Case 161: Car AccidentThis man was involved in a high speed car accident. He was wearing a

seatbelt. The chest injuries seen are the only injuries sustained .

Case 161A: Car AccidentThis is his sputum cup on day two of his hospital recovery .

1 .What does the Chest Xray show?The chest Xray displays many features of severe chest trauma. There are fractures of the left clavicle, and the upper five left sided ribs, including the first rib. There is already patchy consolidation of the left lung field consistent with lung contusion. 2. How would you manage the problem in the emergency

department ?As per any multiply injured patient, guided by ATLS (or

EMST) principles .

Important aspects concerning the chest injury include:

* high flow oxygen * analgesia * continuous oxygen saturation measurements * assessment for a flail segment and subsequent respiratory mechanical failure * possible early intubatiion and mechanical ventilation * consideration of early chest tube insertion * CXR * cardiac investigations - ECG, troponin, Echocardiogram, for possible associated cardiac contusion * CT chest with CT angiogarphy of the great vessels for possible major vessel injury * Intensive care referral

3 .What are the possible complications this man may have during his hospital stay?

*Respiratory failure* pneumothorax* DVT* Pulmonary embolus* chest infection / pneumonia* empyema

4. What does this suggest?Pulmonary contusion. However also consider the rare occurrence of direct major airway injury

5. What if he had coughed this up on day seven ?Consider then superimposed pneumonia, but bright blood in this case and in this clinical setting is almost pathopneumonic of pulmonary embolus .

Case 162: Post op leg pain

Post op leg pain

1 .What is the diagnosis?Superficial Thrombophebitis, in the territory of the long saphenous vein. 2.

How would you manage this problem ?1 .Confirm the diagnosis

2. Exclude extension to the deep system 3. Exclude associated deep vein thrombosis 4. Exclude any underlying predisposition 5. Symptomatic care - leg elevation, analgesia, antiinflammatories, DVT prophylaxis 6. Observation for skin breakdown and superimposed

cellulitis .

Basically a duplex ultrasound of the lower limb is required. It will confirm the diagnosis, judge whether the clot extends up to or through the sapheno-femoral junction, and screen for deep system thrombus.

Underlying predisposition includes all usual causes of DVT. Of special interest is the association with intraabdominal malignancy especially pancreatic cancer. - Trousseau's sign

of migratory thrombophlebitis .

Case 163: Hardware at laparoscopyYou are performing a laparoscopic appendicectomy. Your intern asks what

that white tubing is .

1 .What is it? It is a ventriculo-peritoneal shunt used to treat hydrocephalus.

The problem with this hardware is not its identification, but the diagnostic confusion it can make.

These patients can present with abdominal pain which is difficult to discern. The pain could arise from a primarily infected shunt or could also arise from a primary intraabdominal problem (as in this case)

Methods to differentiate include drawing off some CSF from the reservoir port (performed by the neurosurgeons, if this shows pure growth of a characteristic skin organism then it is more likely a shunt problem) or performing a diagnostic laparoscopy.

Case 164: CollapseAn 82 year old lady collapsed trying to get off the toilet. She had

been feeling faint for the past 24 hours .

1 .What is this characteristic bowel action called?Melaena. The passage of altered blood per rectum. 2. How would you manage the problem in the emergency

department ? Resuscitation, which includes airway control and breathing

assistance if required. Also prompt attention to restoring circulatory volume. These patients often have other medical comorbidities and a multi-team approach with the intensive care team, and the anaesthetic team is required. Early referral to the on-call endoscopist and the surgical team is necessary. Issues are often: anticoagulation, ischaemic heart disease,

cardiac failure, liver disease, portal hypertension .

3 .What are the options for management? Early upper GI endoscopy and proceed as required.

This lady has several risk factors for higher mortality: her age, and the fact that she collapsed. She requires early and aggressive treatment. Acute upper gastrointestinal bleeding carries a hospital mortality in excess of 10%. The most important causes are peptic ulcer disease and varices. Varices are treated by endoscopic band ligation or injection sclerotherapy and management of the

underlying liver disease .

Ulcers with major stigmata of recent bleeding are treated by injection with dilute adrenaline, thrombin, or fibrin glue; application of heat using the heater probe, multipolar electrocoagulation, or Argon plasma coagulation; or endoclips.

Intravenous proton pump inhibitors reduces the risk of re-bleeding in ulcer patients undergoing endoscopic therapy.

Repeat endoscopic therapy or operative surgery are required if bleeding recurs .

Case 165: Urine discolourationThis is a specimen of urine taken from a man who complained recently of

epigastric pain radiating through to his back .

1 .What physical sign does the urine demonstrate?The dark urine of cholestatic jaundice. This man says that 'it was much worse yesterday - almost like Coca-Cola.' 2. How would you manage this problem in the emergency

department ?First confirm the diagnosis with a thorough history, physical examination and then a biliary ultrasound.

Liver function blood tests would also be needed. Other tests required are full blood examination for white cell estimation, clotting parameters, amylase or lipase to exclude gallstone pancreatitis.

The urgency of intervention then depends primarily on the degree of biliary sepsis. The septic and hypotensive patient will require urgent

biliary decompression .

3 .Biliary ultrasound shows stones in the gallbladder. The common bile duct was 8mm in diameter with no stones

seen. Next move - MRCP or straight to ERCP? Some would say that if this was a young man then the

duct being 8mm is above the upper limit of normal and probably obstructed distally. Combined with a good story for obstructive jaundice, then proceeding straight to ERCP would be reasonable. However this approach would high negative rate of having the stones already passed.

MRCP is preferable to save some patients the morbidity (and mortality) of ERCP .

Case 166: Chest PainThis 49 year old lady has had a laparoscopic anti-reflux operation two years previously. She now presents with trouble swallowing and

retrosternal chest pain .

1 .What does the xray show?This a barium swallow, and it demonstrates a paraoesophageal hernia, with a moderate sized portion of the proximal stomach herniating into the chest.

2. What are the options for management?This problem, when symptomatic requires operative repair. This may be possible laparoscopically, or require open repair. The principles are reduction of the hernia,

anatomical hiatal repair, and redo fundoplication .

Case 167: Leg troubleHere is quite a graphic image taken during an operation on this

patients lower limb .

1 .What type of amputation has been performed? An above knee amputation

2. How do you know?

The image is not all that clear, but the knee joint is just visible in the amputated part. The give away is the retractor that is being used. This broad sheet of metal is sloted on one side to accommodate the femoral shaft, thereby retracting the soft tissues of the thigh when using a saw to cut through the bone.

Case 168: Not againA 47 year old man presents with a very painful letf buttock. He says this has happened two times before and each time he

required surgery .

1 .Describe the problem seen in the photo?There is a large left sided ischiorectal abscess. Cellulitis is spreading from this septic source across most of the left buttock. The pus is pointing laterally at about 4 cm's from the anal verge in the 3 O'Clock position. The skin in this area is becoming necrotic.

2. What would be your management?Drainage of the collection under a general anaesthetic through the area of compromised skin. A mushroom catheter placed into the cavity will decrease the incidence of abscess reaccumulation, which can be as high as 10%.

The chance of there being an internal opening is high with the prior episodes, however this may not be able to be found with probing in the acute situation. Overly aggressive attempts to find one may

create a false passage leaving the patient with an iatrogenic fistula .

Case 169: 'My hernia wont go back in'This man was putting off having this incisional hernia repaired. It usually did not cause him much trouble, and if it

did he could lie down and it would reduce .

For the past 24 hrs it has been tender, painful and will not reduce when lying down .

1 .What has happened?

The hernia has incarcerated. A major ventral abdominal hernia of this size will almost certainly contain some bowel, which is now becoming compromised.

2. How would you repair this problematic hernia? Open technique, resecting non-viable bowel if required. If

no resection needed then a repair reinforced with mesh would be ideal to prevent recurrence.

3 .When will you do it? It is getting late, the operating theatre is free now but tomorrow there will also be

some time at 11am. Tonight or tomorrow? Do it tonight.

Tonight you will operate and hopefully just reduce contents and apply a mesh.

Tomorrow you will be resecting bowel in an unwell patient .

Case 170: Industrial AccidentThis gentleman was brought to ED complaining of pain in the left hand. He recalls being at work near a high pressure air tank and hearing a loud explosion. On examination, he has bleeding from the

ears and his L hand is shown .

1 .What is the diagnosis and how will you manage him?Although external soft tissue damage may seem minimal, this man's hand is swollen and is at risk of compartment syndrome. He needs neurovascular examination, imaging for structural damage and urgent plastics review.

2. You order an XR. What is shown?Comminuted fractures of the 2,3,4 metacarpal bones.

3. What can be done for him in theatre?GA + bracial plexus block (providing both perioperative and postoperative analgesia of up to 8Hours), fasciotomy, ORIF (K wires).

The bleeding from the ears most likley represents ruptured tympanic membranes - as part of the blast injury. This injury will reqiure external auditory meatus examination, baseline audiometry and follow up by

ENT surgeons .

