → triceps paralysis + wrist drop + finger drop  Just below brachial plexus  Compression: crutches Viva High → wrist drop + finger drop Causes of Ulnar Nerve Palsy  Occur at spiral groove  Mid-shaft humerus #, Saturday night palsy Anatomical Compression  Cubital tunnel syn.: elbow Low → finger drop  Guyon’s canal syn.: wrist  Occur at elbow  Only involve posterior interosseous nerve  sensation Trauma preserved  Supracondylar #s of humerus  Local wounds, # or dislocation  Elbow dislocation

Ulnar Paradox  Proximal lesions → paralysis of ulnar half of FDP  → ↓ marked clawing of hand

Non-surgical  Avoid repetitive flexion-extension of elbow  Avoid prolonged elbow flexion  Night splinting of elbow in extension

Surgical  Ulnar nerve decompression  Medial epicondylectomy

Examination Examination

Look Look  Flexion deformity of distal phalanx of one or more  Flexion of middle or ring finger fingers Feel Move  Palpate over palm proximally to digit for nodule.  Terminal phalanx cannot be actively extended . ~ @ level of transverse palmar crease  Can be passively extended Move  Test active movement of finger Viva  Snap on passive forced extension

Aetiology  Damage to extensor tendon of terminal phalanx. Viva  e.g. avulsion # due to hyperflexion injury when catching a cricket ball Pathology  Tendon nodule which catches on proximal side of Mx tendon sheath → triggering on forced extension.  X-ray: look for avulsion @ base of distal phalanx  Often FDS tendon  Splint ¯c distal phalanx in extension for 6wks to allow tendon reattachment. Causes  If avulsed bone is large may fix it ¯c a Kirschner wire  Idiopathic  Trauma  Activities requiring repetitive forceful flexion . e.g. use of heavy shears  2O to RA

Mx  Steroid injection: often recurs  Tendon release by sheath incision

Set-Up  Expose pt. to waist  Begin ¯c pt. standing

Look  Assess gait  Spinal curvature  Paraspinal and trapezius muscle bulk  Wall-tragus test if neck hyperflexion

Feel  Paraspinal muscle bulk and tenderness  Spine palpation: masses, steps  Spine percussion: tenderness

Move  Cervical spine movement  Lateral flexion: normally ~30O  Forward flexion: Schober’s Test . Mark 5cm below and 10cm above levels of PSIS (sacral dimples, ~S2) . Maximum flexion should lengthen line by ≥5cm

Lie pt. Supine  Assess back rotation ¯c arms folded across chest  Measure leg lengths: apparent length discrepancy in scoliosis

Sacroileitis Tests  Lateral compression  Stretch: adduction of hip, ¯c hip and knee flexed

Straight Leg Raise  Demonstrates lumbosacral nerve root irritation  Record angle @ pain onset . Lesague’s Sign . ↑ pain ¯c foot dorsiflexion

Quick Neurological Assessment of Lower Limb  Power . L4: foot inversion and dorsiflexion . L5: great toe dorsiflexion . S1: foot eversion and plantar flexion  Reflexes . S1: Ankle  Sensation . L5: great toe and medial dorsum . S1: little toe and lateral sole

Completion  Complete neurological examination of lower limb . Especially perineal sensation  Consider a PR: exclude cauda equina compression

Examination Viva

Look Hx  Gait: half-flexed, painful back  Occupation  Loss of normal lumbar lordosis  Pain: site, radiation, associated injury, worse / better  Posture: sciatic list  Neurology: weakness, numbness and paraesthesia . Attempt to ↓ nerve root compression by leaning  Sphincter disturbance to one side to open up the neural foramen  Hx or features of malignancy  Effect on lifestyle Feel  Previous Rx: analgesia, physio, surgery  Erector spinae spasm or tenderness

Move Pathophysiology  ↓ ROM: limited by pain  Pre-existing lumbar spondylosis  Rupture of annulus fibrosis ¯c herniation of nucleus Special Tests pulposus into spinal canal  Positive straight leg raise

Neurological Risk Factors  Distal weakness and sensory loss Physiological Disc Root Sensory Motor Reflex  ↑ age L4/5 L5 Inner foot dorsum Hallux exten  Poor posture L5/S1 S1 Outer foot sole Foot eversion Ankle  Poor aerobic fitness + plantarflex Occupational  Heavy manual labour Completion  Frequent bending, lifting, twisting  Complete neurological examination of lower limb  Repetitive or static work postures . Especially perineal sensation  Consider a PR: exclude cauda equina compression Psychosocial  Depression

Non-Surgical Mx

Conservative  Max 2d bed rest  Education: keep active, how to lift / stoop  Physiotherapy: “back school”  Psychosocial issues re. chronic pain and disability  Warmth

Medical  Analgesia: paracetamol ± NSAIDs ± codeine  Muscle relaxant: low-dose diazepam (short-term)  Facet joint injections

Surgical Mx

Indications  Progressive neurological deficit  Severe incapacitating pain  Failure of non-surgical options

Procedures  Percutaneous microdiscectomy  Endoscopic discectomy  Hemilaminotomy + discectomy

Contents Minimal Access Surgery ...... 169 Enhanced Recovery After Surgery ...... 169 Surgical Complications ...... 170 Laparoscopic Cholecystectomy ...... 171 Inguinal Hernia Repair: Hernioplasty ...... 171 Appendicectomy ...... 172 Nissen Fundoplication ...... 172 Gastrectomy ...... 173 Ivor-Lewis Oesophagectomy ...... 173 Whipple’s: Pancreaticoduodenectomy...... 173 Abdominal Aortic Aneurysm ...... 174 Carotid Endarterectomy ...... 174 Bypass Grafting ...... 175 Transurethral Resection of the Prostate ...... 175 Surgical Procedures Summary ...... 176

Advantages ERAS  Commonly employed in colorectal and orthopaedic Smaller Incisions surgery  ↓ post-op pain  ↓ risk of wound infection Aims  Faster post-op recovery  Optimise pre-op preparation for surgery  ↓ hospital stay  Avoid iatrogenic problems (e.g. ileus)  Better cosmesis  Minimise adverse physiological / immunological responses to surgery May allow better visualisation and access . ↑ cortisol and ↓ insulin (absolute or relative)  Can visualise and operate on pelvic organs in lap . Hypercoagulability appendicectomy. . Immunosuppression  Dx and fix contralateral hernia in lap hernia repair.  ↑ speed of recovery and return to function  Recognise abnormal recovery and allow early intervention Disadvantages  Different anatomy  ↓ tactile feedback (can’t feel colon tumours) Pre-op: optimisation  2D view of 3D structures  Aggressive physiological optimisation  Technically challenging and old skills may be lost . Hydration  Complications (e.g. haemorrhage) may be harder to Mx . BP (↑ / ↓)  Expensive . Anaemia  May take longer . DM . Co-morbidities  Smoking cessation: ≥4wks before surgery Common Procedures  Admission on day of surgery, avoidance of prolonged fast  Lap cholecystectomy  Carb loading prior to surgery: e.g. carb drinks  Lap appendicectomy  Fully informed pt., encouraged to participate in recovery  Lap hernia repair

 Lap colectomy (~25%)  Lap fundoplication Intra-op: ↓ physical stress  Short-acting anaesthetic agents Relative Contraindications  Epidural use  Pneumoperitoneum may not be tolerated by pts. ¯c  Minimally invasive techniques severe cardiorespiratory insufficiency.  Avoid drains and NGTs where possible . ↓ venous return, ↓ diaphragm movement  Bleeding disorders  Shocked patients Post-op: early return to function + mobilisation  Multiple adhesions  Aggressive Rx of pain and nausea  Early mobilisation and physiotherapy  Early resumption of oral intake (inc. carb drinks)  Early discontinuation of IV fluids  Remove drains and urinary catheters ASAP

Surgical Complications Wound Infection  5-7d post-op Immediate (<24h)  Organisms: S. aureus and Coliforms  Intubation → oropharyngeal trauma  Surgical trauma to local structures Operative Classification  Primary or reactive haemorrhage  Clean: incise uninfected skin w/o opening viscus  Clean/Cont: intra-op breach of viscus (not colon) Early (1d-1mo)  Contaminated: breach of viscus + spillage or opening  Secondary haemorrhage of colon  VTE  Dirty: site already contaminated – faeces, pus, trauma  Urinary retention Risk Factors  Atelectasis and pneumonia  Pre-operative  Wound infection and dehiscence . ↑ Age  Antibiotic association colitis (AAC) . Comorbidities: e.g. DM

. Pre-existing infection: e.g. appendix perforation Late (>1mo) . Pt. colonisation: e.g. nasal MRSA  Scarring  Operative  Neuropathy . Op classification and wound infection risk  Failure or recurrence . Duration . Technical: pre-op Abx, asepsis  Post-operative Colonic Surgery . Contamination of wound from staff  Early . Ileus Mx . AAC  Regular wound dressing . Anastomotic leak  Abx . Enterocutaneous fistulae  Abscess drainage . Abdominal or pelvic abscess  Late . Adhesions → obstruction . Incisional hernia Wound Dehiscence

Presentation Haemorrhage Classification  Occurs ~10d post-op  Preceded by serosanguinous discharge from wound  Primary: continuous bleeding starting during surgery

 Reactive Risk Factors . Bleeding at the end of surgery or early post-op O  Pre-Operative Factors . 2 to ↑ CO and BP . ↑ age  Secondary . Smoking . Bleeding >24h post-op . Obesity, malnutrition, cachexia . Usually due to infection . Comorbs: e.g. BM, uraemia, chronic cough, Ca

. Drugs: steroids, chemo, radio  Operative Factors . Length and orientation of incision . Closure technique: follow Jenkin’s Rule . Suture material  Post-operative Factors . ↑ IAP: e.g. prolonged ileus → distension . Infection . Haematoma / seroma formation

Mx  Replace abdo contents and cover ¯c sterile soaked gauze  IV Abx: cef+met  Opioid analgesia  Call senior and arrange theatre  Repair in theatre . Wash bowel . Debride wound edges . Close ¯c deep non-absorbable sutures (e.g. nylon)  May require VAC dressing or grafting

1. Establish Pneumoperitoneum Open: Lichtenstein Repair  Dissect down to and open the peritoneum @ umbilicus  Can be performed under LA or GA  Insert lap port and establish pneumoperitoneum  Insert 3 further ports under direct vision 1. Enter inguinal canal . Epigastrium  Skin incised along Langer lines from external ring ~5cm . R costal margin towards ASIS. . R flank  Incise Camper’s (fatty), then Scarpa’s (membranous)  Incise external oblique to enter inguinal canal. 2. Identify and Clip CA and CD  Retract gallbladder upwards and identify Calot’s triangle 2. Mobilise and retract spermatic cord . Sup: inferior edge of liver . Med: CHD 3. Identify and dissect hernial sac . Inf: cystic duct  Dissect hernial sac off cord . Contains: cystic artery, Calot’s/Lund’s node ±  May incise carefully and check for viscera aberrant RHA  Invaginate sac into peritoneal cavity.  Key to ID cystic duct and cystic artery and differentiate from CBD and RHA – “critical view of safety” 4. Cover defect and posterior wall c¯ tension-free mesh  Clip CD and CA.  May use operative cholangiogram to confirm absence of stones in CBD. Laparoscopic Repair

3. Dissect and Remove GB 2 Main Repair Techniques  Gallbladder dissected off liver and removed via  Totally ExtraPeritoneal (TEP) umbilical port. . Use balloon to blunt dissect extraperitoneal space posterior to recti. . Reduce hernial sac and cover defect ¯c mesh Complications  Trans-Abdominal Pre-Peritoneal (TAPP)  Conversion to open procedure: 5% . Mesh placed through incision in peritoneum  CBD injury: 0.3%  Bile leak Advantages  Retained stones  Allows ID and repair of contralateral hernia which may  Intra-abdominal haemorrhage or may not have been diagnosed. . May be controlled by compressing the hepatic  Quicker recovery artery in the free edge of the Foramen of Winslow  ↓ acute pain  Pringle’s Manoeuvre  ↓ complications  ↓ chronic pain Jaundice After Cholecystectomy Disadvantages Post-hepatic  Technically challenging  Gallstone retention  Longer operation  Biliary sepsis  More expensive  Thermal injury:  blunt dissection preferred  Ligation of common hepatic or common bile duct Complications  Early Pre-hepatic . Urinary retention  Haemolysis after transfusion . Haematoma / seroma formation: 10% . Infection: 1% Hepatic . Intra-abdominal injury (lap)  Halogenated anaesthetics  Late . Recurrence (<2%) . Ischaemic orchitis: 0.5%  2O thrombosis of pampiniform plexus . Chronic groin pain / paraesthesia: 5%

Post-op  Day cases unless co-morbidities  Discharge ¯c mild analgesics and mild laxatives  Return to work @ 1-2wks

Open Aim  Prevent reflux, repair diaphragm 1. Access the peritoneum  Transverse (Lanz) incision centred on McBurney’s point Procedure  Incise Camper’s and then Scarpa’s fascia  Usually laparoscopic approach  Muscle splitting incisions through abdominal muscles  Wrap gastric fundus around lower oesophagus  Incise transversalis fascia, pre-peritoneal fat and  Close any diaphragmatic hiatus peritoneum. Complications 2. Deliver caecum and find appendix  Gas-bloat syn.: inability to belch / vomit  ID caecum and follow taenia coli convergence at  Dysphagia if wrap too tight appendicular base.

3. Ligate mesoappendix and excise appendix  Identify, clamp, divide and ligate Mesoappendix and appendicular artery.  Clamp, divide and ligate appendix @ base.  Cauterise appendix mucosa and bury stump in caecum ¯c purse-string (absorbable suture)

4. Peritoneal lavage and close abdomen  Close abdomen in layers

If appendix is macroscopically normal  Remove anyway . 20% have microscopic inflammation . Avoids appendicitis in the future  Search for other cause . Meckel’s . Gynae pathology

Complications  Abscess formation  Right hemicolectomy (e.g. for carcinoid, caecal necrosis)

Laparoscopic

Advantages  Visualise and operate on pelvic organs  ↓ pain and quicker recovery  ↓ wound infection  Improved cosmesis

Commonest Appendix Positions  Retrocaecal: 65%  Pelvic:30%  Subcaecal:3%  Anteileal: 2%

© Alasdair Scott, 2012 172 Gastrectomy Ivor-Lewis Oesophagectomy  Two-stage surgical procedure for removing tumours of Antrectomy the distal two 3rds of the oesophagus.  Bilroth I: simple anastomosis  Billroath II / polya: duodenal stump oversewn + Procedure gastrojejunostomy  1st: abdominal roof-top incision . Assess for sub-diaphragmatic spread . Mobilisation of the stomach to form a gastric conduit . Resect para-oesophageal and cardiac LN  2nd: right thoracotomy . Mobilisation and resection of the oesophagus . End-to-end anastomosis of gastric conduit to remaining oesophagus

Whipple’s: Pancreaticoduodenectomy Total Gastrectomy Subtotal Gastrectomy  Performed for Ca of the head of the pancreas  Removal of: . Gastric antrum . Gallbladder . Head of the pancreas . Proximal duodenum . Regional lymph nodes

Complications

Physical  Ca: ↑ risk of gastric Ca  Reflux or bilious vomiting (improves ¯c time)  Abdominal fullness  Stricture  Stump leakage

Metabolic  Dumping syndrome . Abdo distension, flushing, n/v, fainting, sweating . Early: osmotic hypovolaemia . Late: reactive hypoglycaemia  Blind loop syndrome → malabsorption, diarrhoea . Overgrowth of bacteria in duodenal stump  Vitamin deficiency . ↓ parietal cells → B12 deficiency . Bypassing proximal SB → Fe + folate deficiency . Osteoporosis  Wt. loss: malabsorption of ↓ calories intake

Open Repair Indications  Exposure of aorta through midline laparotomy  Symptomatic (ECST, NASCET)  Aortic and iliac clamping . ≥70% (5% stroke risk per yr)  Replacement of aneurysmal segment ¯c dacron . ≥50% if low risk (<3%, typically <75yrs) graft . Perform w/i 2wks of presentation  Asymptomatic (ACAS, ACST) Complications . ≥60% benefit if low risk  Mortality . Elective: 5% Principals . Emergency: 50%  Usually performed under LA  MI . LA allows direct monitoring of neurological status  Renal failure . Under GA, transcranial US can monitor MCA flow  Anastomotic bleeding . EEG may also be used under GA  Graft infection  Internal, external and common carotid arteries are clamped.  Spinal or mesenteric ischaemia  May use temporary shunt to ensure cerebral perfusion  Distal trash from thromboembolisation  Lumen of internal carotid opened and plaque is removed.  Aortoenteric fistula Complications  7% risk of stroke or death w/i 30d Endovascular Repair: EVAR  Haemorrhage → haematoma  Can be carried out under regional anaesthesia or  MI GA  Hypoglossal nerve damage: rare  Involves interventional radiology and vascular . Tongue deviates towards affected side surgeons . Fasciculations  Endograft inserted through femoral artery over a guide-wire into the aneurysmal segment.  Proximal and distal stents are expanded → fixation

Complications  MI  Spinal or mesenteric ischaemia  Renal failure  Graft migration or stenosis  Endoleaks: leak into aneurysm sac . 1: perigraft leakage at proximal/distal attachment . 2: retrograde flow from collaterals – lumbar, IMA . 3: leakage between graft components . 4: leakage through graft fabric

Advantages  ↓ perioperative mortality (0.5-2% vs. 5%)  ↓ stress in high risk pts.  ↓ hospital stay  Improved cosmesis

Disadvantages  No data on long-term outcomes  Not all aneurysms amenable . E.g. need adequate infra-renal neck (≥15mm)  ↑ in late procedure-related complications  Life-long monitoring ¯c CT for endoleaks  No ↓ all-cause mortality at 5yrs due to fatal endograft failures (EVAR 1 and DREAM).  No ↓ all-cause mortality vs. medical therapy for pts. ineligible for open repair (EVAR 2)  More expensive

Indications Indications  V. short claudication distance  Surgical Rx of choice for BPH when medical Rx has failed.  Symptoms greatly affecting pt’s. QoL  Development of rest pain Principals  Performed under spinal anaesthetic Practicalities  Cystoscopic inspection  Need good proximal supply and distal run-off  Locate external urethral sphincter and use as distal  More distal grafts have ↑ rates of thrombosis resection landmark  Saphenous vein graft preferred below inguinal lig  Electrosurgical resection of prostatic tissue under direct . Either reversed or valves destroyed in situ vision . Must tie off tributaries first  Send chippings for histology  Prosthetic grafts may be employed  Insert 3-way catheter post-op to irrigate bladder  Above IL: Dacron  Below IL: PTFE Complications

Procedures Immediate  Aorta / double iliac occlusion  TUR syndrome . Aorto-bifem . Absorption of large quantity of fluids → ↓Na . Axillo-fem (less stressful to pt.)  Haemorrhage  Single iliac . Aorto-fem Early . Fem-fem crossover  Haemorrhage . Axillo-fem  Infection  SFA / PF  Clot retention: requires bladder irrigation . Fem-pop . Fem-distal (distal to popliteal, i.e. tibial A.) Late  Retrograde ejaculation: common Complications  ED: ~10%  Haematoma  Incontinence: ≤10%  Distal embolism  Urethral stricture: LUTS following TURP  Thrombosis  Recurrence

Upper GI

Name Pathology Procedure Pros and Cons Dohlman’s Procedure Pharyngeal pouch  Minimally invasive endoscopic stapling Nissen Fundoplication GORD  Wrap fundus around distal oesophagus Can → dysphagia Heller’s Achalasia  Longitudinal incision through muscularis Can → GORD cardiomyotomy propria @ the LOS Ramstedt’s Congenital pyloric  Longitudinal incision through muscularis pyloromyotomy stenosis propria @ the pylorus Ivor-Lewis Oesophageal Ca  Two-stage oesophagectomy Whipple’s Pancreatic Ca  Pancreaticoduodenectomy

Lower GI

Name Pathology Procedure Pros and Cons Mayo Repair Umbilical Hernia  Double-breast the linea alba ± sublay mesh. Lockwood Approach Femoral Hernia  Low incision over hernia ¯c herniotomy and Used electively herniorrhaphy. McEvedy Approach Femoral Hernia  High approach in inguinal region Used in emergency situation  Herniotomy and herniorrhaphy Allows inspection and resection of non-viable bowel TEP Inguinal Hernia  Totally ExtraPeritoneal lap hernia repair TAPP Inguinal Hernia  Trans-Abdominal Pre-Peritoneal lap hernia repair Lat. Sphincterotomy Anal fissure  Division of internal anal sphincter @ 3 Used when medical Mx fails O’clock SE: minor faecal incontinence Delorme’s Procedure Rectal prolapse  Perineal approach ¯c mucosal excision

Vascular

Name Pathology Procedure Pros and Cons Trendelenberg Op Varicosities  SFJ ligation Cockett’s Op Varicosities  Perforator ligation Trahere Transplantation Chronic  Transplant of axillary vein ¯c valve into venous deep venous leg veins Kistner Operation insufficiency  Venous valvuloplasty Palma Operation  Bypass venous obstruction ¯c contralateral GSV

Urology

Name Pathology Procedure Pros and Cons Palomo Operation Varicocele  High retroperitoneal approach for ligation of testicular veins  Transverse incision at the level of the ASIS centred on the mid-inguinal point. Lord’s Repair Hydrocele  Plication of the tunica vaginalis Jaboulay’s Repair Hydrocele  Eversion of the tunica vaginalis Dartos Pouch Undescended  Mobilisation of testis and placement in a Dartos prevents retraction Procedure testis s/c pouch via a hole in the dartos muscle.

Head and Neck

Name Pathology Procedure Pros and Cons Sistrunk’s Operation Thyroglossal  Excision of cyst and thyroglossal duct cyst

Contents Achalasia ...... 178 Oesophageal Cancer ...... 178 Pharyngeal Pouch: Zenker’s Diverticulum ...... 179 Sliding Hiatus Hernia ...... 179 Small Bowel Obstruction ...... 180 Large Bowel Obstruction ...... 181 Volvulus ...... 182 Other AXRs ...... 182 Perforated Viscus...... 183 Tension Pneumothorax ...... 183 Diverticulosis ...... 184 Colorectal Cancer ...... 184 Ulcerative Colitis ...... 185 Crohn’s Disease ...... 185 Gallstones ...... 186 Nephrolithiasis ...... 188 Subdural or Extradural Haematoma ...... 189 Digital Subtraction Angiogram ...... 190 Cervical Spine ...... 191 Hip Fracture ...... 191 Shoulder Dislocation ...... 192 Femoral and Tibial Fractures ...... 192 Colles’ Fracture ...... 193 Other Fractures ...... 193 Fracture Complications ...... 194

Image Image  Proximal dilatation of the oesophagus ¯c smooth distal  Irregular, shouldered stricture of the oesophagus tapering – the bird’s beak appearance. . An “apple-core” lesion  May be food particles visible.  Where?  Significant negative: apple-core stricture suggestive of . Distal third: adenocarcinoma (commoner) oesophageal SCC. . Proximal third: SCC . Occurs in ~3% of pts ¯c achalasia

Key Facts Key Facts Epidemiology Definition  M>F = 5:1  Focal motility disorder of the oesophagus caused by  ↑ in Transkei and China degeneration of the myenteric plexus of Auerbach Pathophysiology  65% adenocarcinoma Causes rd  Usually idiopathic . Lower 3 O . GORD → Barrett’s → dysplasia → Ca  May be 2 to Chagas disease  35% SCC rds Presentation . Upper and middle 3 . Assoc. ¯c EtOH and smoking  Dysphagia to liquids then solids . Commonest type worldwide  Retrosternal cramps  Spread  Regurgitation: esp. @ night ± aspiration pneumonia . Local → LNs → blood  Wt. loss

Ix Major Risk Factors  GORD → Barrett’s  Ba swallow  EtOH and smoking  CXR: wide mediastinum + double RH boarder  Achalasia  Manometry: failure of relaxation + ↓peristalsis  Plummer-Vinson: 20% risk of SCC  OGD: exclude oesophageal SCC

Mx Presentation  Progressive dysphagia  Med: CCB, nitrates  Wt. loss  Int: botox injection, endoscopic balloon dilatation  Upper 3rd: hoarseness + bovine cough  Surg: Heller’s cardiomyotomy (open or lap)

Ix  Dx: OGD + biopsy  Staging: CT, EUS, laparoscopy, mediastinoscopy

Mx  MDT  Oesophagectomy: 25% have resectable tumours . Ivor-Lewis 2 stage . McKeown 3 stage . 15% 5 year survival  Palliation: 75% of pts. . Analgesia . Laser coagulation . Stenting . 5% 5 year survival

© Alasdair Scott, 2012 178 Pharyngeal Pouch: Zenker’s Sliding Hiatus Hernia Diverticulum Image Image  Dilated pouch (the hernia) below a smooth, short, symmetric, ring-like constriction (the GOJ).  Contrast filling of blind-ended pouch adjacent to and in  May be assoc. ¯c smooth area f concentric narrowing in continuity ¯c the oesophagus. the distal oesophagus: reflux-stricture.

 Significant negative: apple-core stricture

Key Facts Key Facts Pathophysiology  Out-pouching between crico- and thyro-pharyngeal Classification components of the inf. pharyngeal constrictor.  Sliding (80%) . Pulsion diverticulum . Gastro-oesophageal junction slides up into chest  Area of weakness = Killian’s dehiscence . Often assoc. ¯c GORD

 Rolling (15%) Presentation . Gastro-oesophageal junction remains in  Dysphagia abdomen but a bulge of stomach rolls into chest  Swelling on left side of neck alongside the oesophagus  Regurgitation . LOS remains intact so GORD uncommon  Halitosis . Can → strangulation  Mixed (5%) Mx  Excision Presentation  Dohlman’s Procedure: endoscopic stapling  Often asymptomatic  Sliding hernias → GORD: dyspepsia  Rolling hernias → strangulation

Ix  CXR: gas bubble and fluid level in chest  Ba swallow: diagnostic  OGD: assess for oesophagitis  24h pH + manometry . Exclude dysmotility or achalasia . Confirm reflux

Rx  Conservative: ↓wt., raise head of bed, stop smoking  Medical: PPIs, H2RAs  Surgical . If intractable symptoms despite medical Rx. . Should repair rolling hernia (even if asympto) as it may strangulate.

Image Mx  Dilated loops of bowel ≥3cm in width  Centrally located Resuscitate: Drip and Suck  Valvulae coniventes: lines go completely across  Admit . Valvular flaps projecting into SB lumen  NBM  Many loops  Aggressive rehydration c¯ 0.9% NS  Many fluid level . Significant 3rd space losses . State orientation of pt.: erect or supine . On-going requirements  No gas in LB . Electrolyte disturbances . Catheterise: aim for 0.5ml/kg/hr  NGT Differential . Decompress upper GIT . Stops vomiting Common . Prevents aspiration  Mechanical  Analgesia: e.g. paracetamol + codeine phosphate . Adhesions: 60%  Abx: if evidence of strangulation or perforation . Hernias  Non-mechanical / Ileus Hx  Vomiting Other  Absolute constipation  Intraluminal  Colicky abdominal pain . Impacted faeces  Abdominal distension . FB  Past Hx: surgery or hernias . Gallstone  Mural Examination . Benign stricture  Dehydration . Malignant stricture  Features of strangulation or perforation . Congenital atresia  Surgical scars and hernias  Extra-mural  Bowel sounds: mechanical vs. non-mechanical . Pancreatic pseudocyst . Abscess . Congenital bands Ix  Ileus . Post-op Bloods . Peritonitis  FBC, CRP, amylase: inflammatory markers . Pancreatitis / local inflammation  U+E: dehydration and electrolyte abnormalities . Poisons: e.g. TCAs  VBG: ↑ lactate indicates strangulation . Metabolic: ↓K, ↓Na, ↓Mg, uraemia  G+S, clotting: anticipation of surgery . Mesenteric ischaemia Imaging  AXR  Erect CXR  CT ¯c oral contrast: transition point  Gastrograffin follow-thru: may be therapeutic if adhesional obstruction

Mechanical  Regular clinical examination: signs of strangulation  Consider need for parenteral nutrition  ~80% resolve w/o surgery  Laparotomy + adhesiolysis ± resection ± stoma . Failure of conservative Mx: up to 72hrs . Development of sepsis . Peritonitis . Evidence of strangulation

Ileus  Correct any underlying abnormalities . Electrolytes . Drugs  Consider need for parenteral nutrition

Image Resuscitate: Drip and Suck  Dilated loops of bowel ≥6cm in width  Admit  Peripherally located  NBM  Haustra: lines go partially across  Aggressive rehydration c¯ 0.9% NS . Sacculations caused by shorter taenia coli . Significant 3rd space losses  No gas in rectum . On-going requirements . Electrolyte disturbances . Catheterise: aim for 0.5ml/kg/hr Differential  NGT . Decompress upper GIT Common . Stops vomiting . Prevents aspiration  Mechanical  Analgesia: e.g. paracetamol + codeine phosphate . Carcinoma: 60%  Abx: if evidence of strangulation or perforation . Diverticular stricture: 20%

. Volvulus

Other Hx  Intraluminal  Symptoms . Impacted faeces . Vomiting . FB . Absolute constipation  Mural . Colicky abdominal pain . Benign stricture . Abdominal distension . Malignant stricture  Cause  Extra-mural . Ca: change in bowel habit, ↓wt., PR bleed . Adhesions . Diverticulitis . Hernia . Abscess Examination . Haematoma  Dehydration . Tumour: e.g. ovarian  Features of strangulation or perforation  Ileus  Masses: neoplastic or inflammatory . Pseudo-obstruction: Ogilvie’s syndrome  Bowel sounds: mechanical vs. non-mechanical . Metabolic: ↓K, ↓Na, ↓Mg, uraemia  PR: rectal mass, impacted stool, blood . Poisons: e.g. TCAs . Mesenteric ischaemia Ix

Bloods  FBC, CRP, amylase: inflammatory markers  U+E: dehydration and electrolyte abnormalities  VBG: ↑ lactate indicates strangulation  G+S, clotting: anticipation of surgery

Imaging  AXR  CT ¯c oral contrast: transition point  Gastrograffin enema: mechanical obstruction

Mx  Regular clinical examination: signs of strangulation  Consider need for parenteral nutrition  Non-surgical: endoscopic stenting . May offer bridge to surgery (CREST Trial)  Surgical . Indications  Closed loop obstruction  Obstructing neoplasm  Strangulation or perforation  Failure of conservative Mx . Hartmann’s procedure . Colectomy + 1O anastomosis . Palliative bypass procedure

Image Chronic Pancreatitis  Inverted U / Coffee bean sign  Horizontal speckled calcification @ ~ L1/L2  Emerging from LIF: sigmoid (commoner)  Emerging from RIF: caecal Differential: Pancreatic Ca

Causes  Alcohol Key Facts  Genetic: CF, HH

 Immune: lymphoplasmacytic sclerosing pancreatitis Pathophysiology  ↑ TGs  Long mesentery ¯c short base predisposes to torsion  Structural: obstruction by stone  Vascular supply may be compromised → strangulation  ↑ risk in psychogeriatric pts.: disease and Rx AAA  Typically a long Hx of constipation  Fusiform calcification in the midline

Presentation Gallstones  Cluster of circular calcifications @ ~L1  Often elderly pts. c comorbidities ¯  Grossly distended, tympanic abdomen Rigler’s Triad  SBO  Pneumobilia Mx  Gallstone in RIF  Resuscitate: drip and suck  Sigmoid Rigler’s Sign . Detorse c flatus tube ¯  Air on both sides of bowel wall . May need sigmoid colectomy . Looks like double contrast . Often recurs  Is falciform ligament also visible?  Caecal . ~ 10% can be detorsed by colonoscopy Foreign Bodies .  often needs surgery  Unstable: theatre  Caecostomy O  Stable  Right hemi ¯c 1 ileocolic anastomosis . Endoscopic removal

. Watch and wait ¯c serial radiographs  Batteries Gastric Volvulus . Oesophagus: remove . Stomach: safe Film  Large sharp objects  Gastric dilatation . May consider laparotomy  Double bubble on erect films

Presentation  Vomiting  Pain  Failed attempts to pass NGT

Risk Factors  Rolling hiatus hernia  Gastric / oesophageal surgery

Mx  Endoscopic manipulation  Emergency laparotomy

Image Image  Air under the diaphragm  Absent peripheral lung markings  Rigler’s Sign  Mediastinal shift away from abnormality

Differential Extras  Spontaneous: perforated DU  Surgical emphysema  Iatrogenic: laparotomy / laparoscopy  Evidence of cause: e.g. rib #s  Traumatic  Miscellaneous: e.g. via female genital tract Key Facts

Key Facts Mx: surgical emergency  Decompressive thoracostomy Presentation . 14G Venflon in 2nd ICS mid-clavicular line  Sudden onset, severe epigastric pain  Continue resuscitation of pt.  Vomiting  Insert a chest drain  Peritonitic abdomen

Clinical Signs Ix  Respiratory distress  Bloods  ↑JVP, ↓BP . FBC, CRP, amylase  Tracheal shift + displaced apex . U+E  Hyper-resonance to percussion . G+S, clotting  ↓ breath sounds  Imaging  ↓ vocal resonance . Erect CXR  Upright for 15min first  70% show free air Pathophysiology . AXR: Rigler’s sign  One way flap valve allows air to be drawn into pleural cavity on each inspiration without escape.  Mediastinal shift compresses the great vessels, Mx: surgical emergency preventing filling of the heart → shock.

Resuscitation  Admit Types of Pneumothorax  NBM  Aggressive fluid resuscitation Traumatic rd . 3 space + on-going losses  Open: may be sucking . Titrate to UO  Closed  NGT  Either may be under tension  Abx: local guidelines (probably cef+met)  Analgesia: morphine + cyclizine Spontaneous  1O: no underlying lung disease Preparation for Surgery  2O: underlying lung disease  Anaesthetist and book theatre  Bloods: clotting + G&S  Consent  DVT prophylaxis  ECG: if >55yrs or cardiovascular disease

Laparotomy  DU: abdominal washout + omental patch repair  GU: excise ulcer and repair defect . Send specimen for histology to exclude Ca

Conservative  May consider if pt. isn’t peritonitic  Careful monitoring, fluids, Abx  Omentum may seal perforation spontaneously f/up  Test and Treat for H. pylori: +ve in ~90% of perfed DUs

Image Image  Typically double-contrast enema  Typically double-contrast enema  Out-pouchings of mucosa  Apple-core stricture ¯c shouldered margins  Especially around sigmoid colon Extras Extras  Evidence of perforation  Evidence of stricturing  Evidence of obstruction: proximal flow of contrast  Evidence of perforation: contrast leak  Evidence of UC: lead-piping

Key Facts Key Facts

Definition Risk Factors  Out-pouching of tubular structure  Diet: ↓ fibre + ↑ refined carbohydrate  False: composed of mucosa only  IBD: CRC in 15% ¯c pancolitis for 20yrs  Familial: FAP (5), HNPCC (2), Peutz-Jeghers (19) Pathophysiology  Smoking  30% of Westerner’s by 60yrs  Genetics  F>M . No relative: 1/50 CRC risk  High intraluminal pressures → herniation of mucosa . One 1st degree: 1/10 through muscularis propria @ points of weakness  NSAIDs / Aspirin (300mg/d): protective where perforating arteries enter.  May be part of Saint’s Triad Presentation (left-sided) . Diverticular disease  Change in bowel habit . Hiatus hernia  PR mass: 60% . Cholelithiasis  Obstruction: 25%  Tenesmus Diverticular Disease  PR bleed  Altered bowel habit  Systemic: wt. loss, malaise  Left-sided colic: relieved by defaecation  Rx Dukes Staging . High-fibre diet, mebeverine may help  Sir Cuthbert Dukes: St. Mary’s Pathologist . Elective laparoscopic sigmoid colectomy

Spread % 5ys Diverticulitis A Confined to bowel wall 90  Left-sided abdominal pain and localised tenderness B Through bowel wall but no LNs 60  Pyrexia C Regional LNs 30 D Distant mets <10 Ix  CT has very high sensitivity and specificity Mx  Water soluble contrast studies may occasionally be  MDT helpful  Colonoscopy: allows biopsy to grade tumour

Hinchey Grading  Stage ¯c CT or MRI  1: small confined pericolic abscess (<5% mortality)  60% amenable to radical therapy  2: large abscesses extending into pelvis (<5%) . Excision depends on lymphatic drainage, mobility  3: purulent peritonitis (~15%) of bowel and blood supply @ excision margins. . Laparoscopic resection under ERAS pathway is  4: faecal peritonitis (~45%) current standard of care.

. Adjuvant 5-FU for Dukes C: ↓ mortality by 25% Mx

 Resus: admit, NBM, fluids, Abx  1-2: surgery rarely needed Screening  3: on table washout may suffice  FOB . 60-75yrs  4: Hartmann’s . Home testing every 2yrs + colonoscopy if +ve

. ↓ risk of dying from CRC by 25% Other Complications  Flexi Sig  Perforation . Introduced in 2011/12  Abscess . 55-60yrs  Fistula . One of flexi sig  Bleeding . ↓ mortality by ~45%  Stricture

Image Image  Usually a double contrast enema  Small bowel follow through or enteroclysis  Lead-piping: no haustra . Replaced by CT enterography or CT enteroclysis  Mucosal thickening ± thumb-printing  Rose-thorn ulcers  Pseudopolyps  String sign of Kantor: narrow terminal ileum  Cobble-stoning: ulceration of mural oedema Extras  Skip lesions  Transition point to normal bowel  Apple-core lesion Extras  Evidence of perforation: contrast leak

Key Facts Key Facts Pathology  Mucosal inflammation Pathology  Contiguous disease: rectum proximally  Transmural, non-caseating granulomatous inflammation  Broad, shallow ulceration  Non-contiguous: anywhere from mouth to anus  Pseudopolyps: islands of regenerating mucosa . Predilection for terminal ileum  No strictures, fistulae, granulation  Deep, serpiginous ulceration + mucosal oedema . → cobblestone mucosa Severe Attack: Truelove and Witts Criteria  Prominent strictures, fistulae  Hx: motions >6/d + large PR bleed  o/e: temp >37.8 + HR >90 Severity  Ix: ESR >30 + Hb <10.5  Clinical: ↑ temp, ↑HR, wt. loss  Ix: ↑EXR/CRP, ↑WCC, ↓albumin, ↓Hb Acute Mx  Resus: NBM, IV hydration, analgesia Acute Mx  Hydrocortisone: IV + PR  Resus: NBM, IV hydration, analgesia  LMWH  Hydrocortisone: IV ± PR  Monitoring: examination, stool chart, bloods  Abx: metronidazole . Improving: PO steroids + mesalazine  LMWH . Deteriorating: ciclosporin, infliximab, surgery  Dietician review: elemental diet or parenteral nutrition  Monitoring: examination, stool chart, bloods Complications . Improving: PO steroids  Toxic megacolon . Deteriorating: methotrexate, infliximab, surgery  Haemorrhage  Ca: CRC in 15% ¯c pancolitis @ 20yrs Complications  Fistulae  Strictures  Abscesses  Malabsorption

Extra-Intestinal Features of IBD

Skin  Clubbing  Erythema nodosum  PG (esp. UC)

Mouth  Aphthous ulcers

Eyes  Anterior uveitis  Episcleritis

Joints  Large joint arthritis  Sacroileitis

Hepatic  Fatty liver  Chronic hepatitis → cirrhosis  Gallstones (esp. CD)  PSC + cholangiocarcinoma (esp. UC)

Imaging Key Facts

US Epidemiology  Stones → acoustic shadow  ~8% of the population >40yrs  Dilated ducts: >6mm  Incidence ↑ over last 20yrs: western diet . ± stones in ducts  Slightly ↑ incidence in females  Inflamed GB: wall oedema  90% of gallstones remain asymptomatic

Formation ERCP  Endoscopic retrograde cholangiopancreatography General Composition . Side-viewing endoscope  Phospholipids: lecithin . Cannulation of sphincter of Oddi  Bile pigments (broken down Hb) . Injection of radiocontrast allows biliary tree  Cholesterol imaging  Film Aetiology . Filling defects: stones  Lithogenic bile: Admirand’s Triangle . Duct dilatation  Biliary sepsis . Stricturing  GB hypomotility → stasis  PSC . Pregnancy, OCP  Lap chole . TPN, fasting  Cholangiocarcinoma . Extrinsic compression: Ca pancreas Cholesterol Stones: 20%  Therapeutics  Large . Sphincterotomy + trawling of ducts allows stone  Often solitary removal.  Formation ↑ according to Admirand’s Trangle . Strictures may be stented or dilated . ↓ bile salts  Complications . ↓ lecithin . Pancreatitis: 5% . ↑ cholesterol . Bleeding: esp. in jaundiced pts.  Risk factors  Check clotting first . Female . Bowel perforation . OCP, pregnancy . Contrast allergy . ↑ age . High fat diet and obesity . Racial: e.g. American Indian tribes . Loss of terminal ileum (↓ bile salts) MRCP  MR cholangiopancreatography Pigment Stones: 5% . Non-invasive and no contrast necessary  Small, black, gritty, fragile . No therapeutic capabilities: Dx only  Calcium bilirubinate  Film  Associated ¯c haemolysis . Filling defects

. Strictures Mixed Stones: 75% . Duct dilatation  Often multiple  Cholesterol is the major component PTC  Percutaneous transhepatic cholangiography . Injection of contrast into biliary tree via needle Complications directly through skin. . Not commonly performed now In the Gallbladder  Contrast fills from proximal to distal (cf. ERCP) 1. Biliary Colic  Look for presence of needle cannulating a duct. 2. Acute cholecystitis ± empyema  No endoscope visible 3. Chronic cholecytsitis 4. Mucocele 5. Carcinoma 6. Mirizzi’s syndrome

In the CBD 1. Obstructive jaundice 2. Pancreatitis 3. Cholangitis

In the Gut 1. Gallstone ileus

Common Causes Pathogenesis  Gallstones: 45%  Stone or sludge impaction in Hartmann’s pouch  Alcohol: 25%  → chemical and / or bacterial inflammation  Idiopathic: 20% (?microstones)  5% are acalculous: sepsis, burns, DM

Presentation Presentation  Vomiting + severe epigastric pain  Continuous severe RUQ pain → right scapula  Fever  Fever  Hypovolaemia  Murphy’s sign  Bruising: Cullen’s and Grey-Turner’s  Boas’ sign: hyperaesthesia below R scapula

Modified Glasgow Criteria Ix  Valid for EtOH and Gallstones  Urine: ↑ cBR, ↓ urobilinogen  Assess severity and predict mortality  Bloods  Ranson’s criteria are only applicable to EtOH and can . FBC, amylase, CRP only be fully applied after 48hrs. . U+E: dehydration . LFTs PANCREAS . Clotting and G+S: anticipation of surgery  PaO2 <8kPa 1 = mild  Imaging  Age >55yrs 2 = mod . Erect CXR: exclude perfed DU  Neutrophils >15 x109/L 3 = severe . US: stones, inflammation, dilated ducts  Ca2+ <2mM  Renal function U>16mM Mx  Enzymes LDH>600iu/L AST>200 iu/L Conservative  Albumin <32g/L  NBM  Sugar >10mM  IV hydration and correction of electrolyte abnormalities  Analgesia: e.g. paracetamol + pethidine Ix  Abx: cefuroxime + metronidazole  Urine: ↑ cBR, ↓ urobilinogen  80-90% settle over 24-48hrs  Bloods . FBC, amylase, CRP (>150 in 1st 48hrs = severe) Surgical . U+E: dehydration  If <72hrs: may perform “hot gallbladder” . LFTs: cholestatic picture  Otherwise, elective lap chole @ 6-12wks . Ca, glucose, ABG: scoring  Imaging Empyema . CXR: exclude perfed DU, ARDS  High fever . AXR: sentinel loop, pancreatic calcification  RUQ mass . US: gallstones + dilated ducts  Percutaneous drainage: cholecystostomy . Contrast CT: Balthazar severity score

Mx  Principals . Mx @ appropriate level: e.g. ITU if severe . Constant reassessment is key: esp. fluid balance  Conservative . Aggressive fluid resuscitation + UO monitoring . NBM + NGT . Analgesia: pethidine via PCA . Penems if suspicion of sepsis  Interventional . ERCP may be needed if 2O to gallstones

Complications  Early . Hypovolaemia → shock and renal failure . SIRS → ARDS and DIC . Metabolic: ↑ glucose, ↓Ca  Late . Pseudocyst: 20% . Pancreatic necrosis, infection and abscess . Bleeding: e.g. from splenic artery . Thrombosis: e.g. portal vein . Fistula formation: e.g. pancreatico-cutaneous

Image Key Facts

IVU Stone Types  Failure of distal flow of contrast  Calcium oxalate: 75%  Standing column of contrast  Triple phosphate (struvite): 15%  Clubbing of calyces . Ca Mg NH4 – phosphate  Delayed, dense nephrogram . May form staghorn calculi . Assoc. c proteus infection  Visible stone ¯  Urate: 5% (radiolucent) Ask to see KUB control film . Double if confirmed gout  90% of stones radio-opaque  Cystine: 1% (faint) . Assoc. ¯c Fanconi Syn. Technical  600x radiation dose of KUB Pathophysiology  Urograffin contrast injection  ↑ concentration of urinary solute  Immediate film + 30min + 1h  ↓ urine volume  Urinary stasis Contraindications to IVU  Contrast allergy Common Anatomical Sites  Pregnancy  Pelviureteric junction  Severe asthma  Pelvic brim  Metformin  Vesicoureteric junction  Significant renal impairment Ureteric Colic Alternative  Severe loin pain radiating to the groin  Non-contrast CT-KUB is gold standard  Assoc. ¯c n/v  99% of stones visible  Pt. cannot lie still

Initial  Analgesia  IV or oral fluids

Conservative: <5mm in lower 1/3 of ureter  90-95% pass spontaneously  Sieve urine for OPD stone analysis

Medical Expulsive Therapy: 5-10mm  Nifedipine or tamsulosin  Most pass w/i 48h

Active Stone Removal  Indications . Stones >10mm . Persistent obstruction . Renal insufficiency . Infection  Procedures . Extracorporeal shockwave lithotripsy . Ureterorenoscopy + Dormier basket removal . Percutaneous nephrolithotomy . Lap or open stone removal

Febrile c¯ Renal Obstruction  Surgical emergency  Percutaneous nephrostomy or ureteric stent  IV Abx: e.g. cefuroxime 1.5g IV TDS

Imaging Key Facts

Axial Non-Contrast CT Head Brain Injury  Extradural: lentiform opacification  Subdural: sickle-shaped opacification Primary  Occurs @ time of injury as result of direct injury Extras  Diffuse  Midline shift . Concussion: temporary ↓ in brain function  Associated cerebral contusion: coup + contra-coup . Diffuse axonal injury  Associated sub-arachnoid haemorrhage  Focal  Colour of haematoma . Contusion . White (hyperdense): acute . Intracranial haemorrhage . Pale grey (hypodense): chronic (~3wks)  Ask to bony window to accurately assess for skull # Secondary  Occur after primary injury  Causes . ↑ ICP . Infection . Hypoxia or hypercapnoea . Hypotension

Monroe-Kelly Doctrine  Cranium is rigid box  total volume of intracranial contents must remain constant if ICP is not to change.  ↑ in volume of one constituent → compensatory ↓ in another: . CSF . Blood (esp. venous)  These mechanisms can compensate for a volume change of ~100ml before ICP ↑. . As autoregulation fails, ICP ↑ rapidly → herniation.

Cushing Reflex: imminent herniation  Hypertension  Bradycardia  Irregular breathing

NICE Indications for Head CT  Basal or depressed skull #  Amnesia >30min retrograde  Neurology: seizures, focal weakness, blown pupil  GCS: <13 @ scene or <15 2h after trauma  Sickness: persistent vomiting

Any amnesia or LOC + 1 of  Dangerous mechanism  >65yrs  Coagulopathy

Image Key Facts  Vessel stenosis  Distal filling by collaterals Definitions

Extras Acute: ischaemia <14d  Aortoiliac occlusion → Leriche Syndrome  Incomplete: limb not threatened (e.g. thrombosis)  Complete: limb threatened (e.g. embolism) . Loss of limb unless intervention w/i 6hrs  Irreversible: requires amputation

Chronic: stable ischaemia >14d  Critical: ankle pressure <50mmHg + either . Persistent pain requiring opioid analgesia . Ulceration or gangrene

Presentation

Acute Chronic  Pain  Asymptomatic  Pulseless  Intermittent claudication  Pallor  Rest pain  Cold  Ulceration and gangrene  Paraesthesia  Leriche Syndrome  Paralysis . ED + buttock claudication

Risk Factors

Modifiable Non-modifiable  Smoking  FH and PMH  BP  Male  DM control  ↑ age  Hyperlipidaemia  Genetic  ↓ exercise

Mx of Chronic Ischaemia  Non-surgical . CV risk factor control . Antiplatelet agents . Analgesia . Graded exercise programs: walk through pain  Interventional . Angioplasty ± stenting  Surgical . Reconstruction . Endarterectomy . Amputation

Mx of Acute Ischaemia  Resus: NBM, hydration, analgesia  UH IVI: prevent thrombus extension  Angiography: only if incomplete occlusion  Surgery . Embolectomy ¯c Fogarty catheter . Emergency reconstruction  Complications . Reperfusion injury → compartment syndrome . Chronic pain syndromes  Treat cause . e.g. warfarinise . Mx CV risk

Imaging Imaging  Views  Need orthogonal views: AP + Lat . Lateral  Follow Shenton’s lines . AP  Intra- or extra-capsular? . Open-mouth “Peg” view  Displaced or non-displaced: Garden classification  Adequacy . Must see C7-T1 junction Extras . May need swimmer’s view ¯c abducted arm  Osteopaenic?  Alignment: 4 lines  Osteoarthritic? . Ant. vertebral bodies  Check for pelvic ring #s . Ant. vertebral canal . Post. vertebral canal . Tips of spinous processes Key Facts  Bones: shapes of bodies, laminae, processes  Cartilage: IV discs should be equal height Epidemiology  Soft tissue  50% >80yrs . Width of soft tissue shadow anterior to upper vertebrae should be 50% of vertebral width.  F>M=3:1  30% mortality @ 1yr  50% never regain pre-morbid functioning

Clearing the C-Spine Classification

 Intracapsular: subcapital, transcervical, basicervical Clinical Clearance  Extracapsular: Intertrochanteric, subtrochanteric

Indication: NEXUS Criteria Garden Classification of Intracapsular Fractures  Neurological deficit 1. Incomplete #, undisplaced  Spinal tenderness in the midline 2. Complete #, undisplaced  Altered consciousness 3. Complete #, partially displaced  Intoxication 4. Complete #, completely displaced  Distracting injury Initial Mx: Optimise the Pt. Method  Resus: hydration, neurovascular status, analgesia  Examine for bruising or deformity  Anaesthetist and book theatre  Palpate for deformity and tenderness  Bloods: FBC, U+E, clotting, x-match 2u  Ensure pain-free active movement  CXR  DVT prophylaxis  ECG Radiological Clearance  Films: orthogonal x-rays  Get consent Indications  Pt. doesn’t meet criteria for clinical clearance Surgical Mx

Modalities Intracapsular  Radiograph initially  1,2: ORIF ¯c cancellous screws . Clear if normal radiograph and clinical exam  3,4: CT C-spine if abnormal radiograph or clinical exam  . <55: ORIF ¯c screws.  f/up in OPD and do arthroplasty if AVN develops (in 30%) . >55: THR or hemiarthroplasty

Extracapsular  ORIF ¯c DHS

Discharge  Involve OT and physios  Discharge when mobilisation and social circumstances permit.

Specific Complications  AVN of fem head in displaced #s: 30%  Non / mal-union: 10-30%  Infection  Osteoarthritis

Imaging Imaging  Typically anterior dislocation ¯c humeral head located  Request AP and lateral antero-inferiorly.  Bankhart lesion: damage to glenoid labrum  Hill-Sachs lesion: cortical depression in posterolateral Key Facts part of humeral head. Mx  Resuscitate and Mx life-threatening injuries first Key Facts  Assess neurovascular status of limb . Urgent angiography if distal pulses compromised Presentation  X-match: femoral – 4u, tibial – 2u  Severe pain  Open  Loss of shoulder contour . Analgesia: morphine and metoclopramide  Humeral head palpable in infraclavicular fossa . Assess: NV status + photo . Asepsis: wash, cover ¯c sterile soaked gauze Mx . Alignment: reduce and splint  Resuscitate . Abx: augmentin 1.2g IV  Analgesia . Anti-tetanus  Assess NV deficit: 5% axillary nerve injury  Debridement and fixation in theatre . ORIF  Reduction under sedation: e.g. propofol O . Ex-Fix . Hippocratic: Longitudinal traction ¯c arm in 30

abduction and counter traction @ the axilla . Kocher’s: external rotation of adducted arm, Gustillo Classification of Open #s anterior movement, internal rotation 1. Wound <1cm in length  Sling for 3-4wks 2. Wound ≥1cm ¯c minimal soft tissue damage  Physio 3. Extensive soft tissue damage

Complications Clostridium perfringes  Recurrent dislocation  Most dangerous complication of open # . 90% of pts. <20yrs with traumatic dislocation  Wound infections and gas gangrene  Axillary N. injury  ± shock and renal failure  Rx: debride, benpen + clindamycin

Other Complications  Femoral . Hypovolaemic shock . NV: SFA and sciatic nerve  Tibial . NV injury . Compartment syndrome  Fat embolism

Imaging Monteggia rd  Extra-articular # of the distal radius  # of proximal 3 of ulna shaft  Dorsal displacement of distal fragment  Anterior dislocation of radial head at capitellum  Dorsal angulation of distal fragment  May → palsy of deep branch of radial nerve → weak  ± avulsion of ulna styloid finger extension but no sensory loss

Extras Galleazzi rds  ↓ radial height (normal = 11mm)  # of radial shaft between middle and distal 3  ↓ radial inclination (normal = 22O)  Dislocation of distal radio-ulna joint  Loss of volar tilt (normal = 11O volar)

Supracondylar Humeral # Key Facts Classification Eponym  Extension: distal fragment displaces posteriorly  Described clinically by Irish surgeon Abraham Colles in  Flexion: distal fragment displaces anteriorly 1814.  Dinner fork deformity Complications  NV: brachial artery and median nerve mainly Mx  Compartment syndrome  Resuscitate + Mx life-threating injuries  Malunion: gunstock deformity (cubitus varus)

 Assess NV injury: median N. and radial A.  Reduction + fixation . Haematoma block or Bier’s block (c¯ prilocaine) Proximal Humerus # . Dorsal backslab ¯c 3-point pressure  Surgical neck: axillary nerve damage  Fracture clinic appointment for ortho assessment  Shaft: radial nerve → wrist drop  Mx: collar and cuff or ORIF Specific Complications  Median N. injury  Frozen shoulder / adhesive capsulitis Distal Fibula  Tendon rupture: esp. EPL  Carpal tunnel syn. Weber Classification  Mal- /non-union  Relation of # to joint line  A: below joint line  B: at joint line  C: above joint line  B and C represent possible injury to the syndesmotic ligs between tib and fib → instability

Growth Plate  Damage to physis → abnormal bone growth  SH2 is commonest (~75%)  SH5: biggest risk to physis

Salter-Harris Classification 1. Straight across 2. Above 3. Lower 4. Through 5. CRUSH

Pelvic Fracture

Young and Burgess Classification  Lateral compression: ipsilateral pubic rami #s  AP compression: open book #  Vertical shear: inherently unstable

General Complications Nerve Injury

Tissue Damage Seddon Classification  Haemorrhage and shock  Neuropraxia: temporary interruption of conduction  Infection  Axonotmesis  Muscle damage → rhabdomyolysis . Disruption of axon ¯c preservation of connective tissue framework Anaesthesia . Recovery possible  Anaphylaxis  Neurotmesis  Damage to teeth . Disruption of entire nerve fibre  Aspiration . Recovery incomplete

Prolonged Bed Rest Compartment Syndrome  Chest infection, UTI  Oedema → ↑ compartment pressure → vascular compromise  Pressure sores and muscle wasting  Compartment pressure > capillary pressure → ischaemia  VTE  Pain > clinical findings and pain on passive stretch  ↓ BMD Mx  Elevate limb and remove bandages and cast Specific Complications  Fasciotomy

Immediate Problems ¯c Union  Neurovascular damage  Delayed union: union takes longer than expected  Visceral damage  Non-union: # fails to unite  Mal-union: # unites in imperfect position Early  Compartment syn. Causes: 5Is  Infection (worse if assoc. ¯c metalwork)  Infection  Fat embolism → ARDS  Ischaemia  Interfragmentary movement Late  Interposition of soft tissue  Problems ¯c union  Intercurrent illness  AVN  Growth disturbance Mx  Post-traumatic osteoarthritis  Optimise biology: infection, bone graft, blood supply, bone  Complex regional pain syndromes graft, BMPs  Myositis ossificans  Optimise mechanics: ORIF

