Mini Slideshow Mixed Medicine/Surgery Questions

1. Mini SlideshowMixed Medicine/Surgery Questions Ian Anderson 19/03/2007

2. What is this condition? What pattern of inheritance does it have? What problems would this patient be at increased risk of?

3. What are these lesions? List four conditions that they might be a sign of.

4. What abnormality is present in this man (his bruises are from Clexane injections) What is the diagnosis? What is THE MOST LIKELY cause of this? How much Clexane prophylaxis would this man receive on a) a medical ward b) a surgical ward?

5. 1. 2. 3. Name these lesions and suggest the underlying cause for them

6. Non-tender, highly mobile lump • Vague edges, pain on examination What is the most likely diagnosis of these three breast lumps?

7. Which is the odd one out? Why?

8. What procedure is being performed in this image? • For what condition is this operation performed? • What are the common symptoms? • What non-surgical treatments might this patient have previously tried?

9. What is the abnormality in this chest film? What conditions is this abnormality associated with?

10. What is this skin eruption? Give four conditions that it is associated with.

11. What abnormalities are present? What is your diagnosis?

12. Question 1 • Osler-Weber-Rendu syndrome (hereditary haemorrhagic telangectasia) • Autosomal dominant • EpistaxisGI bleedsAV malformation (which may cause high output cardiac failure and increased stroke risk)

13. Question2 • Splinter haemorrhages • Trauma (esp manual labour)Infective endocarditisTrichinella spiralis infestationVasculitides (e.g. RA, SLE, PAN)SepsisHaematological malignancySevere anaemia

14. Question 3 • Tortuous, dilated veins of the abdomen, especially through the central, epigastric region. They do not radiate from the umbilicus and therefore caput medusa is incorrect here • Inferior vena cava obstruction. The most common cause of IVC obstruction is a malignant tumour spreading from one of the abdominal viscera. If the tube in the picture is a nephrostomy, then perhaps this is renal in origin but it may well just be an IV infusion line from a cannula in his hand • Medical patients all get 40mg(4000 units)/24h of clexane and surgical patients all get 20mg(2000 units)/24h. [Other doses: DVT treatment is 1.5mg/kg/24h, unstable angina/NSTEMI get 1mg/kg/12h] NB: Clexane is not a generic name and should technically be prescribed as “enoxaparin sodium” on a drug chart.

15. Other Causes of IVC Obstruction • Thrombosis (For example, in individuals with polycythaemia or congenital clotting disorders, such as factor V Leiden and deficiencies in protein C, protein S, or antithrombin III) • Liver or pancreatic disease • Lymphadenopoathy of paravertebral peritoneal lymph nodes • Fibrous adhesions (These are common in individuals who have had previous abdominal surgery) • Aortic aneurysm (Which is thought in some cases to press directly on the vessel) • Congenital • Embolism • Iatrogenic (For example, accidental surgical clamping)

16. Question 4 • Janeway lesions: Janeway lesions are painless palmar macules seen in patients with infective endocarditis. • Syphilids (i.e. Cutaneous secondary syphilitic lesions on palms or soles): These are due to treponema pallidum infection (a spirochaete). These lesions occur ~6-8 weeks after the development of a primary chancre in 80% of cases. They are symmetrical, generalized, superficial, non-destructive, transient lesions. They may be macular intially but become papular and more tender with time. Lesions are usually found on the face, shoulders, flank, palms and soles, and anal or genital regions. Individual lesions are generally <1 cm in diameter. • Tophi: these are due to gout/pseudogout. If you really wanted to you can do an aspiration and polarized light examination of the synovial fluid - shows negatively birefringent crystals in true gout.

17. Question 5 • Fibroadenoma. Common in young adults. Usually a discrete mass, often in the superio-medial quadrant of the breast. These are thought to be due to increased oestrogen sensitivity. Not commonly excised if <4cm. Can do FNAC although opinion differs (I fucking well would anyway!)

18. Question 6 • Vitiligo is the odd one out (bottom right) • Conjuctivitis, urethritis (shown here with a discharge) and seronegative arthritis are three cardinal features of Reiter’s syndrome • NB: The two commonest causes of Reiter’s syndrome are genital (chlamydia & gonorrhoea) and enteric (salmonella, yersinia, shigella & campylobacter)

19. Question 7 • Nissen fundoplication • Hiatus hernia • 50% are asymptomatic. Other symptoms include: reflux oesophagitis, dysphagia, duodenal or gastric ulcer, regurgitation of food at night, hiccough, nausea and vomiting & waterbrash. It is associated with gallstones and diverticular disease (Saint’s triad). • Conservative management: Don’t lie down before meals, eat small meals, don’t eat before bed, sleep with head elevated, stop smokingDrug management: PPIs, H2 antagonists (in severe cases only), antacids may be helpful, no benefit in H. Pylori eradication therapy.

20. Question 8 • Widened mediastinum (probably dissecting AA) • Causes (in order of commonness):Hypertension (90% of cases)Collagen diseases (e.g. Marfan’s)PregnancyBicuspid aortic valveCoarctation of the aortaAortic surgeryTrauma

21. Question 9 • Erythema nodosum • Sarcoidosis (30 to 40% of cases) • Infectious causes: • streptococcal/viral throat infections - most common • chlamydia - relatively common • tuberculosis - relatively common • mycoplasma • yersinosis - more common in non-UK European countries • Rarely, histoplasmosis, leprosy, psittacosis, cat-scratch disease, lymphogranuloma venereum • Inflammatory bowel disease: • Crohn's • Ulcerative colitis • Rarely, Behcet's disease • Drugs are a common cause: • Sulphonamides • Oral contraceptive pill • Malignancy: • Lymphoma, leukaemia • Post-radiation therapy • Pregnancy • Often no cause is found

22. Question 10 Pre-proliferative diabetic retinopathy: