Practice Short Cases

Read about these drugs in the BNF!

• ACE inhibitors
• Alpha blockers • Antibiotics
• Amiodarone • Insulin
• Opioid analgesics • Oral hypoglycaemic agents
• NSAIDs • Anti-emetics
• Antiplatelet agents • Angiotensin receptor blockers
• Warfarin • Antithyroid drugs
• Heparin • Beta-2-agonists
• Beta-blockers • Diuretics
• Statins • Corticosteroids
• Digoxin • Proton pump inhibitors
• L-Dopa
 10 Most Common Medical
Emergencies in Oral Exam
1. Myocardial infarction
2. Cardiac arrest
3. Asthma
4. Diabetic ketoacidosis
5. Anaphylactic shock
6. Pulmonary oedema
7. Meningococcal meningitis
8. Paracetamol poisoning
9. Addisonian crisis
10. Supraventricular tachycardia
 10 Most Common ECGs
1. Anterior M.I.
2. Inferior M.I.
3. Atrial fibrillation
4. Left bundle branch block
5. Acute Pericarditis
6. Atrial flutter
7. Left ventricular hypertrophy
8. Digitalis effect
9. Pacemaker spikes
10. SVT
Definition and What it does?
• Definition
– Conduit to remove fluid or air from the pleural
space
• What it does?
– Allows for re-expansion of the underlying lung
– Drainage occurs during expiration when pleural
pressure is positive
– Fluid/Air drains into water seal
Chest Tube Indications
 Indications
• Pneumothorax
– Tension pneumothorax after initial needle insertion
– Persistent pneumothorax after simple aspiration
– Large spontaneous pneumothorax
• Malignant Pleural Effusion
• Empyema
• Complicated parapneumonic pleural effusion
• Hemopneumothorax
• Post-op drain
– post throactomy, esophagectomy, cardiac surgery
Chest Tube Insertion
 Insertion
• Pre-procedure CXR (unless emergency)  ID point of drain insertion
• Drain inserted under LA using aseptic technique
• Insert into “safe triangle”  5th intercostal space just anterior to the
mid-axillary line
• Safe Triangle borders
– Anterior border of latissius dorsi
– Lateral border of pec major
– Horizontal line of nipple
• Insert drain over the upper border of rib to avoid vessels and nerves
• Blunt dissection and insertion of finger to ensure pleural cavity is
entered
• Insert drain to base if draining fluid; insert drain to apex if draining air
• Secure drain in place with suturing
• CXR after insertion: Ax position of drain and complications
• Patient education: keep underwater seal below chest
• Monitor drainage/bubbling and record daily
Chest Tube Complications
 Complications
• Early complications
– Hemothorax
– Lung laceration
– Penetrate diaphragm and abdominal cavity
– Tube displacement
• Late complications
– Blocked drain
– Empyema
– Pneumothorax after removal
– Fistula formation
– Infection
Chest Tube Removal
 Removal
• Remove drain as soon as it has served it purpose
– Pneumothorax: bilateral A/E, drain no longer
bubbling, CXR show re-inflation
– Pleural effusion: drainage <100-200 mL fluid in 24h
• To remove drain ask patient to perform a
Valsalva manoeuvre
• Remove drain at the height of expiration
• Occlusive dressing
• Perform post-procedure CXR to r/o a
pneumothorax
Underwater Seal
 Underwater Seal
• 3 Chambers
– Collection chamber – fluid drains here
– Water seal – one-way valve to prevent re-entry of
air/fluid into pleural space (during inspiration)
• Bubbling: suggests air leak or partially fallen out drain
• Ask patient to cough: look for fluid swing in water seal
• Loss of fluid swing  kink/blockage
– Suction control chamber

• Never clamp tube

– Only when changing bottle
Surgical Drain Indications
 Indications
• Drains are inserted to:
– Evacuate established collections of pus, blood or
other fluids (e.g. lymph)
– Drain potential collections
Types
 Types
• Open or Closed
– Open: plastic sheet draining into stoma bag
– Closed: tubes draining into a bag or bottle

• Active or Passive
– Active: maintained under suction
– Passive: gravity; no suction
Urinary Catheters Indications
 Indications
• Alleviate or prevent urinary retention
• Obstructions
• Monitor urine output
• Paralysis