Myositis Ossificans  Heterotopic ossification of muscle @ sites of haematoma formation  → restricted, painful movement  Commonly affects the elbow and quadriceps  Rx: excise

Complex Regional Pain Syndrome 1: Sudek’s Atrophy

Presentation  Wks – months after injury  Affects neighbouring area  Pain, hyperalgesia and allodynia  Vasomotor: hot and sweaty or cold and cyanosed  Skin: swollen or atrophic  NM: weakness, contractures

Mx  Usually self-limiting  May need amitriptyline / gabapentin

Contents Vascular Access ...... 196 Phlebotomy ...... 198 Airways and Breathing ...... 199 Perioperative Mx ...... 202 General Surgery ...... 205 Urology ...... 209 Trauma and Orthopaedics ...... 212 Miscellaneous ...... 216

Peripheral Venous Cannula Triple Lumen Central Venous Catheter

Indication Indication  Peripheral administration of fluid and drugs  CVP measurement: fluid balance  Drugs requiring central administration Features . Amiodarone, mannitol  TPN Colour Gauge Flow Rate (ml/min) Yellow 24 15 Method Blue 22 30  Inserted using the Seldinger technique under US Pink 20 60 . Trendelenberg position Green 18 90 . Sterile Grey 16 230 . Under LA Brown 14 270 . Use US guidance . Order a CXR afterwards Poiseuille’s Law  Internal jugular, Subclavian and Femoral veins  Flow rate . Proportional to the r4 Complications . Inversely proportional to length Immediate Method  Pneumothorax  Inserted into a peripheral vein under ANTT  Arrhythmia  Malposition into an artery Complications Early  Haematoma  Haematoma formation  Malplacement  Infection  Blockage  Catheter occlusion  Superficial thrombophlebitis

Late  Thrombosis  Sympathetic chain → Horner’s syndrome  Phrenic nerve damage → hiccough, weak diaphragm

Other Procedures Using Seldinger Technique  Angiography  Chest drain insertion  Percutaneous endoscopic gastrostomy

Indication  Haemodialysis

Indication Features  Long-term central access: abx, chemo, TPN  Tunnelled subcutaneously  Cuffs promote tissue reaction → better seal Method  Arterial limb takes blood to machine  Inserted into a peripheral vein: e.g. cephalic  Venous limb takes dialysed blood back to pt.  Advanced until the tip sits in the SVC.  X-ray to confirm position Method  Sterile insertion under x-ray guidance Complications  Arterial limb sits more proximally to ↓ recirculation

Early Complications  Arrhythmias  Bleeding Early  Pneumothorax Late  Arrhythmias  Thrombosis  Bleeding  Catheter occlusion  Infection Late  Thrombosis  Catheter occlusion Hickman Line  Infection

Port-a-Cath

Indication  Long-term central access: abx, chemo, TPN, dialysis

Method Indications  Tunnelled under skin to enter IJV and lay in SVC  Long-term chemotherapy or antibiotics

Complications Features  Centrally placed catheter Early  Subcutaneous port made of self-sealing silicone rubber O  Pneumothorax  Accessed ¯c 90 Huber point needle  Arrhythmias  V. low infection risk as skin breech is very small  Bleeding

Late  Thrombosis  Catheter occlusion  Infection

Blood Culture Bottles Vacutainers

Purple Indications  Contains: EDTA  Investigate a patient ¯c pyrexia . Prevents clotting and keep cells alive  Use Features . FBC, CD4, cross-match  Red: anaerobic culture medium . i.e. things you want to do ¯c cells  Blue: aerobic culture medium Yellow Method  Contains: Activated gel  Take blood using ANTT . Promotes clotting  Replace needle with a clean one . Gel facilitates easy separation of serum and red  Wipe top of bottles ¯c alcohol cells.  Fill anaerobic (red) bottle first  Use  Fill in pt. details and send to path lab . Serum chemistries, enzymes  Some hospitals have specific teams that take cultures Red Post-Op Pyrexia  Contains: Nothing, glass tube . “a clotted sample” Early: 0-5d post-op  Use  Blood transfusion . Immunology, Abs, Ig, protein electrophoresis  Physiological: SIRS from trauma: 0-1d  Pulmonary atelectasis:24-48hr Green  Infection: UTI, superficial thrombophlebitis  Contains: Li heparin  Drug reaction . Anticoagulant  Use Delayed: >5d post-op . Plasma chemistries, enzymes  Collections  Pneumonia Blue  DVT / PE  Contains: Citrate  Wound infection: 5-7d . Chelates Ca2+, preventing clotting  Anastomotic leak: 7d  Use . Coagulation determinates Examination of Post-Op Febrile Pt.  Special 2+  Observation chart, notes and drug chart . Ca is added back to sample to allow clotting.  Wound . Therefore need precise blood volume  DRE  Legs Grey  Chest  Contains  Lines . Fluoride: inhibit glycolysis  Urine . Oxalate: anticoagulate  Stool  Use . Glucose

Black  Contains: citrate . Anticoagulant  Use . ESR  Special . Need precise blood volume

Order of Draw  Blood cultures  Blue  Yellow  Green  Purple  Grey

Endotracheal Tube McKintosh Laryngoscope

Indications  To acquire a definitive airway in elective or emergency situations . Abdominal surgery . Head injury

Features  Cuffed . Adults . Secured tube and prevents aspiration

 Uncuffed . Children . Avoid damaging the larynx Indications  Size  ET intubation . Female: 7.5 . Male: 8.5 Features  Double lumen  Handle + light source . Allow single lung ventilation  Removable blade: come in different sizes . Used in thoracic surgery . McKintosh = Curved (preferred)  Radio-opaque line: blue . Miller = Straight

Method Method  Pt. is pre-oxygenated, sedated and a muscle relaxant  Pt. is appropriately sedated and muscle relaxed. may be used.  Inserted with left hand, tongue displaced laterally  Inserted into the trachea under direct vision using a  Tip inserted into valecular laryngoscope.  Light source allows direct vision of vocal cords for  Crichoid pressure may ↓ risk of aspiration intubation.  Bougi may be used for difficult airways . Smaller Complications . Anterior curvature  Oropharyngeal trauma . Can feel tracheal rings with tip  Laryngeal trauma  Position confirmed and tube secured ¯c tape  C-spine injury: e.g. ¯c atlanto-axial instability

Check Position  Inspect for symmetrical chest movements  Listen over epigastrium for gurgling  Listen over each lung for air entry  Use CO2 monitor  CXR: just above carina

Complications

Early  Oropharyngeal trauma  Laryngeal trauma  C-spine injury: e.g. ¯c atlanto-axial instability  Oesophageal intubation  Bronchial intubation

Delayed  Sore throat  Tracheal stenosis  Difficult wean

Definitive Airway  Airway which is protected from aspiration

Types  Orotracheal or nasotracheal airway  Surgical: tracheostomy, cricothyroidotomy

Indications  Non-definitive airway used in short day-case surgery where a pt. doesn’t require intubation.  May also be used in an emergency situation if not able to insert ET tube.

Features  Inflatable cuff to create a seal over the larynx

Method  Cuff is deflated and lubricated ¯c aquagel Indications  Inserted ¯c open end pointing down towards the tongue  Definitive surgical airway  Sits in orifice over the larynx  Acutely: maxillofacial injuries  Cuff inflated and tube secured with tape  Electively: ITU pts. ¯c prolonged ventilation Complications Features  Dislodgement  Obturator  Leak  Cuff to prevent aspiration  Pressure necrosis in airway  Flange to secure to pts. neck  Aspiration: non-definitive airway  Insufflation port.

Method  Transverse incision ~1cm above sternal notch Oropharyngeal / Guedel Airway  Dissect through fascial planes and retract ant. jugular veins and strap muscles Indications  Divide thyroid isthmus  Airway adjunct used in pts. with impaired level of  Stoma fashioned between 2nd and 4th tracheal rings by consciousness to maintain a patent airway removing anterior portion of tracheal ring  e.g. during extubation  Insert trachy ¯c obturator  Secure with tapes. Method  Sized from incisors to angle of mandible Advantages over ET Tube  Insert upside down and rotated once in the oral cavity  Easier to wean pts.  No need for sedation Complications  ↓ discomfort  Oropharyngeal trauma  Easier to maintain oral and bronchial hygiene  Gagging → vomiting  ↓ risk of glottis trauma  ↓ dead space  reduces work of breathing Nasopharyngeal Airway Complications Indications Immediate  Airway adjunct used in pts. with impaired level of  Haemorrhage consciousness to maintain a patent airway  Surgical trauma: oesophagus, recurrent laryngeal N.  Pneumothorax Method  Sized according to diameter of pts. little finger Early  Inserted into the nasopharynx using a rotational action  Tracheal erosion  Safety pin and flared end prevents the tube becoming  Tube displacement irretrievable.  Tube obstruction  Surgical emphysema Complications  Aspiration pneumonia  Bleeding: trauma to nasal mucosa  Intracranial placement Late  Tracheomalacia Contraindications  Tracheo-oesophageal fistula  Absolutely contraindicated in pts. ¯c facial injuries or  Tracheal stenosis evidence of basal skull # . Racoon eyes . Battles’ Sign: mastoid bruising . Haemotympanum . SCF rhinorroea or otorrhoea

Nasal Prongs Types  1-4L/min = 24-40% O2  Non-invasive: tight-fitting mask  Invasive: ET or tracheostomy Simple Face Mask  Variable O2 concentration depending on O2 flow rate Indications  Respiratory failure refractive to less invasive Rx Non-rebreathing Hudson Mask  At risk airway  Reservoir bag allows delivery of high concentrations of  Elective post-op ventilation O2.  Physiological control (e.g. hyperventilation in ↑ICP)  60-90% at 10-15L Complications Venturi Mask  Cardiovascular compromise  Uses the Bernoulli Principle  Pneumothorax . ↑ speed of flow → ↓ pressure  Fluid retention . Altering O2 flow speed can entrain a known  VILI concentration of air for dilution  VAP  Provide precise O2 concentration at high flow rates  Complications of artificial airway: e.g. tracheal stenosis . Yellow: 5% . White: 8% . Blue: 24% . Red: 40% . Green: 60%

CPAP  Tight fitting mask connected to reservoir or high O2 flow allowing FiO2 ~1.  Positive pressure is applied continuously to the patient’s airway.  Benefits . Recruitment of collapsed lung units . ↓ shunt → ↑PaO2 . ↑ lung volume → improved compliance → ↓ work of breathing.  CPAP usually has little effect on PaCO2

Ryles Nasogastric Tube Feeding NG Tube

Indications

 Provide enteral nutrition Indications . Catabolic: sepsis, burns, major surgery  Draining the stomach . Coma/ITU  Part of the “drip and suck” for the management of bowel . Malnutrition obstruction. . Long-term feeding  Pts. ¯c persistent vomiting: e.g. pancreatitis . Dysphagia: stricture, stroke

Features Features  Wide-bore  Fine-bore  Stiffer  Soft silicone  Radio-opaque line  Contains radio-opaque guide-wire to stiffen the tube  Metal tip and aid insertion.

Metal Tip Method  Acts as lead point to facilitate advancement of NGT  Size tube by measuring from tip of pts nose to  Weights the NGT down in the stomach epigastrium, going around the ear.  Radio-opaque on x-ray aiding visualisation  Gain consent and explain the procedure  Lubricate the tip ¯c aquagel Method  Insert the tube and ask pt. swallow ¯c water when they  Size tube by measuring from tip of pts nose to feel it at the back of their throat. epigastrium, going around the ear.  Remove guidewire and secure ¯c tape when position  Gain consent and explain the procedure confirmed  Lubricate the tip ¯c aquagel  Insert the tube and ask pt. swallow ¯c water when they Check Location feel it at the back of their throat.  Aspirate gastric contents and check pH (<4)  Secure ¯c tape when position confirmed  Insufflate air and auscultate for bubbling  CXR: tip below diaphragm Check Location  Aspirate gastric contents and check pH (<4) Complications  Insufflate air and auscultate for bubbling . Best not to do this in bowel obstruction NGT  CXR: tip below diaphragm  Nasal trauma  Malposition: airway, cranium (CI in basal skull #s)  Blockage Complications  Nasal trauma Feeding  Malposition: airway, cranium (CI in cribriform plate #s)  Refeeding syndrome  Blockage  Electrolyte imbalance  Feed intolerance → diarrhoea Contraindication  Any suspicion of basal skull # Contraindication  Any suspicion of basal skull #

© Alasdair Scott, 2012 202 Types of Nutritional Supplementation Refeeding Syndrome  Life-threatening metabolic complication of refeeding via Enteral Nutrition any route after a prolonged period of starvation.  Oral supplements  Polymeric: e.g. osmolite, jevity Pathophysiology . Intact proteins, starches and long-chain FAs  ↓ carbs → catabolic state ¯c ↓insulin, fat and protein  Disease Specific catabolism and depletion of intracellular PO4 . e.g. ↓ branched chain AAs in hepatic  Refeeding → ↑ insulin in response to carbs and ↑ encephalopathy cellular PO4 uptake.  Elemental  → hypophosphataemia . Simple AAs and oligo/monosaccharides . Rhabdomyolysis . Require minimal digestion and used if abnormal . Respiratory insufficiency GIT: e.g. in Crohn’s . Arrhythmias . Shock . Seizures Parenteral Nutrition Chemistry  May be “Total” or used to supplement enteral feeding  ↓K, ↓Mg, ↓PO4  Combined ¯c H2O to deliver total daily requirements At-Risk Patients  Malignancy Indications  Anorexia nervosa  Unable to swallow: e.g. oesophageal Ca  Alcoholism  Prolonged obstruction or ileus (>7d)  GI surgery  High output fistula  Starvation  Short bowel syndrome  Severe Crohn’s Rx  Severe malnutrition  Identify at-risk pts in advance and liaise ¯c dietician

 Parenteral and oral PO supplementation 4  Rx complications Delivery  Delivered centrally as high osmolality is toxic to veins . Short-term: CV catheter . Long-term: Hickman or PICC line

Monitoring  Standard . Wt., fluid balance and urine glucose daily . Zn, Mg weekly  Initially . Blood glucose, FBC and U+E 3x /wk . LFTs 3x /wk  Once stable . Blood glucose, FBC and U+E daily . LFTs weekly

Contents  2000Kcal: 50% fat, 50% carb  10-14g nitrogen  Vitamins, minerals and trace elements

