Hodgkin's lymphoma and prognosis

Nodular sclerosing - Good
Mixed cellularity - Good
Lymphocyte rich - Good
Lymphocyte depleted - Poor

Abdominal Ultrasound and Jaundice

An abdominal ultrasound is of key importance in such cases in order to assess evidence of bile duct dilatation.

Rheumatoid arthritis and Osteoarthritis first line drug

Osteoarthritis - Paracetamol. Can try with NSAIDs too
Rheumatoid arthritis - Methotrexate (Try TNF alpha blcokers later)

Causes of thoracotomy scar

• Fungal infection
• Tuberculosis
• Cancer
• Emphysema
• Abscess that does not clear on antibiotics

Hydatid disease

Hydatid disease occurs because of chronic tapeworm infection. The sheep is an intermediate host for the tapeworm, and as such farmers are likely to be exposed to tapeworm eggs. Patients may suffer progressive liver symptoms over a number of years, and the diagnosis can be an incidental finding. Rapid worsening of symptoms can occur with cyst rupture or infection. Surgical excision of large cysts, coupled with albendazole in repeated 1 month courses or a 3-6 month course of albendazole.

Ventilator acquired pneumonia

Given that this man is pyrexial, with chest signs on the right hand side that match his X-ray picture, the most likely diagnosis is ventilator acquired pneumonia. It occurs because of contamination of the respiratory tract due to aspiration of oropharyngeal secretions which isn't prevented by a cuffed ET tube. Diagnosis is clinical and is supported by bronchial washings. Initial antibiotic therapy should cover anaerobes, MRSA, pseudomonas and acinetobacter until definitive culture and sensitivity testing is available.

Carpal tunnel syndrome

Compressed as it passes through space between the carpal bones and the flexor retinaculum. The median nerve supplies the muscles of the thenar eminence. The recurrent thenar nerve is the nerve that actually supplies the thenar eminence - however, it does not pass through the carpal tunnel individually; it actually branches off the median nerve beyond the carpal tunnel. Associations include pregnancy, acromegaly, and diabetes, as well as several other diseases. It may also be a complication of trauma to the forearm.

Pancreatic carcinoma

Painless jaundice is an ominous sign in a patient who has been losing weight. The presence of jaundice, dark urine, and pale stools indicate an obstruction to biliary flow, which may be caused by gallstones, a biliary stricture of a mass compressing bile ducts. Courvoisier's law states that a palpable gall bladder in the presence of painless jaundice is unlikely to be gallstones. Patients present with painless obstructive jaundice, a mass in the right hypochondrium and significant weight loss. This strongly suggests a diagnosis of pancreatic carcinoma. A CT scan is typically undertaken to diagnose and stage the tumour. Prognosis is poor. Surgery should be considered as early as possible to avoid metastases if possible. Pancreaticoduodenectomy (Whipple's procedure) have up to 25% 5 year survival. Those with unresectable tumour have less than 6 months usually.

Triangle of Calot

Hepatic duct medially
Cystic duct laterally
Inferior edge of liver superiorly


Contains: Right hepatic artery, cystic artery, cystic lymph node (of Lund), connective tissue and lymphatics. May contain accessory hepatic ducts and arteries.

Dissected in a cholecystectomy in order to identify the cystic artery and the cystic duct before ligation and division.

Femoral canal

Femoral nerve and femoral artery pass through it.

Ulcer on penis

Painful and painless

Painful

• HSV
• Chancroid

Painless

• Lymphogranuloma venereum (chlamydia trachomatis)
• Syphilis

Traveller's diarrhoea - E. Coli

Traveller's diarrhoea is often due to a mundane ubiquitous organism such as E.coli. Salmonellosis, Giardiasis, Amoebiasis may all cause significant diarrhoea also. Blood in the stool suggests a colitis which is likely to be viral or due to toxogenic E.coli.

Retinoblastoma

Retinoblastoma accounts for about 5% of cases of severe visual impairment in children. The mean age of presentation is 18 months of age. A significant proportion of cases are inherited. The suspected gene is located on chromosome 13 and the mode of inheritance is dominant. Children in families that suffer from the hereditary form should undergo regular screening. They are commonly have bilateral disease. The commonest presentation is a white pupillary reflex or strabismus. Treatment is with chemotherapy to shrink the tumour, followed by laser therapy to the retina to preserve vision. Although most patients are cured, many suffered from impaired vision. There is a significant risk of secondary malignancy in survivors, especially sarcoma.

Femoral shaft fracture

Femoral shaft fractures usually follow high velocity trauma in young patients, particularly common in motorbike accidents. Patients are often shocked and fat embolisation may occur. Internal fixation or traction may be used to immobilise the fracture. Risk of infection in high with open fracture if they are managed with internal fixation. Conservative treatment is favoured in open and distal fractures, and in children.

Pickwickian syndrome

Early morning headaches and daytime somnolence are a result of his nocturnal hypoventilation, hypercapnia, and intermittent episodes of sleep apnoea and wakening. Patients classically have episodes of snoring followed by episodes of upper airway obstruction and apnoea. They should be treated as with any patient with COPD but should be encouraged to lose weight and may benefit from non-invasive ventilation at night which maintains the patency of the upper airway and thus oxygenation, whilst avoiding the apnoea and hypercapnia.

Ankylosing spondylitis features - the 'A's

• Apical fibrosis
• Anterior uveitis
• Aortic regurgitation
• Achilles tendonitis
• AV node block
• Amyloidosis

Chickenpox

Chickenpox is caused by primary infection with varicella zoster virus. Shingles is reactivation of dormant virus in dorsal root ganglion.

Chickenpox is highly infectious

• Spread via the respiratory route
• Can be caught from someone with Shingles
• Infectivity = 4 days before rash, until 5 days after rash first appeared
• Incubation period = 10-21 days

Clinical features (tend to be more severe in older children/adults)

• Fever initially
• Itchy rash starting from head/trunk before spreading. Initially macular then papular then vesicular
• Systemic upset is usually mild

Management is supportive

• Keep cool, trim nails
• Calamine lotion
• School exclusion: current HPA advice is 5 days from start of skin eruption
• Immunocompromised patients and newborns with peripartum exposure should receive varicella zoster immunoglobulin (VZIG). If chickenpox develops then IV aciclovir should be considered

A common complication is secondary bacterial infection of the lesions. Rare complications include

• Pneumonia
• Encephalitis (cerebellar involvement may be seen)
• Disseminated haemorrhagic chickenpox
• Arthritis, nephritis, and pancreatitis may very rarely be seen

Genital ulcers

Painful: Herpes simplex 2, Chancroid (Haemophilus Ducreyi)
Painless: Syphilis, Lymphogranuloma Venereum (Chlamydia Trachomatis)

Altitude related disorders

There are three main types of altitude related disorders: acute mountain sickness (AMS), which may progress to high altitude pulmonary oedema (HAPE) or high altitude cerebral oedema (HACE). All three conditions are due to the chronic hypobaric hypoxia which develops at high altitudes.

Acute mountain sickness is generally a self-limiting condition. Features of AMS start to occur above 2500 and 3000m, developing gradually over 6-12 hours and potentially lasting a number of days.

Headache, nausea, fatigue.


Prevention and treatment of AMS.

The risk of AMS may actually be positively correlated to physical fitness
Gain altitude at no more than 500m per day
Acetazolamide (a carbonic anhydrase inhibitor) is widely used to prevent AMS and has a supporting evidence base
Treatment is descent.

HAPE: Classical pulmonary oedema features.
HACE: Headache, ataxia, papilloedema

Management of HACE: Descent, dexamethasone

Management of HAPE: Descent, nifedipine, dexamethasone, acetazolamide, phosphodiesterase type V inhibitors, oxygen if available

Sectioning under the Mental Health Act

This is used for someone over the age of 16 years who will not be admitted voluntarily. Patients who are under the influence of alcohol or drugs are specifically excluded.


Section 2

• Admission for assessment for up to 28 days
• A GP, psychiatrist and approved social worker is required

Section 3

• Admission for treatment for up to 6 months
• Nearest relative or social worker along with 2 doctors

Section 4

• 72 hour assessment order
• Used as an emergency, when a section 2 would involve an unacceptable delay
• A GP and an approved social worker or relative
• Often changed to section 2 upon arrival at hospital

Section 5(2)

• A patient who is a voluntary patient in hospital can be legally detained by a doctor for 72 hours

Section 5(4)

• Similar to section 5(2), allows a nurse to detain a patient who is voluntarily in hospital for 6 hours

Section 135

• A court order can be obtained to allow police to break into a property to remove a person to a Place of Safety

Section 136

• Someone found in a public place who appears to have a mental disorder can be taken by the police to a Place of Safety