• Suprapubic Indications
– Obstruction.
– Stricture.
– Urethral injury.
– Acute prostatitis.
– neurogenic
Urinary Catheters Types
 Types
• Transurethrally or suprapubically
• Catheters vary by:
– Material
• Silastic: for long term
• Foley Latex (Brown): cheaper
– Diameter of the catheter (10 Fr to 24 Fr)
– Number of lumens
• Single lumen (self catheterization)
• Double lumen (Foley)
– For inflating balloon to hold urinary catheter in place
• Triple lumen catheter
– For irrigation
Triple Lumen Catheter
Indications
• Clot retention
• Gross hematuria
• Usually after prostate or bladder surgery
Urinary Catheters Complications
 Complications
• Trauma on insertion
• Blockage
• Infection
• Paraphimosis (foreskin cannot be pulled back)
• Failure of balloon to deflate
• Urethral strictures
Examine
 Ileal Conduit
• Urinary reconstruction and diversion
• Ureters are resected from the bladder and a
ureteroenteric anastomosis is made to drain the urine
• One end is closed and the other end is brought out
through an opening of the abdominal wall (stoma)
• Urine collected into a bag
• Stents are used to bypass the surgical site and divert
urine externally, to ensure the anastomotic site heals
– Generally removed 1 week after surgery
Indications for Ileal Conduit
 Indications
• In conjunction with a radical cystectomy
– Re Bladder cancer
• Neurogenic bladder
• Congenital anomalies
• Severe radiation injury to bladder
 Nephrostomy
• Artificial opening created between the kidney
and skin which allows for urinary diversion
directly from the renal pelvis

• Performed under radiographic imaging

Indications for Nephrostomy
 Indications
• Upper urinary tract obstruction
– Access to kidney not possible from LUT due to stones,
infections, tumors, anatomic anomalies
• Remove or dissolve renal calculi
• Rising Cr and urine cannot be drained through
ureter
• Hydronephrosis
• Renal pelvis disorders (UPJ obstruction, horseshoe
kidneys, etc)
Midline Sternotomy Scar DDx
 DDx
• CABG
• Valve replacement
• Cardiac transplant
• Congenital Heart Defect
• Thyroid surgery
• Aortic Dissection
• Esophagectomy
Keloid vs Hypertrophic Scar
 Hypertrophic Keloid
Features Confined to borders of Grow beyond the borders
original incision of original incision
Regression Can regress spontaneously Do not regress
spontaneously
Sites Areas of tension Anywhere
Race No racial predilection Racial predilection
Fluid Management and Why?
 Fluid Management
• 1 L Normal Saline + 20 mmol KCL
• 1 L 5% Dextrose + 20 mmol KCL
• 1 L 5% Dextrose + 20 mmol KCL

• 125 ml/hr (infusion rate)

• Why?
– Provides patient with adequate electrolytes
– Na: 140-150 /day
– K: 60/day
Stages of Clubbing
 Stages of Clubbing
1. Fluctuation and softening of nail bed
2. Loss of normal angle between nail bed and
fold
3. ↑ curvature of nail
4. Thickening of the distal digit
Causes of Clubbing
 Causes of Clubbing
• Respiratory
– Suppurative lung disease
• Bronchiectasis, Abscess, Empyema
– CF
– Lung Ca
– Pulmonary fibrosis
• GI
– IBD
– Cirrhosis
– Celiac disease
• CVS
– Cyanotic congenital heart disease
– IE
• Other
– Grave’s disease/Thyrotoxicosis (acropachy)
– Hereditary
– HPOA
Describe
 Horner’s Syndrome
• Pstosis
• Miosis
• Anhidrosis
• *Deficiency of sympathetic activity; lesion is on the ipsilateral side
of sxs
• *Light reflex maintained
• Causes:
– Pancoast tumor
– Carotid aneurysm
– Demyelination
– Vascular disease
– Trauma, etc
Describe
 Cushing Syndrome
• Rounded face with plethoric cheeks
• Hiruistism
• Acne
• Supraclavicular and dorsal adiposity
• Central adiposity
• Abdominal striae (purple)
• Thin extremities
• Bruising
• Skin ulcers
Other Clinical Features
 Other Sxs/Signs
• Mind
– Change in mood
– ↓ concentration
– Psychosis
• Cataracts
• IGT or DM – ask about polydipsia and polyuria!
• Bones – ask about back pain!
– Osteoporosis
– AVN
• HTN
– *ask about HA (benign intracranial HTN)
• Amenorrhea, impotence, ED
• Muscle weakness
• ↑ susceptibility to infection
Definition Cushing Syndrome
 Definition
• Disease process characterized by excessively
high levels of cortisol!

