PACES

Alasdair Scott
BSc (Hons) MBBS PhD

2012
dr.aj.scott@gmail.com
 Medicine
Contents
Cardiology .................................................................................................................................................................................. 3 
Pulmonology ............................................................................................................................................................................ 16 
The Medical Abdomen ............................................................................................................................................................. 30 
Neurology................................................................................................................................................................................. 49 
Shorts ....................................................................................................................................................................................... 71 

© Alasdair Scott, 2012 2

 Cardiology
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 

© Alasdair Scott, 2012 3

 General Cardio Tips
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. c̄ 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
 Optimise CV risk: statins, anti-HTN, DM, anti-plat
Heart Sounds
 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
nd
 Right 2 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 c̄ ↓ 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

© Alasdair Scott, 2012 5

 Mitral Regurgitation
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)
 Functional: LV dilatation (e.g. 2O 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

© Alasdair Scott, 2012 6

 Aortic Regurgitation
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 c̄  AI disease: ESR, HLA-B27, ANA
proximal compression.
 Diastolic murmur c̄ 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)
 Regurgitant jet volume
Pulse
 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
 Monitor: regular f/up and echo
 Rumbling MDM @ apex 2O 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  Calcified mitral valve
 Left parasternal heave: RVH 2O 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 2 to PR)
O 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 c̄ 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

© Alasdair Scott, 2012 8

Rheumatic Fever Infective Endocarditis
Pathophysiology Normal Valves → Acute Endocarditis
 Ab cross-reactivity following S. pyogenes infection → T2
hypersensitivity reaction (molecular mimicry). Risk Factors
 Abs cross-react c̄ 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% c̄ 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

© Alasdair Scott, 2012 9

 Valve Replacement
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 c̄ pulse  Echo + Doppler
 Occur in time = mitral valve  Valve regurgitation or stenosis
 Peri-valvular leak
 Vegetations
Precordium  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
 Bovine pericardium sewn into a metal frame
 Discontinued
Features
 Less durable cf. mechanical valves: ~10yrs
 Don’t require long-term oral anticoagulation
 Take aspirin
Use
 Older patients
 Women of child-bearing age
 Bleeding risk: e.g. peptic ulcer, frequent falls
 Thromboembolism: 1-2% per annum despite warfarin
 Anaemia: warfarin and haemolysis
 Bleeding: minor – 7%/yr, major – 3%/yr
 Infective endocarditis
 Early: Staph. epidermidis
 Late: Strep. viridans
nd
 May require 2 valve replacement
 Mortality: 60%
 NB. avoid erythromycin if on warfarin
 Failure
 Chronic: stenosis or incompetence
 Acute: dehiscence, breakage, thrombus

© Alasdair Scott, 2012 11

 Atrial Fibrillation
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
 Valve pathology
Significant Negatives
 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

© Alasdair Scott, 2012 12

 AF: Key Facts
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
 Avoid certain foods: e.g. grapefruit
Persistent AF
 Care starting new meds
 Lasting >7d
 Wear medic alert bracelet
Rhythm control  Come to hospital if uncontrolled bleeding
 Younger pts., treated precipitants
 ≥3wks anticoagulation c̄ Warfarin first or TOE to
exclude mural thrombus
 Cardioversion: DC or medical
 May need maintenance anti-arrhythmic

Rate control
st
 1 : 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

© Alasdair Scott, 2012 13

 Pacemakers
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
st
 1 : 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 c̄ 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)
 2nd: add Spironolactone
 Pitting oedema
 3rd: consider digoxin
 Ascites
 4th: consider cardiac resynchronisation therapy
New York Classification Surgery
1. No breathlessness  LVAD
2. Breathless c̄ moderate exertion  Heart transplant
3. Breathless c̄ 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

© Alasdair Scott, 2012 15

 Pulmonology
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 

© Alasdair Scott, 2012 16

 COPD
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
 Pursed lip breathing
Definitions
 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 c̄
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

© Alasdair Scott, 2012 17

 COPD: Key Facts
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 c̄ 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 c̄ 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: PaO2 ≥8 for ≥15h / day (↑ survival by 50%)
 BMI
 Indications
 Obstruction: FEV1
 Sable non-smokers c̄ PaO2 <7.3
 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

© Alasdair Scott, 2012 18

 Asthma
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 c̄ β-agonist

PEFR monitoring / diary

 Diurnal variation >20%
 Morning dipping

Atopy: skin-prick testing, RAST

Mx
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 c̄ 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

© Alasdair Scott, 2012 19

 Acute Severe Asthma

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: SpO2 @ 92-94%, PEFR
 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%
 MgSO4 2g IVI over 20min
 SpO2 <92%, PCO2 >4.6kPa, PaO2 <8kPa
 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
 Pre- and post-β agonist
Admission Criteria
 SpO2: keep >92%
 Life-threatening attack
 ABG if initial PaCO2 normal or ↑
 Feature of severe attack persisting despite initial Rx
 May discharge if PEFR > 75% 1h after initial Rx

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

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

© Alasdair Scott, 2012 20

 Pulmonary Fibrosis
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 c̄ coughing  HRCT: fibrosis, Honeycomb Lung
Extras
Spirometry: restrictive
 Cor pulmonale
 ↓TLC¸ ↓RV, ↓FEV and ↓FVC
 FEV1:FVC >0.8
Significant Negatives  ↓ 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