Case 171: Pain into the backA man fell and presented with back pain. The casualty doctor was

worried about the appearance of the aorta.

1.Which vertebral body is affected?L2 - The second lumbar vertebral body. 2.

If the aorta is 'damaged', what possible problems could arise? Rupture - retroperitoneal or free intraperitoneal rupture

Dissection Embolism to the distal vessels - a cholesterol embolii from this calcified aortic wall could acutely occlude a lower limb vessel.Occlusion - due to acute thrombosis All of these eventualities would be unusual, even with this impressive X-ray appearance. 3.

Which investigation is required ? Firstly a careful lower limb neurological and vascular examination.

Remember this patient has a fractured spine and could possibly have cauda equina (or even conus medullaris / spinal cord) injury. A careful vascular history and examination should exclude significant major vessel

compromise .

Case 172: Facial LesionThis boy had a lesion on his face which had been present for 6 weeks. It is

not particulaly painful, but does bleed when irritated .

1 .What is the diagnosis?A pyogenic granuloma 2.

What treatment would you recommend?Excision and diathermy to the usually found feeding vessel. The lesion should be sent for histopathology to confirm the clinical suspicion, also a swab for micro will often grow staph aureus. The significance of the staph is

not really known .

Case 173: Scalp LesionThis lady says that she hit her head and the wound failed to heal. When asked how long ago that injury was her family think it may have been 6 months ago. They say that they have noticed a lesion there that has

slowly grown bigger with time .

1 .If you took a small punch biopsy of the edge of this lesion what do you think it may show?

Most likely - Basal Cell Carcinoma, next Squamous cell carcinoma, amelanotic melanoma is also a possibility. Then possibly granulation tissue (if biopsy not accurate, foreign body reaction or mycobacterium infection) 2. The lesion feels to be fixed to the underlying pericranium.

Now what are the options?This is the classical 'rodent ulcer' of a locally invasive BCC. Excision will need to involve at least the pericranium, the outer table of the

skull, or more depending on its level of invasion .

Case 175: Fat legThis elderly man has had longstanding bilateral calf oedema due to his mild right heart failure. After spending a few days

in hospital he was noted to be increasingly short of breath .

1.Using the information from the photo, can you suggest a possible cause for his shortness of breath?

A right leg deep vein thrombosis and subsequent pulmonary embolism.

In fact this man on further inspection, can be seen to have swelling of the entire right thigh as well, indicating clinically, that the thrombosis extends well above the knee. On lower limb duplex ultrasonography there was a thrombosis extending proximally to the common iliac vein. This was not well captured in the photo, but clinically the patient had a Phlegmasia Cerulea Dolens.

Case 176: Very Fat legThis man has had a larger leg on the left side for many years. He first noticed this at the age of 37. Lately there are nodules developing and also the right leg is enlarging. He says that other memebers of his family

have had leg swelling .

1.What process is shown? This man gives a history consistent with adult onset

lymphoedema. The photo demonstrates developing lymphatic vesicles (or these could represent lymphangiomas or even lymphangiosarcomas) there is skin excoriation with some skin ulceration. This patient would most likley suffer repeated episodes of cellulitis.

2.What is this condition called? Hereditary lymphedema, or Nonne-Milroy-Meige disease.

See reference below. 3.What type?

Type II

Case 177: Sore toeAn 18 year old man presents to you with a painful right great toe. He had a similar problem with the left toe in the past and underwent surgery a few years ago.

1 .What is the diagnosis?Ingrown toenail affecting both sides of the great toenail

2 .What operation has been performed on the

left?Bilateral nail bed wedge excisions

Case 178: Lump in the neckA 43 year old woman presents with a long history of a slowly enlarging mass in the neck. She nows considers it a cosmetic problem.

1 .What is the diagnosis?Goitrous enlargement of the thyroid. Most likely benign multinodular goitre.

2 .What issues in the history would you explore?

Functional stateFamily historyRisk of malignancy

3 .What investigations would you arrange?Thyroid function tests - in particular TSHThyroid US to assess the nodularity and extent of diseaseCT neck is appropriate for large thyoids with intrathoracic extension to allow planning of surgery. Note that iodine based intravenous contrast agents commonly administered during CT scans may precipitate hyperthroidism - the Jod-Basedow phenomenon.

Case 179: Lumps on the armsA 39 year old man presents with poorly controlled hypertension. You note that he has multiple subcutaneous nodules on both his arms. He recalls that his mother had similar lumps.