Complications  Line-related . Pneumothorax / haemothorax . Cardiac arrhythmia . Line sepsis . Central venous thrombosis → PE or SVCO  Feed-related . Villous atrophy of GIT . Electrolyte disturbances: e.g. refeeding syndrome . Hyperglycaemia and reactive hypoglycaemia . Vitamin and mineral deficiencies

Indications Crystalloid  Used to prevent VTE  All patients undergoing surgery NS  All immobile pts  0.9% NaCl = 9g/L  154mM NaCl Method  Use: normal daily fluid requirements + replace losses  Available in different sizes . Width: widest point of calf 5% Dextrose . Length: heel to buttock fold  50g dextrose /L  Often used in conjunction ¯c LMWH  Use: normal daily fluid requirements

Complications Dextrose-Saline  4% dextrose = 40g/L  Contraindicated in pts ¯c arterial disease  0.18% NaCl = 31mM NaCl

 Use: normal daily fluid requirements

Preventing DVT Hartmann’s / Ringer’s Lactate  DVT is commonest complication of THR  Na: 131mM  Peak incidence @ 5-10d post-op  Cl: 111mM  K: 5mM Pre-Op  Ca: 2.2mM  Pre-op VTE risk assessment  Lactate / HCO3: 29mM  TED stockings  Use: Trauma, Burns (Parkland)  Aggressive optimisation: esp. hydration  Stop OCP 4wks pre-op Daily Requirements . 3L dex-saline ¯c 20mM K+ in each bag Intra-Op . 1L NS + 2L dex ¯c 20mM K+ in each bag  Minimise length of surgery . Each bag over 8h = 125ml/h  Use minimal access surgery where possible  Intermittent pneumatic compression boots Problems  Give 1L NS → ~210ml remaining IV Post-Op  Give 1L D5W → ~70ml remaining IV  LMWH  Acidosis or electrolyte disturbances  Early mobilisation  Fluid overload  Good analgesia  Physio  Adequate hydration Colloid

Synthetic  Gelofusin  Volplex  Haemaccel  Voluven

Natural  Albumin  Blood

Use  Fluid challenge  Hypovolaemic shock  Burns: Muir and Barclay

Problems  Anaphylaxis  Volume overload

Surgical Drains Robinson  Type: closed, passive Indications  Use: abdominal surgery  Prophylactic . Risk of infection . Prevent fluid accumulation . Contamination: faeces or pus  Therapeutic . Drainage of established collections . Drain a viscus: e.g. bladder . Collect blood for autotransfusion

Types

Open or Closed  Open Redivac . e.g. corrugated rubber or plastic sheets . Fluid collects into dressing or stoma bag  Type: closed, active  Closed  Use . e.g. chest drains, Robinson or Redivac . Breast surgery: prevent seroma or haematoma . Tube attached to a container . Thyroid surgery: risk of haematoma

Active or Passive  Active: driven by suction . e.g. Redivac drain  Passive: no suction, driven by pressure differential . e.g. Robinson drain

Removal  Remove drain once drainage stopped or <25ml/d  Perioperative bleeding and haematoma: 24-48hrs Bile Bag  Intestinal anastomosis: >5d  Type: closed, passive  T-tube: 6-10d  Use . T-tube cholangiogram first to ensure distal . NGT patency of CBD . T-tube  Shortening: removal of drain by 2cm/d to allow tract to heal gradually.

Complications  May ↑ risk of infection  Damage may be caused by mechanical pressure or suction.  May limit pt. mobility. Pemrose Drain  Type: open, passive  Use: abdominal surgery

Tissue Drain  Type: open, passive  Use: large cavities

Suture Types

Monofilament  Advantages . ↓ risk of infection . ↓ friction in tissues  Disadvantages . Harder to handle: stiff and has more memory . Knots may slip . Less tensile strength Indications Braided  Surgical instrument used in open abdominal surgery to  Advantages retract viscera and ↑ the field of view . Easier to handle: less memory . Knots slip less Method . Greater tensile strength  Curved end inserted into abdomen and placed carefully  Disadvantage to retract the viscera. . ↑ risk of infection  Can be bent to a suitable shape . ↑ friction in tissues Complications Natural  Damage to skin and internal structures

Absorbable  Catgut / Chromic Self-Retaining Retractor Non-absorbable  Silk: braided suture that may be used to secure drains

Synthetic

Absorbable

Name Material Construction Use Monocryl Poliglecaprone Mono Subcuticular skin closure Vicryl Polyglactin Braided Subcutaneous closure Bowel anastomosis PDS Polydioxanone Mono Closing abdominal wall Indications Non-Absorbable  Used to retract a surgical excision and retain the incision open. Name Material Construction Use  E.g. in hernia repair or and appendicectomy Prolene Polypropelene Mono Skin wounds Arterial anastomosis Complications Ethilon Nylon Mono Skin wounds Metal Steel Clips or mono Skin wounds  Compression of nerves of vessels Sternotomy closure

Suture Removal Needle Holders  Further away from heart = longer time  Face and neck: 3-5d  Scalp: 5-7d  Trunk: 10d  Arms: 7d  Legs 10-14d  Pts. ¯c poor wound healing may need longer

Needles  Straight: hand-held, used for skin closure  Curved: require needle-driver Indications  Diameter  Forceps designed to hold the needle, allowing the . Fine: GI and vascular surgery surgeon to suture accurately. . Medium: general closure . Heavy: hernia repair  Tip . Blunt: abdominal wall closure  Shape . J-shaped: abdominal wall closure © Alasdair Scott, 2012 206 Disposable Proctoscope Disposable Rigid Sigmoidoscope

Indications  Investigation and management of pts. ¯c perianal pathology: e.g. haemorrhoids, low rectal Ca  Examination of the anal canal and lower rectum ± biopsy  Therapeutic: banding, sclerotherapy

Features

 Obturator to aid insertion  Attachment for a light source Indications

 Allows endoscopic examination of the rectum and recto- Method sigmoid junction ¯c possible biopsy.  Consent pt. and explain procedure.  Can be used in the outpatient or inpatient setting  Examine perineum and perform DRE ¯c pt. in left-lateral  Investigation of position. . Rectal bleeding  Lubricate scope ¯c aquagel, attach light source . Colonic Neoplasia  Hold in left hand and insert into the rectum. . IBD

Complications Features  Haemorrhage  Graduated plastic tube ¯c an obturator to aid insertion  Perforation Method  For good views a suppository should be given prior to Shouldered / Gabriel Syringe examination  Consent pt. and explain procedure.  Examine perineum and perform DRE ¯c pt. in left-lateral position. . Ensure no obstruction to scope  Lubricate scope ¯c aquagel and insert into anal canal  Remove obturator  Attach light source, bellows and eye piece and insufflate air  Visualise mucosa as scope withdrawn

Complications  Perforation . Mechanical: pushing against bowel wall . Pneumatic: over-inflation  Bleeding Indications  Injection of haemorrhoids with 5% phenol in almond oil PR Bleeding Differential . Sclerosant Commonest Method  Perianal: haemorrhoids, fissure  Consent and explain procedure to pt.  Diverticular disease  Pt. placed in left lateral position and syringe used ¯c  Malignancy proctoscope to enable haemorrhoid visualisation  2ml of phenol is injected above dentate line: insensitive Other  IBD Complications  Infection  Upper GI bleed Immediate  Angiodysplasia  Pain if injected below dentate line  Damage to nearby structures  Primary haemorrhage

Late  Prostatitis  Impotence

Indications  Access the abdomen during laparoscopic surgery  E.g. lap chole

Features  Trocar ± sharp blades  CO2 insufflation port  Instrument port with rubber flanges

Method  Small incision made in the abdominal wall  Either trocar used to enter abdomen or surgical entry is made  Laparoscope usually inserted @ the umbilicus  Abdomen inflated ¯c CO2: cheap, soluble, inert gas

Complications  Visceral trauma on insertion Indications  Rectal anastomosis  Gastrectomy Advantages of MAS  Haemorrhoids  Rectal prolapse Smaller Incisions  ↓ post-op pain Features  ↓ risk of wound infection  Anvil sutured into proximal limb ¯c purse string suture  Faster post-op recovery  Anvil fits into stapler and provides counterpoint for  ↓ hospital stay staple insertion.  Better cosmesis Complications May allow better visualisation and access  Anastomotic leak  Can visualise and operate on pelvic organs in lap appendicectomy.  Dx and fix contralateral hernia in lap hernia repair. Checking the Integrity of an Anastomosis

Intra-operative

 Fill pelvic cavity with saline Disadvantages of MAS  Insufflate rectum ¯c air and look for bubbles in the saline.  Different anatomy  ↓ tactile feedback (can’t feel colon tumours) Post-operative  2D view of 3D structures  Water-soluble contrast enema  Technically challenging and old skills may be lost  Complications (e.g. haemorrhage) may be harder to Mx  Expensive

General Catheterisation Indications Mx of Non-draining catheter  Bypassing catheter: consider condom catheter Diagnostic  Blocked: flush ¯c 20ml sterile 0.9% NS or consider 3-  Measure urine output way  Sterile urine sample  Slipped into prostatic urethra: flushes but won’t drain  Renal tract imaging  Catheter has perforated the lower tract on insertion and is not in the bladder Therapeutic  Renal or pre-renal failure  Urinary retention  Immobile patients  Bladder irrigation TWOC  Intermittent decompression of neuropathic bladder  After 24-72 hrs in AUR  May be performed as a urology outpt. if retention likely.  Tamsulosin ↓s risk of retention after TWOC Foley Catheter

Features Indications for Long-Term Catheterisation  One port for drainage and one to fill the distal balloon ¯c  Chronic bladder outlet obstruction sterile water.  Neurogenic bladder ¯c chronic retention  Distal balloon sits in the bladder and prevents  Complications of incontinence displacement of the catheter. . Refractory skin breakdown  Material . Palliative care . Usually latex . Pt. preference . Silastic better for long-term placement  ↓ blockage and ↓ infection Clean Intermittent Self-Catheterisation Method  Alternative to indwelling catheter in CUR  Consent and explain the procedure to the patient.  Also useful in pts. who fail to void after TURP  Use smallest diameter possible to achieve adequate drainage Indications . French = circumference of catheter in mm  Chronic retention . Male: 16-18F  Neuropathic bladder . Female: 12-14F . MS  Clean perineal area . DM neuropathy  Use ANTT and insert the catheter ¯c the aid of instilagel . Spinal trauma  Ensure that urine is draining before inflating the balloon (10ml of water)  Replace foreskin to prevent paraphimosis  May give a STAT dose of Gentamicin IV to prevent transient bacteraemia.

Complications  Early . Creation of false tract . Urethral rupture . Paraphimosis . Haematuria  Delayed . Infection . Blockage

Contraindications  Urethral trauma . Blood @ urethral meatus . High-riding prostate . Scrotal haematoma . Pelvic fracture

Other Catheter Types  Coude catheter: angled tip may help in big prostates  Condom catheter

Indication Clinical Features  Irrigate bladder in pts @ risk of clot retention  Suprapubic tenderness  E.g. after TURP or in pts ¯c haematuria  Palpable bladder . Dull to percussion Features . Can’t get beneath it  3 ports  Large prostate on PR . Balloon inflation . Check anal tone and sacral sensation . Drainage (middle)  <1L drained on catheterisation . Irrigation Ix  Blood: FBC, U+E, PSA (prior to PR) Suprapubic Catheter  Urine: dip, MC+S  Imaging

. US: bladder volume, hydronephrosis . Pelvic XR

Conservative  Analgesia  Privacy  Walking  Running water or hot bath

Indications Catheterise  Urethral injuries  Use correct catheter: e.g. 3-way if clots  Urethral obstruction  STAT gent cover . BPH  Hrly UO + replace: post-obstruction diuresis . Ca prostate  Tamsulosin: ↓ risk of recatheterisation after retention  TWOC after 24-72h Method . May d/c and f/up in OPD  US guided insertion of catheter under LA . More likely to be successful if predisposing factor  Trocar inserted into catheter and unit advanced through and lower residual volume (<1L) skin. TURP Complications  Failed TWOC  Viscus perforation  Impaired renal function  Haemorrhage  Elective  Malignancy seeding

Advantages  ↓ UTIs  ↓ stricture formation  TWOC w/o catheter removal  Pt. preference: ↑ comfort  Maintain sexual function

Disadvantages  More complex: need skills  Serious complications can occur

CI  Known or suspected bladder carcinoma  Undiagnosed haematuria  Previous lower abdominal surgery . → adhesion of small bowel to abdo wall

Indication  Relieve ureteric obstruction . Stones . Tumours  May be inserted intra-op during renal Tx

Method  Retrograde: cystoscopic guidance  Anterograde: percutaneous

Complications  Infection  Blockage  Displacement / migration

Chest Drain Tube and Trocar Chest Drain Bottle

Indications Indications  Drainage of the pleural cavities  As for chest drain tube  PTX . Traumatic Method . Ventilated  Fill bottle to prime level ¯c sterile water . Following needle decompression of tension  Connect to drain to bottle . Persistent after aspiration  Underwater seal allows one-way flow out of pleural  Pleural effusion: malignant, pus, blood, lymph cavity  Post-op: thoracotomy, post-oesophagectomy  May add suction → active drainage

Method Complications  Consent and explain procedure to pt.  Lifting the bottle above the pt can → retrograde flow  Commonly insert smaller drains ¯c Seldinger technique into chest.  Morphine analgesia  Complications of chest tube insertion  Clean and drape area  ID safe triangle: 4th-6th ICS, just anterior to mid-axillary line, posterior to pectoralis major muscle.  Infiltrate 1% lignocaine to rib below and pleura of ICS. Check that air or fluid can be aspirated.  Make small 1cm incision just above rib below, blunt dissect ¯c Spencer-Wells down to pleura, sweep finger to clear adhesions and check location.  Attach drain to bottle and advance it into pleural cavity, directing it postero-inferiorly.  Close wound and ICD using modified mattress suture.  Get patient to cough and take deep breaths, check for swinging and bubbling.  CXR to check location.

Complications

Early  Pain due to inadequate analgesia  Haemorrhage due to NV bundle damage  Organ perforation  Incorrect location: e.g. abdomen

Late  Failure: bronchopleural fistula  Long-thoracic N. damage → winged scapula  Wound infection  Blockage

Removal  Remove when no longer swinging or bubbling and CXR confirms resolution of PTX  Using two people, remove in forced expiration and use mattress suture to close wound.  CXR to check no new PTX.