• High levels of ACTH cause release of cortisol

from the adrenal cortex
Causes of Cushing Syndrome
 Causes
• ACTH independent  ↓ACTH due to –ve
feedback
– Iatrogenic (corticosteroids)
– Adrenal tumor (adenoma or carcinoma)
– Adrenal hyperplasia
• ACTH dependent  ↑ ACTH
– ACTH secreting pituitary adenoma
• *Cushing disease, ant. Pituitary, <5mm
– Ectopic ACTH secretion
• SCLC or carcinoid
S/Es of Steroids
 S/Es of Steroids *see notes too
• PUD!
• IGT or DM
• Osteoporosis
• Cushingnoid like
– Acne, hirsutism, skin thinning, central adiposity,
round facies, gynacomastia
• Cataracts, glaucoma
• Immunosupression  risk of infection
• Depression, psychosis
• HyperNa and hypoK (Addisons)
 Cushing Syndrome
• Diagnosis
• DDx
• Treatment

• *see notes!
Examine
 Acromegaly
• Coarse facial features
• Acanthosis nigricans
• Frontal bossing
• Proximal muscle weakness
• Large supraorbital ridges
• Gynacomastia
• Wide nose
• Enlarged hands
• Enlarged lips
• • Carpal Tunnel Syndrome
Prognathism
• Macroglossia • Hepatosplenomegaly
• ↑ interdental separation and • Dark skin
malocclusion • Oily/sweating
• Goitre
• Skin tags
 Other
• Deepened voice
• HA
• Fatigue
• Arthralgia
• OSA
• Vision changes, bitemporal hemianopia
• Amenorrhea, ↓ libido
Complications
 Complications
• IGT or DM
• CVS
– HTN
– CCF
– Cardiomyopathy
– Arrhythmias
– IHD
– Stroke
• ↑ CRC
Diagnosis
• *Ask to look at old photos
• IGF-1 (insulin-like GF)
– If ↑ do OGTT
• OGTT
– Measure serum GH @ 0, 30, 60, 90, 120, 150
• Normally GH inhibited by high glucose levels
• Acromegaly  GH >1ug/L (failure to suppress)
• False + = pregnancy, AN, DM, puberty, hepatic/renal
disease

• If diagnosis made  further Ix

 Further Investigations
• MRI pituitary  pituitary adenoma/hyperplasia
• Pituitary function tests for hypopituitarism
– FSH, LH, testosterone, prolactin, estrogen, TSH
• HbA1C
• Visual fields and visual acuity
• Vascular assessment (BP, ECG, ECHO)
• Colonoscopy (q3 years)
• Sleep study for OSA
Treatment
 Treatment
• Aim: remove lesion and reduce GH
1.Transphenoidal surgery (1st line)
2.Somatostatin analogues (SSA)
– If surgery fails to correct GH/IFG-1 hypersecretion
– Octreotide (monthly IM injections)
3. GH Antagonist (if resistant/intolerant to SSA)
– Pegvisomant
4. Radiotherapy
Examine
 Thyroid
• Grades of exophthalmus - check
– 1. griddiness and discomfort
– 2. lid retraction
– 3. proptosis
– 4. optic nerve involvement
– 5. fibrosis of eye muscles
Thyroidectomy Complications
 Thyroidectomy Complications
• Immediate (<24h)
– Hemorrhage, laryngeal edema, thyroid storm,
damage to surrounding structures (laryngeal
nerve, trachea)
• Early (<3 weeks)
– Hemorrhage, infection, hypocalcemia
• *Surgical clips removers always by bedside of post-
thyroidectomy patients in case of hemorrhage
• Late (>3 weeks)
– Hypothyrodisim, keloid scar formation
 Scenario
• Patient presents with high fever, tachycardia, agitation,
confusion, vomiting, diarrhea.

• PMHx
– HTN
– Hyperthyroidism
– Recent pneumonia

• DDx?
• Mx?
 DDx
• Thyroid Storm
– Acute exacerbation of thyrotoxicosis symptoms 2°
to uncontrolled hyperthyrodism
– Precipitants: surgery, infection, trauma
• Sepsis
• Malignant hyperthermia
• Drug OD
• Phaeochromacytoma
 Mx
• ABCs
• O2, IVs, Fluids
• Draw stat bloods (↓/undetectable TSH, ↑T4)
• Vitals
1. Manage symptoms
 Propanolol PO/IV
 ± Supportive Treatment  Fluids, diuresis, vasopressors, cooling
blankets, paracetamol
2. Inhibit hormone synthesis
 PTU 1000mg PO STAT (high dose)
 Lugol’s Solution (iodine)
 Dexamethasone 2mg IV QDS
3. Treat underlying cause
 DKA
• Hyperglyemia
• Ketosis
– Blood Ketons >0.6 mmol/L
– Urinary +1
• Metabolic Acidosis
– pH <7.3; bicarbonate <18

• Fatigue, confusion, abdominal pain, N&V, polyuria, polydipsia,

kussmaul’s breathing, ± known DM, ketotic breath, weight loss
• Signs of infection
Immediate Management
• ABCs with 100% O2 high flow
• Vitals (esp O2 sats!)
• Cardiac monitoring (re. ?MI)
• 2 large bore IVs
• ASAP  BM glucose, urinalysis, ABG/VBG
• Administer STAT:
– 6 units Actrapid IV
– 1 L 0.9% NaCl
• Start fixed rate IV insulin infusion @ 6 U/hr
– Or 0.1 U/kg/hr in patients <60kg
• Draw bloods:
– FBC, glucose, U&E, liver profile, blood cultures
Ongoing Management
• Monitoring
– BM glucose q30m for 1st hr; then q hour
– Bloods @ 1h and q 4h
• U&E, venous glucose and bicarb, ketones
• Fluid replacement Time Rate
– If glucose >14  0.9% NaCL
Hour 1 1 L/h
– If glucose <14  start 5% Dextrose
Hour 2 500 ml/h
• Targets
Hour 4 250 ml/h
– Ketones, bicarb** and glucose
Thereafter 125 ml/h
• K+ replacement (2L of fluids onward!)
– K+>5  none
– K+ 3.5-5  20 mmol/L
– K+<3.5  40 mmol/L
• Insulin infusion
– Continue infusion @ 6U/h until glucose <14
– When glucose <14  switch to IV Insulin Sliding Scale
 IE
• Definition
• Risk Factors
• Etiology
• Symptoms and Signs
• Clinical Manifestations
• Ixs
• Diagnosis Criteria
• Mx
• Indications for surgery
 AFib
• Definition
• Causes
• Presentation
• Ixs
• Management
– Stable vs unstable
– Goals (3)
– Rate vs Rhythm
• Long term management options
• Anticoagulation
Amiodarone S/Es
 Amiodarone S/Es
• Pulmonary fibrosis
• Thyroid disease
• ↑ LFTs
• Photosensitivty
• Long QT
• Optic neuritis
• Monitoring (bimonthly)
– CXR/PFTs
– TFTs
– LFTs
 Acute Inferior MI
• Pathophysiology
• Risk Factors
• Symptoms
• Ix
• DDx of ↑ troponins
• Acute management
– NSTEMI + TIMI Score
– STEMI
• PCI vs Thrombolysis
• Absolute CI to Thrombolysis
• Risks of PCI
• Complications of MI
• Post-MI Treatment
Heart Failure
Causes of CCF
 CCF
• Definition
• Types
Causes of CCF
 Causes
• IHD
• HTN
• Valvular abnormalities
• Cardiomyopathies
– EtOH, infiltrations, infections, radiotherapy, chemo,
• MI

• Congenital Heart Defects

• Myocarditis
• Arrhythmias
• Other
– OSA, severe anemia, thyroid disease, DM, infiltrative
• High output failure – pregnancy, thyrotoxicosis, severe
anemia, Paget’s
Clinical Features of CCF
 Clinical Features
LVF
•Dyspnea RVF
•Orthopnea and PND
•Fatigue/poor exercise tolerance
•↑ JVP
•Cough + pink frothy sputum •Pedal and sacral
•Cardiac wheeze
•Angina edema
•Syncope •Hepatomegaly
•↓ peripheral perfusion
•Tachycardia •Pulsatile liver
•Displaced apex
•Crackles and crepitations
•Ascites
•S3 •TR
•Murmur
•↓ pulse pressure •Loud P2
•Pulsus alternans
NYHA Classification
 NYHA
• I = no symptoms with normal activity
– No limitation of activity
• II = mild symptoms with normal activity
• III = marked symptoms with minimal activity
• IV = symptoms at rest
 CCF
• Diagnosis Criteria

• Ixs
CXR
 CXR Findings in CCF
• A = alveolar edema (bat wings)
• B = (kerley) B lines (interstitial edema)
• C = cardiomegaly
• D = dialated prominent vasculature
• E = effusion (pleural)
Treatment of CCF