© Alasdair Scott, 2012 21

 Bronchiectasis
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
© Alasdair Scott, 2012 22
 Bronchiectasis: Causes
Cystic Fibrosis
Genetics
 Incidence: 1/2500 live Caucasian births
 Carrier frequency: 1/25
 Autosomal recessive
 Mutation in CFTR gene on Chr 7
 Commonly ∆F508
Pathophysiology
 → ↓ luminal Cl secretion and ↑ Na reabsorption →
viscous secretions.
 Bronchioles → bronchiectasis
 Pancreatic ducts → DM, malabsorption
 GIT → Distal Intestinal Obstruction Syndrome
 Liver → gallstones, cirrhosis
 Fallopian tubes → ↓ female fertility
 Seminal vesicles → male infertility
Dx
 Genetic screening for common mutations
 Immunoreactive trypsinogen (neonatal screening)
 Sweat test: Na and Cl > 60mM
 False +ve: hypothyroidism, Addison’s
 Faecal elastase: tests pancreatic exocrine function
Ix
 Bloods: FBC, LFTs, clotting, ADEK levels, glucose
tolerance test
 Sputum MC+S
 CXR: diffuse tramlines and rings
 Abdo US: fatty liver, cirrhosis, pancreatitis
 Spirometry: obstructive defect
 Aspergillus serology / skin test (20% develop ABPA)
Mx
PCD and Kartagener’s
 Autosomal recessive defect in ciliary motility
 Poor mucociliary clearance → chronic recurrent
inflammation and bronchiectasis.
 ↓ sperm motility in males → infertility
Kartagener’s Syndrome
 Situs inversus + PCD (~50% of individuals c̄ PCD)
 Situs inversus
 Chronic sinusitis
 Bonchiectasis
Young’s Syndrome
 Bronchiectasis
 Rhinosinusitis
 Azoospermia (no sperm in semen) → ↓ fertility
Hypogammaglobulinaemia
 Primary immune deficiency due to ↓ Ig
Presentation
 Recurrent sinopulmonary infections → bronchiectasis
 Diarrhoea
 Commonly encapsulates: pneumococcus, haemophilus
Causes
X-linked Agammablobulinaemia: Bruton’s
 X-linked recessive mutation of Bruton’s tyrosine kinase
 Failure to generate mature B cells → ↓ Ig
 Rx: pooled Ig → passive immunity
Common Variable Immunodeficiency
 Commonest 1O immune deficiency: 1/5000
 Splenomegaly: 25-50%
 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 c̄ 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 c̄ meniscus
 Auscultation  Unilateral or bilateral
 ↓ AE  Cardiomegaly
 ↓ VR  Coin lesions
 Hilar LNs
 Apical TB
Significant Negatives
 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 c̄ lignocaine + aspirate c̄ 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
- Renal failure - Ca: 1O or 2O  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 c̄ Abrams needle

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

© Alasdair Scott, 2012 24

Lung Cancer Lobectomy and Pneumonectomy
Peripheral Inspection Examination
General Peripheral Inspection
 Cachexia  Clubbing
 Hoarse voice or stridor  Cachexia
Hands
Chest
 Clubbing ± HPOA
 Scars
 Tar staining
 Lateral thoracotomy
 Claw hand c̄ 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 c̄
 Plethoric, oedematous face and upper limbs
 Dilated neck and chest veins  ↑ ASA grade
 Stridor  Age >70
 RLNP: hoarse voice c̄ bovine cough  Poor resp function
 Pancoast Tumour  FEV1:FVC <55%
 Horner’s
 Claw hand c̄ interossei wasting Discussion
 Dermatomyositis  Lung Ca
 TB

Differential
 Consolidation
 Collapse
 Effusion

© Alasdair Scott, 2012 25

 Lung Cancer: Key Facts
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)
 LFTs: deranged LFTs 2O 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 c̄ 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 c̄ 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 c̄ 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% c̄ spread
 Addison’s  SCLC: 1-1.5yrs median survival treated; 3mo untreated

© Alasdair Scott, 2012 26

 Pneumonia
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
 Auscultation Bedside
 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 c̄ 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 PaCO2 <4.6 KPa
 Pneumococcus: 50%
 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 c̄ 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)
O
 Rarely may → 1 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
 Thoracoplasty: rib removal to collapse lung
Dx
 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 c̄ 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

© Alasdair Scott, 2012 29

 The Medical Abdomen
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 

© Alasdair Scott, 2012 30

 Chronic Liver Disease
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
 Dupuytren’s contracture  PMN >250mm3 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. c̄ EtOH)
Liver Screen
Trunk  EtOH: MCV, GGT, AST:ALT >2
 Spider naevi  Viral: Hep B and C serology
 Gynaecomastia  NASH: lipids
O
 Loss of 2 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

Complications
CLD Differential
 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

© Alasdair Scott, 2012 31

 CLD: Key Facts
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. c̄ 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 c̄ high carbs Presentation
 Thiamine supplements  Pt. c̄ 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
 Bloods: daily FBC, U+E, LFT, INR Ix: ascites PMN >250mm3 + 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
 Urine dip: proteinuria in nephrotic syndrome  FBC
 U+E
 LFTs: esp. albumin
 INR
Significant Negatives  Glucose
 CLD  Liver screen
 Acute liver failure / decompensation
 Cause: ↑ JVP, periorbital oedema Ascitic tap
 Chemistry
3
 Cytology: malignancy, PMN (>250/mm = 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

© Alasdair Scott, 2012 33

 Medical Jaundice

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

Hepatic
Abdomen
 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  Drugs: avoid
- MAHA Ca: 1O, 2O 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

© Alasdair Scott, 2012 35

 Hepatomegaly

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 c̄ 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  HH: venesection ± desferrioxamine
 Malignancy: 2O  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

© Alasdair Scott, 2012 36

 Splenomegaly
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 c̄ 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
Anatomy
CML  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
 Film: leukoerythroblastic c̄ teardrop poikilocytes  Rupture: e.g. 2O to EBV
 Cytopenias  AIHA
 BM: dry tap (need trephine biopsy)  ITP
 50% JAK2+ve  HS
 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 c̄ spleen
 ↑ susceptibility to infections
 Encapsulates: haemophilus, pneumo, meningo

© Alasdair Scott, 2012 38

 Enlarged Kidneys
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 c̄ 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
 Recurrent UTIs
Pathology
 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. c̄ 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
 2O 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 c̄ 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

© Alasdair Scott, 2012 41

 Renal Transplant: Key Facts
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 c̄ 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
 t½ for HLA-identical live grafts: >20yrs
 ↑ risk of infection: CMV, PCP, fungi, warts
 ↑ 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

© Alasdair Scott, 2012 42

 Renal Replacement Therapy
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
 Renal cysts → RCC
Mechanism
 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 c̄ ~4h dwell times
Mechanism
Types
Counter-current flow  CAPD: fluid exchange during day c̄ long dwell @ night
 Blood flows on one side of semipermeable membrane  APD: fluid exchanged during night by machine c̄ 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
st
 Disequilibration syndrome (usually only 1 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

© Alasdair Scott, 2012 43

 Renal Access
AV Fistula Tunnelled Cuffed Catheter
Examination Tessio Lines
 Two lines tunnelled under skin and entering IJV
Inspection
 Swelling c̄ 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 c̄ 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)

© Alasdair Scott, 2012 44

 CRF: Key Facts
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 c̄ lucent centre
O
 Pyelonephritis: usually 2 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 D3)
 May be large: polycystic, amyloid
 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 c̄ Congo Red
Restless Legs: clonazepam

© Alasdair Scott, 2012 45

 CRF: Specific Causes
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. c̄ ↑↑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 c̄ 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

© Alasdair Scott, 2012 46

 Inflammatory Bowel Disease
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
 May be multiple and atypical in Crohn’s  Toxic megacolon in UC
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
 Assess disease severity
Completion  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
 Chronic Mx
Differential
 Crohn’s
 UC
 Malabsorption: coeliac
 Mid-line lap: FAP