Indications  Internal fixation of fractures  This particular type can be used to fix tibial #s

Method Indications  Requires open reduction  Intracapsular # NOF: Garden 3/4  Plate aligned with orientation of bone  Screws used to fix plate to bone Features  Fenestrated stem for osseous integration Complications . Non-cemented  Relate to #, procedure and the plate  Shouldered  Large head The Plate  Infection Method  Failure  Placed in theatre under GA  Malposition of the remodelled fracture  Posterior or anterolateral (commonest) approaches  Head of femur resected femoral shaft reamed Other Types of Fixation  Stem is cemented (Thompson) or uncemented (Austin  POP Moore)  Continuous traction: collar and cuff  Head relocated and joint function and stability assessed  External fixation before closure.  Intramedullary nail  K wires  DHS Complications of the Prosthesis  Cannulated screws  Complications involve the fracture, the procedure and the prosthesis.

Early  Cement reaction  Deep infection  Fracture  Dislocation (3%): squatting and adduction

Late  Loosening: septic or aseptic  Failure: stem #  Revision: most replacements last 10-15yrs

Indications  OA hip Indications  Form of internal fixation used in the Mx of long-bone #s Features . Femur, tibia, humerus  Femoral component with small head  Polyethylene acetabular component Features  Most are cemented  Titanium or titanium alloy  Screws insert proximally and distally provide rotational Method and longitudinal stability  Placed in theatre under GA  Curve fits contour of tibia  Posterior or anterolateral (commonest) approaches  Head of femur resected Dynamisation  Acetabulum and femoral shaft are reamed  Removal of one or more screws in order to allow  Stems and cups are trialled to find most suitable collapse  Head relocated and joint function and stability assessed . ↑ loading of fracture site → quicker union before closure. Method Complications of the Procedure and Prosthesis  Inserted under GA  Nail hammered into medulla of bone Immediate  Screws lock nail in place  Nerve injury  Fracture Complications of the Prosthesis  Cement reaction  Fracture during nail insertion  Infection Early  Fat embolus  DVT: up to 50% w/o prophylaxis  Delayed or non-union  Deep infection  Must remove metalwork before revision.  Dislocation (3%): squatting and adduction Fat Embolism Syndrome  Presentation: SOB, petechial rash, confusion Late . Typically 24-72h between injury and onset  Loosening: septic or aseptic . Resp: dyspnoea ± chest pain  Failure: stem #, wear . Petechial rash: upper anterior trunk, arms, neck  Revision: most replacements last 10-15yrs . CNS: headache, confusion, agitation . Renal: oliguria, haematuria  Ix . ABG: hypoxia, hypocapnoea . FBC: ↓ plats, ↓Hb . CT chest  Mx . Supportive: O2, volume resuscitation . Steroids

Indications Indications  Stabilise the cervical spine in trauma pts.  Osmotic diuretic  Used ¯c two sandbags and tape  Lower intracranial pressure  ↓ IOP in hyphema Features  Comes flat packed and must be assembled Method  Hole at front allows access to the trachea  Given centrally

Method Complications  Sized by measuring the number of fingers from the  May ↑ ICP in the long-term clavicle to the angle of the mandible  CI in severe cardiac failure and pulmonary oedema  “Key dimension” then compared to the sizing peg on the hard collar.

Complications  Incorrect placement . Neck not in neutral alignment . Chin not flush ¯c end of chin piece

Clearing the C-Spine

Clinical Clearance  Indication: NEXUS Criteria . Neurological deficit . Spinal tenderness in the midline . Altered consciousness . Intoxication . Distracting injury  Method . Examine for bruising or deformity . Palpate for deformity and tenderness . Ensure pain-free active movement

Radiological Clearance  Indications . Pt. doesn’t meet criteria for clinical clearance  Modalities . Radiograph initially  Clear if normal radiograph and clinical exam . CT C-spine if abnormal radiograph or clinical exam

Swan Ganz Catheter Tru-Cut Biopsy Needle

Indications Indications  Flow directed pulmonary artery catheter  Used to take histological specimens from lesions  Measure the pulmonary capillary wedge pressure . Part of triple assessment of breast lumps . Indirect measure of LA filling pressure . Liver  Measure cardiac output . Kidney  Used in cardiogenic or septic shock when accurate . Prostate: transrectally haemodynamic data is required  Its use has not been shown to improve outcome Method  Consent and explain procedure to pt. Method  Anaesthetise area ¯c LA  Used in the intensive care setting  Needle advanced under US guidance  Inserted into a central vein.  Spring handle is pressed, advancing the specimen tray into the target lesion  Further pressure fires the surrounding sheath, obtaining a biopsy Fogarty Embolectomy Catheter Complications  Bleeding  Pain  Cancer seeding

Renal Biopsy

Indications  Unexplained ARF/CRF  Acute nephritic syndrome  Unexplained proteinuria / haematuria  Systemic disease ¯c renal involvement (e.g. SLE) Indication O  Suspected Tx rejection  Mx of acutely ischaemic limb 2 to embolus CI Method  Abnormal clotting  Vascular access gained to femoral artery @ groin.  Single kidney (except Tx)  Catheter passed distal to embolus  Small kidneys from CRF (↑ bleeding risk + too late)  Balloon is inflated and catheter withdrawn.  Renal neoplasms

Procedure  Stop aspirin (1wk) and warfarin (2d) in advance  Check FBC, clotting and G&S  US-guided Tru-Cut needle biopsy

Complications  Macroscopic haematuria in 1%  Transfusion needed in 0.1%

Contents Chest Wall ...... 218 Thoracic Cavity ...... 219 Inguinal Region ...... 220 Abdominal Wall and Surface Anatomy ...... 221 The Bowel ...... 222 Abdomen Neurovascular Supply ...... 223 Gastrointestinal Adnexae ...... 223 Urinary Tract ...... 224 Head and Neck ...... 225 The Thigh ...... 226 The Leg ...... 227 The Arm ...... 228

Surface Landmarks Breast  Superior angle of scapula : T2  Mammary glands and connective tissue stroma  Inferior angle of scapula: T8  Anterior to ribs 2–6 and extend superolaterally to the  Sternal angle: T4/5 mid-axillary line.  Subcostal plane: L3  Nipples: 4th ICS Mammary glands  Ducts and secretory lobules converge to form 15-20 lactiferous ducts which each open onto the nipple. Surface Markings Connective tissue  Pleura: 8th, 10th and 12th ribs  Surrounds mammary glands  Lung: 6th, 8th and 10th ribs  Suspensory lgts. (of Cooper) are continuous with the

dermis and support the breast. Oblique fissure  Layer of loose connective tissue (retromammary space)  T4 in midline posteriorly separates the breast from the deep fascia and allows  5th rib laterally th some movement over the underlying structures.  6 costal cartilage anteriorly Arterial Supply Horizontal fissure th  Laterally: vessels from the axillary artery  Follows contour of 4 rib anteriorly  Medially: branches from the internal thoracic artery nd th  2 – 4 intercostals via superficial perforating branches The Breast

 Attached between rib 2-6 Lymphatic Drainage  Axillary tail follows lower margin of pec major  75% drain superolaterally into axillary nodes

 Remainder into deep parasternal nodes

Thoracic Plane: T4/5 – Sternal Angle  Aortic arch: beginning and end  SVC enters the RA  Bifurcation of the pulmonary arterial trunk  Carina  2nd costosternal joint  Division of superior and inferior mediastinum

The Diaphragm Recurrent Laryngeal Nerve  3 main openings  RLN supplies all intrinsic laryngeal muscles except . Aortic hiatus: T12 cricothyroid (external branch of sup. laryngeal N.) . Oesophagus: T10  Left nerve recurs around the ligamentum arteriosum . Vena Cava: T8 (remnant of ductus arteriosum)  Congenital hernia  Right nerve recurs around right subclavian artery . Morgagni: anterior  Damage may occur during thyroid or parathyroid surgery . Bochdalek: posterior or due to bronchogenic Ca  Unilateral palsy → hoarseness (bilat → aphonia)

Superior Mediastinum Chylothorax  Thoracic duct drains whole lymphatic field below Boundaries diaphragm and left half of lymphatics above it.  Sup: thoracic inlet  Surgical procedures involving the posterior mediastinum  Inf: angle of Louis: T4/5 (Thoracic Plane) or neck can → lymph leak into thoracic cavity.  Lat: pleura  Ant: manubrium Venous System at the Thoracic Outlet  Post: T1-4  Subclavian veins join internal jugular veins behind SCJs  Brachiocephalic veins form SVC behind right 1st Contents sternocostal joint.  Arteries: aortic arch and branches  SVC enters RA @ right 3rd sternocostal joint  Veins: brachiocephalics, SVC  Nerves: vagi, phrenics, L recurrent laryngeal Oesophagus  Organs: thymus, trachea, oesophagus, thoracic duct,  25cm long muscular tube (40cm from GOJ → lips) LNs Path Anterior Mediastinum  Starts at level of cricoid cartilage (C6)  Anterior to pericardium  Lies in the visceral column in the neck  Thymus and LNs  Runs in posterior mediastinum and passes through right crus of diaphragm @ T10. Posterior Mediastinum  Continues for 2-3cm before entering the cardia  Descending aorta  Azygous vein and hemiazygous 4 locations of narrowing  Thoracic duct  Level of cricoid: junction ¯c pharynx  Esophagus  Posterior to aortic arch  Sympathetic trunks  Posterior to left main bronchus  LOS

Histology  Divided into 3rds: reflects change in musculature from striated → mixed → smooth.  Lined by non-keratinising squamous epithelium.  Z-line: transition from squamous → gastric columnar

Gastro-oesophageal Sphincter  3 main components to prevent reflux  LOS: 4cm long hypertrophied smooth muscle  Extrinsic Sphincter: skeletal muscle of R crus of diaphragm  Physiologic sphincter . Distal component projects into abdominal cavity and ↑ IAP → compression . Angle of His also forms valve preventing reflux.

Superficial Ring  Split in external oblique aponeurosis just superior and medial to the pubic tubercle.

Inguinal canal  4cm long  Floor: inguinal ligament  Roof: arching fibres of internal oblique and transversus abdominis  Anterior: external oblique aponeurosis + internal oblique for lateral 3rd  Posterior: transversalis fascia + conjoint tendon for medial 3rd  Laterally: deep ring  Medially: pubic tubercle

Conjoint tendon: combined insertion of internal oblique and transversus abdominis into pubic crest and pectineal line

Contents  M: ilioinguinal N. + spermatic cord  F: ilioinguinal N. + genital branch of genitofemoral N. + round lig. of uterus

Ilioinguinal N. (L1)  Enters canal directly through anterior wall: does not pass through the deep ring  Exits through the superficial ring  Supplies skin at the root of the penis and the scrotum (or the labia majus) and small area of skin of upper inner thigh.

Genital branch of the genitofemoral N. (L1/2)  Supplies cremaster muscle and scrotal skin or the labia majus.

Spermatic Cord Femoral Sheath  3 layers of fascia  In femoral triangle, femoral artery, vein and lymphatics . External spermatic: from external oblique are enclosed w/I femoral sheath. . Cremasteric: from internal oblique  Sheath continuous superiorly ¯c transversalis fascia . Internal spermatic: from transversalis fascia  Each structure has its own compartment  3 arteries  Most medial compartment = femoral canal . Testicular: from aorta . Ant: inguinal ligament . Cremasteric: from inf. epigastric . Post: pectineal lig (lig. of Cooper) + pectineus . Artery of the vas: from inf. vesicular A. . Med: lacunar lig. and pubic bone  3 veins . Lat: femoral vein . Pampiniform plexus (R→IVC, L→ Left renal) . Contents: fat and Cloquet’s node . Cremasteric vein . Vein of the vas  2 nerves . Nerve to cremaster: from genito-femoral N. . Sympathetic fibres from T10-11 . (Ilioinguinal N. is on the cord)  3 other structures . The vas deferens . Lymphatics of the testis (→para-aortic nodes) . Obliterated processus vaginalis

Operative Anatomy Inferior epigastric vessels  Arise from external iliac vessels immediately superior to inguinal ligament.  Can be seen passing deep to the posterior wall (transversalis fascia)  Sac arises lateral to vessels = indirect hernia  Sac arises medial to vessels = direct hernia

Hesselbach’s triangle  Area of entry for direct hernias through posterior wall  Laterally: inf. epigastric artery  Medially: rectus abdominis muscle  Inferiorly: inguinal ligament © Alasdair Scott, 2012 220 Abdominal Wall and Surface Anatomy

Abdominal Wall Surface Anatomy

Layers L1: Transpyloric Plane of Addison  Skin  Midway between jugular notch and pubic symphysis  Camper’s fascia: fatty  9th costal cartilage  Scarpa’s fascia: membranous  Pyloric orifice and D1  External oblique  DJ flexure  Internal oblique  Fundus of the gallbladder  (nerves and vessels)  Left and right colic flexures  Transversus abdominis  Neck of the pancreas  Transversalis fascia  Lower part of left renal hilum, upper part of right  Pre-peritoneal fat  Origin of the SMA and coeliac trunk  Parietal peritoneum L3: Subcostal Plane Innervation  Joins lowest points of the 10th ribs  Intercostal nerves: T7-T11  Origin of IMA  Subcostal nerve: T12  Ilio-inguinal and ilio-hypogastric nerves: L1 L4: Intercristal Plane  Joins the highest points of the iliac crests Blood Supply  Bifurcation of the aorta  Superiorly . Superficial: musculophrenic A . Deep: superior epigastric A. Surface Markings  Both terminal branches of int. thoracic A.  Inferiorly Umbilicus . Superficial: superficial epigastric + superficial  Inconsistent position circumflex iliac As.: branches of the femoral A.  Normally L3/L4 disc . Deep: Inf. epigastric + deep circumflex iliac As.: branches of the external iliac A. Liver  Upper border at the level of the fifth ICS on each side Rectus Sheath  Lower border from tip of 10th rib on right to just medial  Arcuate line of Douglas: midway between umbilicus and to mid clavicular line in the left 5th ICS pubic symphysis  Above the arcuate line the sheath completely encloses Gallbladder the rectus muscle.  Where the mid clavicular line meets the right costal  Below the arcuate line the sheath is deficient posteriorly margin: 9th costal cartilage and the rectus is in direct contact ¯c transversalis fascia.  This arrangement allows expansion of pelvic contents Spleen into the abdomen.  Underlies ribs 9-11 on the left.  Semilunar lines: aponeurosis of ext. oblique at its line of division to enclose the rectus.