1 .What diagnostic features can you see?As well as the obvious subcutaneous nodules there are also pigemented cutaneous "cafe au lait" markings.

2 .What is the diagnosis?

These are features of neurofibromatosis type I and together with the family history of a similar condition the diagnosis is elatively certain.

3 .Why is his blood pressure a problem?

There is an increased incidence of adrenal phaeochromocytoma in the setting of NF1.

Case 185: Breast lesionA 60 year old woman presents with a lesion on her right breast. She thinks it started as an insect bite but has been getting progressively

worse over the last 6 months .

1 .What is the diagnosis? This appears to be a locally advanced carcinoma of the right

breast. It is stage T4b at least. 2 .What investigations would you arrange?

The diagnosis should be confirmed with mammography and core biopsy of the lesion. Then ffter appropriate history and examination to detect regional and systemic metastases she should undergo thorough staging. This includes FBE, LFTs and serum calcium. Imaging with bone scan and CT chest and abdomen would be appropriate with other investigations as directed by the clinical findings.

3 .What are the principles of management? After staging there should be discussion in a

multidisciplinary setting to plan therapy which takes into account the patient's overall condition and wishes.

Case 186: Epigastric pain and feverA 25 year old woman has been celebrating the end of her exams. Over the last few days she has been binge drinking. She now presents with epigastric and right upper quadrant pain associated with fever. The emergency department call you to see her as suspected complicated

pancreatitis .

1 .What is the diagnosis? The chest xray shows an air fluid level in the right

hemithorax in the region of the middle lobe. This would indicate a lung abscess likely secondary to aspiration during an episode of intoxication.

2 .What investigations would you arrange?

A CT chest is useful to confirm the diagnosis and the anatomical location of the abscess. Sputum should be sent for microbiology. A bronchoscopy may be required to obtain adequate material for culture.

Pancreatitis or other complications of alcohol abuse should be excluded with appropriate investigations such as serum amylase or lipase.

Case 187: Severe abdominal painA 42 year old man presents with sudden onset of severe, constant central abdominal pain. On examination his abdomen is distended

but soft and only mildly tender .

1 .What are the xray findings? There are several loops of small bowel seen within the central

abdomen. They are distended and there is loss of the normal folds of plicae circulares. Adjacent loops of small bowel are separated by several millimetres indicating thickening of the bowel wall likely due to oedema. The colon contains gas throughout its length but is not distended and there are no diagnostic features in the colon. There is loss of the normal psoas shadow on the right possibly indicating retroperitoneal oedema but there are no other obvious soft tissue or boney abnormalities seen. The clinical picture of pain out of proportion to examination findings and abnormal small bowel on imaging raises the possibility of ischaemic

small bowel .

2 .What are the principles of management? Rapid fluid resuscitiation followed by urgent transfer to the operating

theatre for exploratory laparotomy.

Case 188: Scrotal lesionA 36 year old man presents with a painful lesion on his scrotum. Initially ne noticed a single nodule but several others have developed.

The largest is now painful. He is concerned about cancer .

1 .What is the diagnosis? Multiple sebaceous cysts are evident with a typical

rounded appearance with central puntum and thick white sebaceous material contained within the cysts. The largest cyst is surrounded by erythema and oedema suggesting that it is

infected .

2 .What are the principles of management? Antibiotics and surgical removal of the sebaceous material.

Once infected these cysts are more difficult to excise without rupture. It is important to remmove the entire cyst wall to prevent recurrence.

Case 189: Abdominal painA 75 year old man is referred in from his hostel with abdominal pain and bloating. He has a history of chronic constipation and laxative use. The emergency department has arranged an erect chext xray and call

you with the result .

1 .What sign does the xray demonstrate? Chilaiditi's sign or syndrome. This an anatomic variation

where the hepatic flexure of the colon is located above the liver and below the diaphragm. It occurs usually in association with abnormalities of the falciform ligament and hepatic

attachments to the diaphragm .

2 .What treatment is required for this syndrome?The condition requires no specific treatment and is usually an incidental asymptomatic finding. It's importance is that it mimics free gas under the diaphragm and may prompt unnecessary laparotomy.

Case 195: Bleeding Skin lesion

This man had noticed this lesion growing and occasionally bleeding for the past 12 months .

Bleeding skin lesion

1 .What is the primary abnormality demonstrated?A large ulcerated cutaneous malignancy

2. What two secondary lesions can be seen?Satellite lesions close to the primary and also posterior triangle lymphadenopathy.

The presence of satellite lesions is more common with melanoma, than other cutaneous malignancies. This

lesion was an amelanotic melanoma .