© Alasdair Scott, 2012 47

 IBD: Key Facts for Medicine
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

© Alasdair Scott, 2012 48

 Neurology
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 

© Alasdair Scott, 2012 49

 Parkinson’s Disease
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  Ioflupane I123 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
 Akinesia: slow initiation, difficulty c̄ repetitive movement,  Vertical gaze palsy
micrographia, monotonous voice, mask-like face  Pseudobulbar palsy: speech and swallowing problems
 Postural instability: stooped gait c̄ festination  Parkinsonism
 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 c̄ 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 c̄ Benign Essential Tremor
progressively shorter benefit.  AD
 On-Off effect: unpredictable fluctuations in motor  Occur with movement and worse c̄ anxiety, caffeine
performance unrelated to timing of dose.  Doesn’t occur c̄ sleep
 Better c̄ EtOH

© Alasdair Scott, 2012 51

 Cerebellar Syndrome

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
 Infarct: brainstem stroke  MDT: GP, neurologist, radiologist, neurosurgeon,
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

© Alasdair Scott, 2012 52

 Cerebellar Syndrome: Key Causes
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. c̄ 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 th
 HOCM: ESM + 4 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. c̄ 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
© Alasdair Scott, 2012 53
 UMN Signs
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 c̄ 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

© Alasdair Scott, 2012 54

 Cord Disease

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 c̄ ↓ flow from posterior fossa
 Malignancy: breast, thyroid, bronchus, kidney, prostate  Arnold-Chiari malformation (cerebellum herniates
 Disc prolapse: above L1/2 through foramen magnum)
 Masses
 Spina bifida
Ix
 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 c̄ 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

© Alasdair Scott, 2012 55

 Acute Stroke: Key Facts
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

© Alasdair Scott, 2012 56

 Non-Acute Stroke: Key Facts
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 c̄ 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
O
 Cardiomegaly 2 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%

© Alasdair Scott, 2012 57

 Multiple Sclerosis
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 c̄ 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
nd
 2 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 ↓ c̄ 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

© Alasdair Scott, 2012 58

 Motor Neurone Disease
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
 E.g. absent knee jerks c̄ extensor plantars General
 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

© Alasdair Scott, 2012 59

 LMN Signs
Examination Ix
LMN Signs Peripheral Neuropathy
 Wasting  See below
 Fasciculation
 Hypotonia Proximal Myopathy
 Hyporeflexia  Bloods
 DM: glucose, HbA1c
 Muscle damage: CK, ESR, AST, LDH
Causes  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 c̄ 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
 Dipstick: glucose  DM: Glucose, HBA1c
 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

© Alasdair Scott, 2012 61

Diabetic Neuropathy Charcot-Marie-Tooth Syndrome
= Peroneal Muscular Atrophy
Examination of the Lower Limbs = Hereditary Motor and Sensory Neuropathy

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

HMSN2
Pathophysiology
 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
 Genetic testing
Rx
 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 c̄ 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
© Alasdair Scott, 2012 62
Myasthenia Gravis GBS
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 c̄ 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 c̄ 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)

© Alasdair Scott, 2012 63

 Facial Nerve Palsy
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
 Raising eyebrows: frontalis  Rash or external ear pain
 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

© Alasdair Scott, 2012 64

Facial Nerve Palsy: Key Causes Facial Anaesthesia
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. c̄ 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: c̄ 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 c̄ 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

© Alasdair Scott, 2012 65

 Abnormal Pupils
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
 Quaternary syphilis: RPR or TPHA
Completion
 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
O
 Usually 2 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
 Perimetry  Craniopharyngioma
 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 c̄ 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

© Alasdair Scott, 2012 67

 Ophthalmoplegia
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 c̄ affected eye
 Thyrotoxicosis

Simple Palsies Ix
 Urine dip: glucose
3rd 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
© Alasdair Scott, 2012 68
 Hearing Loss
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

© Alasdair Scott, 2012 69

 Speech
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 c̄ 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

© Alasdair Scott, 2012 70

 Shorts
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 

© Alasdair Scott, 2012 71

 Psoriasis
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

© Alasdair Scott, 2012 72

Dermatitis Cutaneous Manifestations of DM
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. c̄ 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
Adjuvants  Eruptive tendon xanthoma: 2O 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

© Alasdair Scott, 2012 73

 Skin Malignancy

BCC Malignant Melanoma

Examination Examination

Lesions Pt. Characteristics

 On face in sun-exposed areas  Fair skin c̄ freckles
 Pearly nodule c̄ 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 c̄ 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
O
 2 excision margin depends on stage
Dx  ± lymphadenectomy
 Excisional biopsy  ± adjuvant chemo
Mx
 Surgery ± radiotherapy

© Alasdair Scott, 2012 74

Neurofibromatosis Tuberous Sclerosis
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 c̄ 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
 BP: RAS + phaeochromocytoma  Renal enlargement 2O 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

© Alasdair Scott, 2012 75

 Spot Skin Diagnoses
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 c̄ 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 c̄ 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

© Alasdair Scott, 2012 76

 Rheumatoid Hands
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
 Soft tissue swelling
Presentation
 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)

© Alasdair Scott, 2012 77

 RA: Key Facts
Extra-Articular Features: aNTI CCP OR RF Rheumatoid Factor
 Nodules  Anti-IgG IgM
 Tenosynovitis: de Quervains and atlanto-axial  Present in ~70% c̄ 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 c̄
 Ophthalmic: episcleritis, scleritis, Sjogren’s  More severe disease
O
 Renal: nephrosis 2 to amyloidosis  Erosions
 Raynaud’s  Extra-articular manifestations
 Felty’s: RA + ↓PMN + splenomegaly

Seronegative RA
Anatomy of Rheumatoid Hands  RA c̄ 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 c̄ 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
 Derived from collagen
Biologicals
 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 c̄ 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

© Alasdair Scott, 2012 78

 Systemic Sclerosis
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

Mx
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

© Alasdair Scott, 2012 80

 Ankylosing Spondylitis
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
 ↓ chest expansion: <5cm  Diarrhoea
 Measure @ nipples

Tests for Sacroiliitis Ix

 Direct pressure
ECG
 Sacroiliac stretch
 AV block
 Pain on adduction of hip, c̄ 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%

Mx
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

© Alasdair Scott, 2012 81

 Marfan’s Syndrome
Examination Viva
General Hx
 Tall c̄ long arms  Cardiac problems
 Arm-span > height  Family history

Hands Genetics
 Arachnodactyly: encircle waste c̄ 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 c̄ 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

© Alasdair Scott, 2012 82

Tophaceous Gout Osteoarthritis
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
 3rd: steroids Surgical
 Joint arthroplasty
Chronic
 Modify precipitants
 Allopurinol: XO inhibitor
 Mx cardiovascular risk

© Alasdair Scott, 2012 83

 Thyrotoxicosis

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’
 ↓ uptake in thyroiditis
Completion
 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. c̄ 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

© Alasdair Scott, 2012 84

 Hypothyroidism
Examination Viva
General Hx
 Large body habitus  Symptoms
 Depressed mentation  Cold intolerance
 Gruff voice  Appetite but ↑ wt.
 Constipation
Skin  Menorrhagia
 Dry skin  Lethargy, tiredness
 Other AI disease: vitiligo  Depression
 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
 Autoimmune: 1O atrophic and Hashimoto’s thyroiditis
Other Differentials
 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

© Alasdair Scott, 2012 85

 Acromegaly
Examination Viva
Hands Hx
 Spade-like: compare directly c̄ your own  Symptoms
 Tight rings  Headaches
 ↑ skin fold thickness  Problems c̄ 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
© Alasdair Scott, 2012 86
 Cushing’s Syndrome
Examination Viva
Hands Hx
 Thin skin: compare c̄ your own  Symptoms
 Evidence of cause: e.g. RA  Headaches
 Visual disturbance
Arms  Wt. gain
 BP  Bruising
 Cause
 Steroid use
Face  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

Mx
General Mx
 Control BP
 Anti-DM
 Bisphosphonates

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

© Alasdair Scott, 2012 87

 Addison’s Disease
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% c̄ AI disease)

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

Other
 CXR: TB
 AXR: adrenal calcification

Mx
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

© Alasdair Scott, 2012 88

Steroids: Key Facts Neuro Shorts
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 c̄ other drugs: e.g. NSAIDs  Propranolol
 Consider osteoporosis and PUD prophylaxis  Primidone: anti-epileptic

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

© Alasdair Scott, 2012 89

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

© Alasdair Scott, 2012 90

 Superficial Lesions
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 

© Alasdair Scott, 2012 91

 Lump Examination
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 c̄ 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

Hx
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?

© Alasdair Scott, 2012 92

 Skin Lumps
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

© Alasdair Scott, 2012 93

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 c̄ 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. c̄ 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 c̄ 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 c̄ 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
 Body habitus  Multinodular goitre
 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

 Look for collar scars  TFTs: TSH, fT3, fT4
 Ask pt. stick out tongue and swallow water  Other: FBC, Ca2+, 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 c̄ 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 O
 2 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. c̄ 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

© Alasdair Scott, 2012 96

 Solitary Thyroid Nodules
Benign
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. c̄ 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 c̄ 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

© Alasdair Scott, 2012 98

 Midline and Anterior Triangle Lumps

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 c̄ 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
st
undergo malignant change → papillary Ca May see opening of a thyroglossal - 40% in 1 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 c̄ 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

© Alasdair Scott, 2012 99

 Posterior Triangle Lumps

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

© Alasdair Scott, 2012 100

 Cervical Lymphadenopathy
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
 Rest of reticuloendothelial system  Lung
 Gastric

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

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

Radiological
 US
 CT scan

Pathology
 FNAC
 Excision biopsy

© Alasdair Scott, 2012 101

 Salivary Glands
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 c̄ a pen torch
 Stenson’s duct opposite the 2nd 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
 Test CN7  2nd: 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

© Alasdair Scott, 2012 102

Hypertrophic and Keloid Scars Digital Clubbing
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
and impact in digital capillaries.
Non-surgical
 They release growth factors such as PDGF → clubbing
 Mechanical pressure therapy
 Topical silicone gel sheets
 Intralesional steroid and LA injections
Stages
 1: bogginess of the nail bed
Surgical
 2: loss of the nail angle
 Revision of scar c̄ closure by direct suturing
 3: ↑ curvature
 4: expansion of the distal phalanx

© Alasdair Scott, 2012 103

 Abdomen
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 

© Alasdair Scott, 2012 104

 Abdominal Examination
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
1. Clubbing  Role pt. towards you
 Cirrhosis: esp. c̄ PBC
2. Leukonychia  Percuss if palpable
 IBD
3. Terry’s nails  Kidneys
 Coeliac  Left then right
 White ground glass nail
 GI lymphoma  Ballot c̄ respiration
 Loss of lunula
 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 c̄ pt. sitting forward  Central arteriole c̄ 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

© Alasdair Scott, 2012 105

 Inguinal Hernia
Examination Viva

Set-Up Groin Lump Differential

 Expose pt. from umbilicus to knees
 Begin c̄ 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.
 Comment on appearance of mass Lymphatics LN
Veins Saphena varix
 Site, size
 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
 Below (and lateral): femoral hernia
Hx
 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 c̄ 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

© Alasdair Scott, 2012 106

 Inguinal Hernia: Key Facts
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
Inguinal Canal
 Ant: ext. oblique + int. oblique for lateral 3rd
 Post: transversalis fascia + conjoint tendon for medial 3rd
 Floor: inguinal ligament
 Roof: arching fibres of transversus and int. oblique
Open
 Open can be done under LA or GA: day case
 RCS recommends the Lichtenstein Tension Free
Mesh Repair
 Less recurrence cf. older Shouldice Repair
NB. In children, simple ligation and division of the patent
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%
O
 2 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 c̄ 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

© Alasdair Scott, 2012 107

 Incisional Hernia
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 c̄ 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

© Alasdair Scott, 2012 108

 Umbilical and Paraumbilical Hernia
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. c̄ other abnormalities
 Promt surgical repair after fluid resuscitation

Exomphalos
 Protrusion of abdominal contents w/i in a 3-layered sac
 Commonly assoc. c̄ 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

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

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

© Alasdair Scott, 2012 110

 Examination of a Scrotal Lump
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

© Alasdair Scott, 2012 111

 Hydrocele
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 c̄ 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

Mx
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

© Alasdair Scott, 2012 112

Epididymal Cyst Varicocele
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.

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

Surgical
 Often advised as the problem usually gets worse c̄ age
and can → subfertility
 Palomo operation
 High approach c̄ 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
Palpation
 Can get above mass
 Inseparable from testis
 Hard, irregular, nodular
 Non-tender
 Doesn’t transilluminate
Presentation
Completion
 Examine contralateral scrotum
 Abdo exam: hepatomegaly
 Chest exam: thoracic mets
 Examine for abdominal lymphadenopathy
Differential
 Testicular tumour Classification
 Chronic infection → scarring: orchitis, TB
 Chronic, calcified hydrocele
 Pain, discomfort
 SOB: lung mets
 Back pain: para-aortic node involvement
 Haematospermia
 Hydrocele
 Previous history: tumour, infection
 Commonest malignancy in men 15-45yrs
 Painless lump or dull ache in one testis in young man
 Occasionally a Hx of trauma accompanying discovery of mass.
 10% present c̄ acutely painful testis
 Haematospermia
 2O hydrocele
 95% are germ cell tumours
 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 c̄ orchidectomy
 Groin incision c̄ 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)

© Alasdair Scott, 2012 114

 Stomas
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
trephine colostomy
Indications
 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

© Alasdair Scott, 2012 115

 Stomas: Key Facts
Ileostomy
Located in RIF
Small bowel content is an irritant  ileostomies are spouted

Type Features Surgery Indication

End Ileostomy Permanent: Panproctocolectomy (no anus) Proctocolectomy UC
Temporary: Total colectomy Total colectomy c̄ 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 c̄ Stoma Nurse to arrange siting  Good skin care and cleanliness
 Psychosexual support
Siting
 Done c̄ 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

© Alasdair Scott, 2012 116

 Surgical Scars
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 c̄ easy

- Modified Hernia conversion to laparotomy if necessary

“Half” a Pfannenstiel

Loin Nephrectomy

Vascular Access Bypass

Embolectomy
EVAR / TEVAR
Stent Insertion
Femoral Endarterectomy
Angioplasty

© Alasdair Scott, 2012 118

 Colonic Resections
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

© Alasdair Scott, 2012 119

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

© Alasdair Scott, 2012 120

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

© Alasdair Scott, 2012 121

 Inflammatory Bowel Disease
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 O
 Bowel obstruction 2 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

© Alasdair Scott, 2012 122

 IBD: Key Facts for Surgery
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 c̄ 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 c̄ 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 c̄ 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
© Alasdair Scott, 2012 124
 Right Iliac Fossa Mass

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 c̄ scar)

Skin and Soft Tissues

Palpation  Sebaceous cyst
 Differentiate mass before continuing c̄ 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 c̄ 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

© Alasdair Scott, 2012 125

 Abdominal Masses

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 c̄ 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

© Alasdair Scott, 2012 126

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

© Alasdair Scott, 2012 127

 Breast Examination

Set Up
 Request a chaperone
 Expose pt. from waist up and start c̄ 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 c̄ 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

© Alasdair Scott, 2012 128

 Breast Lumps
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

© Alasdair Scott, 2012 129

 Post-Mastectomy Breast
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
 Symptoms of mets
Palpate
 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 c̄ drains and district nurse support.

© Alasdair Scott, 2012 130

 Breast Reconstruction
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 c̄ implants
 Ask pt. to lift head of bead (when lying supine) to see
 Autologous tissue reconstruction c̄ 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
Useful when little remaining
skin or muscle
Good cosmetic result
Primary or delayed
Disadvantages
↑ blood loss
↑ op time and complications
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 c̄ 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

© Alasdair Scott, 2012 131

 Gynaecomastia
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

© Alasdair Scott, 2012 132

 Vascular
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 

© Alasdair Scott, 2012 133

 Venous Examination

Set-Up Great Saphenous Vein Anatomy

 Expose pt. from groin to toes
 Examine c̄ 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
© Alasdair Scott, 2012 134
 Varicose Veins
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 c̄ varicose veins Mx
Conservative
Causes  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 c̄ 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
 Tingling  Trendelenberg: saphenofemoral ligation
 Bleeding: may be severe  SSV ligation: in the popliteal fossa
 Swelling  LSV stripping: no longer performed due to potential
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 c̄ 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 c̄ valve into
deep venous system of leg
 Wrap c̄ PTFE cuff
 Kistner Operation
 Valvuloplasty of damaged valves

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

© Alasdair Scott, 2012 136

 Arterial Examination
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 c̄ 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
 Examine the rest of the vascular system
Auscultate for Bruits
 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

© Alasdair Scott, 2012 137

 Chronic Limb Ischaemia
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
 BP  PMH
Bypass Grafting
 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

© Alasdair Scott, 2012 138

 Abdominal Aortic Aneurysm
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 c̄ 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.

© Alasdair Scott, 2012 139

Popliteal Aneurysm Aneurysms: Key Facts
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 c̄ femorals
 Comment on presence and character
 Aneurysmal popliteals are very easily palpable
 Popliteal aneurysm ≥2cm in diameter
 50% bilateral: examine the other knee
 Distal pulses may not be palpable
Completion
 Complete peripheral vascular examination
 Abdominal examination for AAA
 Present in 50%
Viva
Presentation
 Popliteal aneurysms represent 80% of all non-aortic
aneurysms
 Lump behind the knee
 50% present c̄ distal limb ischaemia: thromboembolism
 <10% rupture
 Dilatation of a blood vessel involving all layers of the
wall and is >50% of its normal diameter
 Two different morphologies
 Fusiform: e.g AAA
 Saccular: e.g Berry aneurysm
False Aneurysm
 Collection of blood around a vessel wall that
communicates c̄ the vessel lumen.
 Usually iatrogenic: puncture, cannulation
Dissection
 Vessel dilatation caused by blood splaying apart the
media to form a channel w/i the vessel wall.
 Used to be classified as “dissecting aneurysms” but not
technically correct as represents a different pathology.
Causes
Congenital
 ADPKD → Berry aneurysms
 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)
 Salmonella typhi: assoc. c̄ AAA
Mx
 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 c̄ US.
 UK men offered one-time US screen @ 65yrs

© Alasdair Scott, 2012 140

False Aneurysm Amputations
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 c̄ 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 c̄ 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 c̄ 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 c̄ 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) c̄ 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 c̄ 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

© Alasdair Scott, 2012 142

Vascular Effects of the Diabetic Foot Gangrene
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 c̄ Diabetics Undergoing Angiography  Crepitus from surgical emphysema
 Often have a degree of renal impairment which can be  Bubbly brown pus
dramatically worsened c̄ contrast agents.
 Metformin must be stopped prior to the procedure to Rx
prevent lactic acidosis  Debridement (may need amputation)
 Benzylpenicillin + metronidazole
 Hyperbaric O2

© Alasdair Scott, 2012 143

Raynaud’s Phenomenon Thoracic Outlet Obstruction
Examination Examination
Key Questions Inspection
 What is the main problem you have c̄ 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. c̄ vasospasm
 Disease: primary Raynaud’s phenomenon occurring in Ix
isolation
 X-Ray: cervical rib
 Syndrome: secondary Raynaud’s phenomenon assoc.
 Duplex in abduction
c̄ 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
 Acquired: clavicle #, pathological enlargement of 1st 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

Mx
Conservative
 Wear gloves and avoid cold
 Stop smoking

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

Surgical
 Cervical sympathectomy
 Amputate gangrenous digits

© Alasdair Scott, 2012 144

 Peripheral Ulcer Examination
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

© Alasdair Scott, 2012 145

Venous Ulcer Ischaemic Ulcer
Examination Examination
Inspection Inspection
 Site: medial malleolus  Site
 Size: variable, can be v. large  Tips of and between toes
 Base  Base of 1st and 5th 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
 Deep vein reflux: e.g. post DVT
Causes
 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 c̄ larval therapy  Inhibit sympathetic-mediated vasoconstriction
 Topical antiseptics: Manuka honey  Relief of pain
 Surgical: split-thickness skin grafts  Often unsuccessful in DM: neuropathy

© Alasdair Scott, 2012 146

Neuropathic Ulcer
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 c̄ 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

© Alasdair Scott, 2012 147

 Lymphoedema

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

© Alasdair Scott, 2012 148

 Musculoskeletal
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 

© Alasdair Scott, 2012 149

 Hip Examination
Set-Up
 Pt. should be in their underwear
 Note presence of walking aids
 Start c̄ pt. standing

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
 Soft tissue or bony swelling +ve Trendelenberg Test
 Muscle wasting: esp. gluteals  Abductor wasting 2O 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
 Stiffness
Completion  ↓ 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

© Alasdair Scott, 2012 150

 Knee Examination
Set-Up
 Pt. should be in their underwear
 Note presence of walking aids
 Start c̄ 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  90% = ACL rupture
 Position knees @ 90O  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

© Alasdair Scott, 2012 151

 Osteoarthritis: Key Facts
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 c̄ 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. c̄ 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 c̄ cysts.
 Proliferation and ossification of cartilage in unstressed
OA vs. RA
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

© Alasdair Scott, 2012 152

 Hip Arthroplasty
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.

© Alasdair Scott, 2012 153

Knee Arthroplasty Knee Ligament Damage
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
 10% 2O to patellar dislocation
 10%
The Surgery
 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. c̄ 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% c̄ 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.
© Alasdair Scott, 2012 154
Hallux Valgus Lesser Toe Deformities
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. c̄ RA
 ↑ c̄ 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. c̄ RA

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

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

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

© Alasdair Scott, 2012 155

Charcot Joints
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

© Alasdair Scott, 2012 156

Gait Popliteal Swellings
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 c̄ 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 c̄ 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. c̄ semimembranosus
 Baker’s Cyst

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

Dx: US

Mx
 Aspiration possible: high recurrence

© Alasdair Scott, 2012 157

 Shoulder Examination
Set-Up
 Expose chest and shoulders

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

O
 Shoulder and elbow flexed @ 90 .
 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
st
 Ulnar nerve: 1 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
 Thumb  Ulnar: 1st 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% c̄ 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

© Alasdair Scott, 2012 160

 Carpal Tunnel Syndrome
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
 RA
Move
 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

© Alasdair Scott, 2012 161

 Rheumatoid Hands
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
 Volar subluxation of the ulnar styloid
Ix

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

© Alasdair Scott, 2012 162

 OA Hands
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
 DIPJs
Completion
 Bouchard’s Nodes are strongly assoc. c̄ polyarticular OA
 Hx
 Examine other joints for OA
 Hips, lumbar spine, knees
Mx of OA Hands
Non-Surgical
Differential
 Physiotherapy
 RA hands
 Analgesia
 Tophi
Surgical
 Joint arthrodesis

© Alasdair Scott, 2012 163

Ulnar Nerve Palsy Radial Nerve Palsy

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

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

Surgical
 Ulnar nerve decompression
 Medial epicondylectomy

© Alasdair Scott, 2012 164

Mallet Finger Trigger Finger
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 c̄ distal phalanx in extension for 6wks to allow
tendon reattachment. Causes
 If avulsed bone is large may fix it c̄ 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

© Alasdair Scott, 2012 165

 Back Examination
Set-Up
 Expose pt. to waist
 Begin c̄ 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 c̄ arms folded across chest
 Measure leg lengths: apparent length discrepancy in scoliosis

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

Straight Leg Raise

 Demonstrates lumbosacral nerve root irritation
 Record angle @ pain onset
 Lesague’s Sign
 ↑ pain c̄ 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

© Alasdair Scott, 2012 166

 Lumbar Disc Herniation
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 c̄ 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

© Alasdair Scott, 2012 167

 Practical Surgery
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 

© Alasdair Scott, 2012 168

Minimal Access Surgery Enhanced Recovery After Surgery
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
 Admission on day of surgery, avoidance of prolonged
Common Procedures
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. c̄  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

© Alasdair Scott, 2012 169

 Surgical Complications
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
 Pre-Operative Factors
 2O 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 c̄ sterile soaked
gauze
 IV Abx: cef+met
 Opioid analgesia
 Call senior and arrange theatre
 Repair in theatre
 Wash bowel
 Debride wound edges
 Close c̄ deep non-absorbable sutures (e.g. nylon)
 May require VAC dressing or grafting

© Alasdair Scott, 2012 170

Laparoscopic Cholecystectomy Inguinal Hernia Repair: Hernioplasty
 6% of all general surgical operations
Principals  15% of all general surgical outpt. consultations

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 c̄ 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 c̄ 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 c̄ mild analgesics and mild laxatives
 Return to work @ 1-2wks

© Alasdair Scott, 2012 171

Appendicectomy
Open
1. Access the peritoneum
 Transverse (Lanz) incision centred on McBurney’s point
 Incise Camper’s and then Scarpa’s fascia
 Muscle splitting incisions through abdominal muscles
 Incise transversalis fascia, pre-peritoneal fat and
peritoneum.
2. Deliver caecum and find appendix
 ID caecum and follow taenia coli convergence at
appendicular base.
Nissen Fundoplication
Aim
 Prevent reflux, repair diaphragm
Procedure
 Usually laparoscopic approach
 Wrap gastric fundus around lower oesophagus
 Close any diaphragmatic hiatus
Complications
 Gas-bloat syn.: inability to belch / vomit
 Dysphagia if wrap too tight

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
c̄ 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 c̄ 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

© Alasdair Scott, 2012 173

Abdominal Aortic Aneurysm Carotid Endarterectomy
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 c̄ 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 c̄ 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

© Alasdair Scott, 2012 174

Bypass Grafting
Indications
 V. short claudication distance
 Symptoms greatly affecting pt’s. QoL
 Development of rest pain
Practicalities
 Need good proximal supply and distal run-off
 More distal grafts have ↑ rates of thrombosis
 Saphenous vein graft preferred below inguinal lig
 Either reversed or valves destroyed in situ
 Must tie off tributaries first
 Prosthetic grafts may be employed
 Above IL: Dacron
 Below IL: PTFE
Transurethral Resection of the Prostate
Indications
 Surgical Rx of choice for BPH when medical Rx has failed.
Principals
 Performed under spinal anaesthetic
 Cystoscopic inspection
 Locate external urethral sphincter and use as distal
resection landmark
 Electrosurgical resection of prostatic tissue under direct
vision
 Send chippings for histology
 Insert 3-way catheter post-op to irrigate bladder
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

© Alasdair Scott, 2012 175

 Surgical Procedures Summary
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 c̄ 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 c̄ 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 c̄ valve into
venous deep venous leg veins
Kistner Operation insufficiency  Venous valvuloplasty
Palma Operation  Bypass venous obstruction c̄ 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

© Alasdair Scott, 2012 176

 Surgical Radiology
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 

© Alasdair Scott, 2012 177

Achalasia Oesophageal Cancer
Image Image
 Proximal dilatation of the oesophagus c̄ 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 c̄ 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
Causes  65% adenocarcinoma
 Usually idiopathic  Lower 3rd
 May be 2O to Chagas disease  GORD → Barrett’s → dysplasia → Ca
 35% SCC
 Upper and middle 3rds
Presentation  Assoc. c̄ 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. c̄ smooth area f concentric narrowing in
continuity c̄ 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. c̄ 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.

© Alasdair Scott, 2012 179

 Small Bowel Obstruction
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 c̄ 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 c̄ oral contrast: transition point
 Gastrograffin follow-thru: may be therapeutic if
adhesional obstruction

Mx
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

© Alasdair Scott, 2012 180

 Large Bowel Obstruction
Image Resuscitate: Drip and Suck
 Dilated loops of bowel ≥6cm in width  Admit
 Peripherally located  NBM
 Haustra: lines go partially across  Aggressive rehydration c̄ 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
 Stops vomiting
Common
 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 c̄ 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
O
 Colectomy + 1 anastomosis
 Palliative bypass procedure

© Alasdair Scott, 2012 181

Volvulus Other AXRs
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 c̄ 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. c̄ comorbidities
 Grossly distended, tympanic abdomen
Rigler’s Triad
 SBO
 Pneumobilia
Mx  Gallstone in RIF
 Resuscitate: drip and suck
 Sigmoid Rigler’s Sign
 Detorse c̄ 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
  often needs surgery
Foreign Bodies
 Unstable: theatre
 Caecostomy
O  Stable
 Right hemi c̄ 1 ileocolic anastomosis
 Endoscopic removal
 Watch and wait c̄ 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

© Alasdair Scott, 2012 182

Perforated Viscus Tension Pneumothorax

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
 3rd 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

© Alasdair Scott, 2012 183

Diverticulosis Colorectal Cancer
Image Image
 Typically double-contrast enema  Typically double-contrast enema
 Out-pouchings of mucosa  Apple-core stricture c̄ 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% c̄ 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 c̄ 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

Prognosis
 10-30% recurrence w/i a decade
© Alasdair Scott, 2012 184
Ulcerative Colitis Crohn’s Disease
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% c̄ 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)

Other  AA amyloidosis
© Alasdair Scott, 2012
 Oxalate renal stones 185
 Gallstones
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 c̄ 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

© Alasdair Scott, 2012 186

Pancreatitis Acute Cholecystitis
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

© Alasdair Scott, 2012 187

 Nephrolithiasis

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. c̄ 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. c̄ 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. c̄ n/v
 99% of stones visible  Pt. cannot lie still

Mx
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 c̄ Renal Obstruction

 Surgical emergency
 Percutaneous nephrostomy or ureteric stent
 IV Abx: e.g. cefuroxime 1.5g IV TDS

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 Subdural or Extradural Haematoma
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

© Alasdair Scott, 2012 189

 Digital Subtraction Angiogram
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 c̄ Fogarty catheter
 Emergency reconstruction
 Complications
 Reperfusion injury → compartment syndrome
 Chronic pain syndromes
 Treat cause
 e.g. warfarinise
 Mx CV risk

© Alasdair Scott, 2012 190

Cervical Spine Hip Fracture
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 c̄ 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 c̄ cancellous screws
 Clear if normal radiograph and clinical exam  3,4:
 CT C-spine if abnormal radiograph or clinical exam  <55: ORIF c̄ screws.
 f/up in OPD and do arthroplasty if AVN
develops (in 30%)
 >55: THR or hemiarthroplasty

Extracapsular
 ORIF c̄ 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

© Alasdair Scott, 2012 191

Shoulder Dislocation Femoral and Tibial Fractures
Imaging Imaging
 Typically anterior dislocation c̄ 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 c̄ 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
 Reduction under sedation: e.g. propofol  ORIF
 Hippocratic: Longitudinal traction c̄ arm in 30O  Ex-Fix
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 c̄ 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

© Alasdair Scott, 2012 192

Colles’ Fracture
Imaging
 Extra-articular # of the distal radius
 Dorsal displacement of distal fragment
 Dorsal angulation of distal fragment
 ± avulsion of ulna styloid
Other Fractures
Monteggia
 # of proximal 3rd of ulna shaft
 Anterior dislocation of radial head at capitellum
 May → palsy of deep branch of radial nerve → weak
finger extension but no sensory loss

Extras Galleazzi
 ↓ radial height (normal = 11mm)  # of radial shaft between middle and distal 3rds
 ↓ 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 (c̄ prilocaine) Proximal Humerus #
 Dorsal backslab c̄ 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

Complications
 Haemorrhage
 Urethral injury
 Bladder injury
© Alasdair Scott, 2012 193
 Fracture Complications
General Complications Nerve Injury

Tissue Damage Seddon Classification

 Haemorrhage and shock  Neuropraxia: temporary interruption of conduction
 Infection  Axonotmesis
 Muscle damage → rhabdomyolysis  Disruption of axon c̄ 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 c̄ 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. c̄ metalwork)  Infection
 Fat embolism → ARDS  Ischaemia
 Interfragmentary movement
Late  Interposition of soft tissue
 Problems c̄ 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

© Alasdair Scott, 2012 194

 Instruments
Contents
Vascular Access .................................................................................................................................................................... 196 
Phlebotomy ............................................................................................................................................................................ 198 
Airways and Breathing ........................................................................................................................................................... 199 
Perioperative Mx .................................................................................................................................................................... 202 
General Surgery..................................................................................................................................................................... 205 
Urology................................................................................................................................................................................... 209 
Trauma and Orthopaedics ..................................................................................................................................................... 212 
Miscellaneous ........................................................................................................................................................................ 216 

© Alasdair Scott, 2012 195

 Vascular Access
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

© Alasdair Scott, 2012 196

PICC Line Tessio Catheter

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
 Pneumothorax  Accessed c̄ 90O Huber point needle
 Arrhythmias  V. low infection risk as skin breech is very small
 Bleeding

Late
 Thrombosis
 Catheter occlusion
 Infection

© Alasdair Scott, 2012 197

 Phlebotomy

Blood Culture Bottles Vacutainers

Purple
Indications  Contains: EDTA
 Investigate a patient c̄ pyrexia  Prevents clotting and keep cells alive
 Use
Features  FBC, CD4, cross-match
 Red: anaerobic culture medium  i.e. things you want to do c̄ 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 c̄ 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
 Observation chart, notes and drug chart  Ca2+ 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

© Alasdair Scott, 2012 198

 Airways and Breathing
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 c̄ tape  C-spine injury: e.g. c̄ 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. c̄ 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

© Alasdair Scott, 2012 199

Temporary Tracheostomy Tube Laryngeal Mask Airway
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 c̄ aquagel
Indications  Inserted c̄ 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. c̄ 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 c̄ 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. c̄ facial injuries or
 Tracheal stenosis evidence of basal skull #
 Racoon eyes
 Battles’ Sign: mastoid bruising
 Haemotympanum
 SCF rhinorroea or otorrhoea

© Alasdair Scott, 2012 200

Oxygenation Ventilation
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

© Alasdair Scott, 2012 201

 Perioperative Mx
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. c̄ 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 c̄ aquagel
Method  Insert the tube and ask pt. swallow c̄ 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 c̄ tape when position
 Gain consent and explain the procedure confirmed
 Lubricate the tip c̄ aquagel
 Insert the tube and ask pt. swallow c̄ water when they Check Location
feel it at the back of their throat.  Aspirate gastric contents and check pH (<4)
 Secure c̄ 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 c̄ ↓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 c̄ 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 c̄ dietician
 Parenteral and oral PO4 supplementation
 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

© Alasdair Scott, 2012 203

Thromboembolic Deterrent Stockings Major Fluids
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 c̄ LMWH  Use: normal daily fluid requirements

Dextrose-Saline
Complications
 4% dextrose = 40g/L
 Contraindicated in pts c̄ 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 c̄ 20mM K+ in each bag
Intra-Op  1L NS + 2L dex c̄ 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

© Alasdair Scott, 2012 204

 General Surgery
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
 e.g. corrugated rubber or plastic sheets
Redivac
 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

© Alasdair Scott, 2012 205

Sutures Dever’s Retractor
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. c̄ 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. c̄ 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 c̄ possible biopsy.
 Consent pt. and explain procedure.  Can be used in the outpatient or inpatient setting
 Examine perineum and perform DRE c̄ pt. in left-lateral  Investigation of
position.  Rectal bleeding
 Lubricate scope c̄ aquagel, attach light source  Colonic Neoplasia
 Hold in left hand and insert into the rectum.  IBD

Complications Features
 Haemorrhage  Graduated plastic tube c̄ 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 c̄ pt. in left-lateral
position.
 Ensure no obstruction to scope
 Lubricate scope c̄ 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 c̄  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

© Alasdair Scott, 2012 207

Laparoscopic Port Circular Bowel Stapler
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 c̄ 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 c̄ 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 c̄ 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

© Alasdair Scott, 2012 208

 Urology
General Catheterisation Indications Mx of Non-draining catheter
 Bypassing catheter: consider condom catheter
Diagnostic  Blocked: flush c̄ 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 c̄  Chronic bladder outlet obstruction
sterile water.  Neurogenic bladder c̄ 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 c̄ 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

© Alasdair Scott, 2012 209

3-Way Irrigation Foley Catheter Acute Urinary Retention (AUR)
Indication Clinical Features
 Irrigate bladder in pts @ risk of clot retention  Suprapubic tenderness
 E.g. after TURP or in pts c̄ 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)
 Urine: dip, MC+S
Suprapubic Catheter
 Imaging
 US: bladder volume, hydronephrosis
 Pelvic XR

Mx
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

© Alasdair Scott, 2012 210

JJ or Ureteric Stent

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

© Alasdair Scott, 2012 211

 Trauma and Orthopaedics
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 c̄ 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 c̄ 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 c̄ 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.

© Alasdair Scott, 2012 212

Fracture Plate Hemi-Arthroplasty Prosthesis: Austin Moore

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

© Alasdair Scott, 2012 213

Total Arthroplasty Prosthesis Intramedullary Nail

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

© Alasdair Scott, 2012 214

Stiff Neck Collar Mannitol
Indications Indications
 Stabilise the cervical spine in trauma pts.  Osmotic diuretic
 Used c̄ 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 c̄ 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

© Alasdair Scott, 2012 215

 Miscellaneous

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 c̄ 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 c̄ renal involvement (e.g. SLE)
Indication  Suspected Tx rejection
 Mx of acutely ischaemic limb 2O 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%

© Alasdair Scott, 2012 216

 Key Anatomy
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 

© Alasdair Scott, 2012 217

 Chest Wall
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 some movement over the underlying structures.
 6th costal cartilage anteriorly
Arterial Supply
Horizontal fissure  Laterally: vessels from the axillary artery
 Follows contour of 4th 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

© Alasdair Scott, 2012 218

 Thoracic Cavity
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 c̄ pharynx
 Esophagus  Posterior to aortic arch
 Sympathetic trunks  Posterior to left main bronchus
 LOS

Histology
rds
 Divided into 3 : 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.

© Alasdair Scott, 2012 219

 Inguinal Region
Deep Ring
 1.5cm above femoral pulse, or
 Mid-point of inguinal ligament (ASIS → PT)

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 c̄ 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
th
Innervation  Joins lowest points of the 10 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 c̄ 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.

© Alasdair Scott, 2012 221

 The Bowel
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 c̄ 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

© Alasdair Scott, 2012 222

Abdomen Neurovascular Supply Gastrointestinal Adnexae
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 c̄ each major branch
 Drain superiorly to cisterna chyli → thoracic duct

© Alasdair Scott, 2012 223

Urinary Tract
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

© Alasdair Scott, 2012 224

 Head and Neck
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 c̄ cords half aducted /
abducted
 Cannot speak or cough
 Trauma but not transection of RLN
 → partial paralysis c̄ 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

Posterior
 Post. margin of SCM
 Ant. margin of trapezius
 Mid 1/3 of clavicle
© Alasdair Scott, 2012 225
 The Thigh
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 c̄ 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 c̄ 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.
 Superior  Supplies skin between great and 2nd 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 c̄ 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 c̄ 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 Median  4 tendons of FDP
C7
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

© Alasdair Scott, 2012 228