Duodenum Distinguishing Features of Large Bowel  4 parts  Large diameter  Mostly retroperitoneal  Condensation of longitudinal muscle → taenia coli  Epiploic appendages D1  Sacculations / Haustra  Duodenal cap  Commonest place for DUs Rectum  Overlapped by gallbladder  12cm . Stones can erode into D1 → ileus  Sacral promontory to levator ani muscle

 The 3 tenia coli fuse around the rectum to form a D2 continuous muscle layer.  Descending part  Contains Major Duodenal Papilla (mid → hind gut) Anal Canal D3  4cm  Inferior part  Levator ani muscle to anal verge  Can be compressed by SMA aneurysm  Upper 2/3 of canal . Lined by columnar epithelium D4 . Insensate  Ascending part . Sup. rectal artery and vein  Ends at DJ flexure / Ligament of Trietz . Internal iliac nodes  Distal 1/3 of canal PUD Perforation . Lined by squamous epithelium . Sensate  Posterior DU can erode into GDA → massive . Middle and inf. rectal arteries and veins haematemesis . Superficial inguinal nodes  Anterior DU → pneumoperitoneum and peritonitis  Dentate line = squamomucosal junction

 White line = where anal canal becomes true skin Jejunum  Proximal 2/5  Larger diameter + thicker wall Anal Sphincters  Less prominent arcades  Longer vasa recta Internal  Thickening of rectal smooth muscle Ileum  Involuntary control  Distal 3/5  Narrower diameter + thinner wall External  More prominent arcades  Three rings of skeletal muscle  Shorter vasa recta . Deep . Superficial Appendix . Subcutaneous  Base is consistently found @ confluence of the caecal  Voluntary control taenia coli  Position of rest of appendix is highly variable Anorectal Ring . Retro-caecal: 75%  Deep segment of external sphincter which is . Sub-caecal and pelvic: 20% continuous ¯c puboretalis muscle (part of levator ani) . Retro- or pre-ileal: 5%  Palpable on PR ~5cm from the anus  Appendicular artery runs in the mesoappendix and is a  Demarcates junction between anal canal and rectum. branch of the ileocolic artery.  Must be preserved to maintain continence

Appendicitis Pain Common Areas for Collections  Initially visceral pain carried by sympathetic afferents in the  Subphrenic recess lesser splanchnic nerve which refers to T10 dermatome  Hepatorenal recess: Morrison’s pouch  Later peritonitis → somatic pain and localisation to RIF.  Lesser sac  Paracolic gutters Meckel’s Diverticulum  Small bowel (interloop spaces)  Ileal remnant of vitellointestinal duct  Pelvis: Pouch of Douglas . Joins yoke sac to midgut lumen  A true diverticulum  2 inches long  2 ft from ileocaecal valve on antimesenteric border  2% of population  2% symptomatic: PR bleed, diverticulitis, intussusception  Contain ectopic gastric or pancreatic tissue

Arteries Liver  Functionally divided by line through gallbladder fossa L1: Coeliac Trunk and IVC.  Left gastric  Split into 8 Couinaud segments  Common hepatic . 4 on Right  Splenic . 3 on Left . Caudate lobe is functionally distinct L1: SMA  Inf. pancreaticoduodenal  Ileal and jejunal vessels Gallbladder  Middle colic  Stores and concentrates ~50ml of bile  Right colic  Supplied by cystic artery but also receives rich supply  Ileocolic from the gallbladder bed: gangrene is  rare

L1: Renal Vessels Calot’s Triangle  Sup: inferior edge of liver L3: IMA  Med: CHD and RHD  Left colic  Inf: cystic duct  Sigmoidal branches  Contains  Superior rectal artery . Cystic artery . Calot’s/Lund’s node Marginal Artery of Drummond . Aberrant RHA  Anastomotic artery between middle colic and ascending branch of left colic  May maintain hind-gut blood supply even when IMA stenosed.

Nerves

Sympathetic  Thoracic an d lumbar splanchnic nerves

Parasympathetic  Vagus nerve  Pelvic splanchnic nerves

Splanchnic Nerves  Greater Splanchnic Nerve (T5-T10): foregut  Lesser Splanchnic Nerve (T10-T11): midgut  Least Splanchnic Nerve (T12): kidneys  Lumbar Splanchnic Nerve (L1-L2): hindgut

Enteric NS  Independent of CNS but does receive some sympathetic and parasympathetic input.  Two layers . Myenteric plexus of Auerbach . Submucosal plexus of Meisner

Lymphatics  Follow arteries  Para-aortic nodes associated ¯c each major branch  Drain superiorly to cisterna chyli → thoracic duct

Ureter Course  25cm long  Start at renal pelvis: L1 on left, slightly lower on right  Runs inferiorly on the psoas muscle anterior to the tips of the transverse processes of the lumbar vertebrae  Cross sacroiliac joints passing anterior to iliac bifurcation  Pass posteriorly to the ischial spines then anteriorly to the bladder.

Ureteric Narrowings  Pelviureteric junction  Crossing the iliac vessels at the pelvic brim  Vesicoureteric junction

Male Urethra  20cm long  4 main parts . Pre-prostatic: internal urethral sphincter . Prostatic  Openings of ejaculatory ducts  Widest part . Membranous  External urethral sphincter  Narrowest part . Spongy: longest part (for most)

Coverings of the Vas Deferens in the Scrotum  Skin  Superficial scrotal fascia (Dartos fascia)  External spermatic fascia  Cremasteric fascia  Internal spermatic fascia  Pre-peritoneal fat  Tunica vaginalis  Vas

Neck Fascia Branches of the External Carotid Artery  Superior thyroid Superficial: platysma  Ascending pharyngeal  Lingual Investing  Facial  Completely surrounds neck  Occipital  Encloses SCM and trapezius  Posterior auricular  Superficial temporal Pre-vertebral  Maxillary  Surrounds vertebral column and associated muscles

Pre-tracheal Facial Nerve  Surrounds trachea, oesophagus and thyroid  Arises in medulla and emerges between pons and medulla to travel in the internal auditory canal. Carotid Sheath  Exits the internal auditory canal and forms the geniculate  Surrounds internal carotid, internal jugular + CNX ganglion in the middle ear  Traverses the length of the temporal bone, giving off 3 Thyroid Gland branches  Lies over 3rd-4th tracheal cartilages . Greater superficial petrosal N.: lacrimation  Invested in pretracheal fascia . Nerve to stapedius: lesions → hyperacusis  Strap muscles lie anterior . Chorda tympani: anterior 2/3 taste  Parathyroid glands posteriorly  Exists temporal bone via stylomastoid foramen and runs  2 arteries into parotid gland. . Sup. thyroid (ECA)  Gives off nerves to post. belly of digastric and stylohyoid . Inf. thyroid (thyrocervical trunk)  Divides into 5 motor branches  3 veins: sup, middle and inf. thyroid veins . Temporal . Zygomatic Larynx . Buccal . Mandibular Innervation . Cervical  Motor  Upper motor neurone lesions spare the forehead as . Recurrent laryngeal N. supplies all intrinsic suprapontine crossover → bilateral representation muscles except cricothyroid . External branch of superior laryngeal N. supplies cricothyroid.  Sensory . Int. branch of superior laryngeal N.: above folds . Recurrent laryngeal N.: below folds

Semon’s Law  Transection of RLN . → complete paralysis ¯c cords half aducted / abducted . Cannot speak or cough  Trauma but not transection of RLN . → partial paralysis ¯c cords adducted . Cannot breath if bilateral

Triangles of the Neck

Anterior  Ant. margin of SCM  Midline  Ramus of the mandible  Roof: investing fascia

Submandibular  Mental process  Ramus of the mandible  Line between two angles of the mandible

Hip Joint

Structure  Ball and socket synovial joint between the head of the femur and the lunate surface of the acetabulum.  Lgt. teres connects fovea on femoral head to acetabular fossa and transmits the artery lgt. teres (from obturator A.).  Fibrous capsule composed of three lgts (ilio-, ischio and pubofemoral lgts.) and extends from margin of acetabulum to intertrochanteric line of the femur.

Muscles

Movement Flexion Extension Adduction Abduction Int. rotation Ext. rotation Segment L2/3 L4/5 L2/3 L4/5 L2/3 L5/S1 Nerve Femoral Inf. gluteal Obturator Sup. gluteal Obturator Various Muscles Iliopsoas Gluteus maximus Adductors Gluteus minimus Adductors Short ext. rotators Rectus femoris Gluteus medius Gluteus maximus Sartorius

Blood Supply to the femoral head 1. Intramedullary vessels 2. Retinacular vessels from the medial and lateral circumflex femoral arterie . Distal → proximal in the capsule. 3. Artery of the ligamentum teres from the obturator artery (only contributes in children)

Femoral Triangle: SAIL Anterior Compartment of the Thigh  Lateral: medial margin of Sartorius  Medial: medial margin of Adductor longus Function  Base: Inguinal Ligament  Flex the hip: L2-3  Floor: pectineus and adductor longus  Extend the knee: L3-4  Apex: continuous ¯c Hunter’s canal  Contents: femoral N., A., V. and canal Nerve  Femoral N.: L2-L4

Hunter’s (Adductor) Canal Muscles  Iliopsoas  Anterolateral: vastus medialis  Sartorius: ASIS → pes anserinus  Posterior: adductor longus and magnus  Rectus femoris: AIIS → patellar lgt.  Roof and medially: Sartorius  Vastus muscles  Contents: SFA, femoral V., saphenous nerve

Medial Compartment of the Thigh Gluteal Region Function

Muscles  Adduct and externally rotate the hip: L2-3

 Abductors: superior gluteal N. Nerve . Gluteus medius . Gluteus minimus  Obturator N.: L2-L4

 Extensor: inferior gluteal N. Muscles . Gluteus maximus  Pectineus (femoral N.)  Short external rotators . Piriformis  Adductor brevis, longus and magnus . Obturator internus  Gracilis . Quadratus femoris  Obturator externus . Gemelli: inf. + sup. Posterior Compartment of the Thigh Sciatic N.: L4-S3  Enters via greater sciatic foramen below piriformis Function  Found in lower medial quadrant of gluteal region  Extend the hip: L4-5  Motor  Flex the knee: L5-S1 . Hamstrings . Hamstring part of adductor magnus Nerve . Muscles of leg and foot  Tibial division of sciatic.: L4-S3  Sensory . Lateral leg and foot Muscles . Sole and dorsum of foot  Biceps femoris  Semitendinosus  Semimembranosus © Alasdair Scott, 2012 226 The Leg

The Knee Joint Posterior Compartment of the Leg

Structure Function  Weight-bearing articulation between femur and tibia  Plantarflexion of the foot: S1-2  Articulation between patella and femur  Flex the toes and invert the foot . ↓ tendon wear . ↑ moment around knee joint. Nerve  Tibial nerve Menisci  2 fibrocartilaginous menisci Muscles  Medial meniscus attached at its margin to medial  Superficial collateral lgt. . Gastrocnemius . Plantaris Bursae . Soleus  Suprapatellar bursa: continuous ¯c joint capsule  Deep  Subcutaneous prepatellar bursa . Popliteus . Can → housemaids knee . FHL  Deep and superficial infrapatallar bursae . FDL . Tibialis posterior (L5) Ligaments  Patellar lgt.: inf. patella to tibial tuberosity  Collaterals: medial and lateral Lateral Compartment of Leg  Anterior cruciate . Prevents anterior displacement of the tibia Function relative to the femur  Evert the foot: S1  Posterior cruciate . Prevents posterior displacement of the tibia Nerve relative to the femur  Superficial fibular N.

Muscles Muscles  Fibularis longus Movement Flexion Extension  Fibularis brevis Segment L5/S1 L3/4 Nerve Sciatic (Tibial) Femoral Muscles Hamstrings Quads Anterior Compartment of Leg - biceps femoris - Vastus muscles - semimem - Rectus femoris Function - semiten  Dorsiflexion of the foot: L5-S1 Sartorius ( fem)  Extension of the toes and eversion of the foot: S1

Nerve Popliteal Fossa  Deep fibular N. nd  Superior . Supplies skin between great and 2 toe . Medial: semitendinosus and semimembranosus . Lateral: biceps femoris Muscles  Inferior  Tibialis anterior . Medial: medial head of gastrocnemius  EHL . Lateral: lateral head of gastrocnemius + plantaris  EDL  Floor: capsule of knee joint  Fibularis tertius  Roof: deep fascia (continuous ¯c fascia lata)

Contents  Popliteal artery and vein  Tibial nerve  Common fibular nerve

Blood Supply  Popliteal artery → anterior + posterior tibial arteries  Anterior tibial . Supplies anterior compartment of leg . Palpable as dorsalis pedis A.  Posterior tibial . Supplies posterior compartment of leg . Gives rise to fibular A. (supplies lat compartment) . Palpable behind the medial malleolus © Alasdair Scott, 2012 227 The Arm

Brachial Plexus Anatomical Snuff Box  C5-T1  Lateral: APL and EPB  Roots leave vertebral column between scalenus  Medial: EPL anterior and medius.  Proximal: radial styloid process  Divisions occur under the clavicle, medial to coracoid  Floor: scaphoid and trapezium process.  Contents: radial artery, cephalic vein, dorsal cutaneous  Plexus has intimate relationship ¯c subclavian and branch of radial nerve. brachial arteries.  Median N. is formed anterior to brachial artery. Carpal Tunnel C5  Carpal tunnel formed by flexor retinaculum and carpal Lat MC bones.  Contains C6 . 4 tendons of FDS Post Axillary C7 Median . 4 tendons of FDP Radial . 1 tendon of FPL C8 . Median N. Med Ulnar  Median N. supplies LLOAF (aBductor pollicis brevis)  Palmer cutaneous branch travels superficial to flexor T1 retinaculum → spares sensation over thenar area. Roots (5) Divisions (6) Trunks (3) Cords (3)

Anterior Compartment of the Arm  Function: forearm flexion (C5-6)  Nerve: musculocutaneous  Muscles . Biceps brachii . Coracobrachialis . Brachialis

Posterior Compartment of the Arm  Function: forearm extension (C7)  Nerve: radial  Muscle: triceps

Antecubital Fossa  Superficial: median cubital vein  Deep . Radial nerve . Brachial artery . Median nerve

Anterior Compartment of the Forearm  Function: wrist and finger flexion (C7-8)  Nerve: mostly median N.  Muscles . Superficial  Pronator teres  FCR  Palmaris longus  FDS  FCU (ulnar N.) . Deep  FDP (ulnar and median Ns.)  FPL  Pronator quadratus