Acute Management
General
Pharmacological
 Acute Treatment
• Acute
– ABCs + Vitals
– 100% O2 and sit upright
– 2 large bore IVs
– LMNOP
• IV Lasix 40-80 mg (furesomide), morphine (IV 2-4 mg),
nitrates, O2, PPV/positioning
– Bloods, BNP, ECG, CXR, ECHO
 Treatment
• General
– Treat underlying cause
– Smoking cessation, optimize weight and nutrition,
limit salt and water intake, vaccinations

• Pharmacological
– Disease Modifying
• ACEI/ARB, B-blocker, Aldosterone antagonist,
pacemaker/ICD
– Symptom Relief
• Diuretics, nitrates, digoxin
 CRT
• Biventricular pacing
• Criteria
– NYHA III/IV
– On optical medical tx
– EF <35%
– QRS >120 msecs
 ICD
• What is it?
• What it does?
• Indications(next slide)
• Reasons to switch off device?
 ICD – Indications
• Previous cardiac arrest (prevention)
• Known dangerous arrhythmias
• CRT for CCF
• Dilated cardiomyopathy
• Familial
– HOCM
– Long QT syndrome
– Brugada
 Pacemaker
• What is it?
• Indications? (5)
• How are they inserted? Complications?
• Number and location of leads
– VVI
– DDD
• Describe
• Indications for
surgery
 AS

Causes + Presentation
Describe findings
Further examination, Ixs, Tx
 Causes
• Presentation
– Triad: Angina, syncope, CCF
– Dyspnea, dizziness, faints,

• Supravalvular
– Williams Syndrome
• Valvular **
– Calcific degeneration (elderly)
– Congenital biscuspid valve
– Rheumatic HD
 AS
• Narrow pulse pressure and slow rising, low volume pulse
• The apex beat is non-displaced and heaving
• Aortic thrill located in aortic area
• HS 1&2 are present and audible; S2 may be soft
• ESM murmur best heard at the aortic area and loudest on
full expiration with the patient leaning forward. It is X out
of 6 in intensity and it radiates to the carotids. ↑ with
standing  squatting; ↓ with valsalva
• Aortic Sclerosis: ESM, no carotid radiation, normal pulse
and normal S2
• These findings are consistent with AS which is
severe/not severe due to the presence/absence of:
– Signs of HF
– Long duration of murmur
– Soft murmur
– Soft S2
– Narrow pulse pressure
– Heaving apex
• I would like to take a full history to ask about
symptoms of AS such as syncope, angina and
dyspnea.
• I would like to Ix this patient with:
– Bloods (hematological, biochemistry)
– ECG (LVH, LAD, LBBB)
– CXR (calcified aortic valve, LVH, signs of HF)
– Doppler ECHO (valve anatomy, degree of
calcification, valve area, gradient across valve)
• Severe stenosis if gradient ≥50 mmHg and valve area
<0.5cm2
– (normal: few mmHg and area of ~2cm)
 Management
• Management options include:
– Modify risk factors for CAD
– Maintain sinus rhythm
– Surgical replacement once symptoms occur
• TAVI
• Replacement (tissue or metallic)
 AR

Causes
Describe findings
Further examination, Ixs and Tx
 Causes
• Acute
– Dissection aortic aneurysm
– Chest trauma
– IE
– Failed prosthetic valve
• Chronic
– Rheumatic fever
– Congenital biscupid valve
– CTD (Marfan’s, Ehlers Danlos)
– Ankyloysis spondilytis
– Aortitis (Rheumatoid, Syphillis)
 AR
• Wide pulse pressure and collapsing pulse
• The apex beat is displaced and hyperdynamic
• HS 1&2 are audible and S2 is soft, ± S3
• Early diastolic decresendo murmur, best
heard along the LLSB on full expiration with
the patient leaning forward.
• These findings are consistent with…
• Other possible findings on examination:
– Austin Flint murmur: apical med diastolic murmur
– Quinke’s sign: capillary pulsations in nail bed
– Corrigans sign: visible neck pulsations
– DeMusset’s sign: head bobbing with each HB
– Muller’s sign: systolic pulsations of uvula
– Duroziez’s sign: finger compression of femoral artery
• 2cm proximal to stethoscope – systolic murmur
• 2cm distal to stethoscope – diastolic murmur
– Traube’s sign: pistol shot femorals

• “The collapsing pulse, wide pulse pressure, length of

murmur, soft S2, S3, austin flint murmur and LVF
suggest that the AR is significant”
• I would like to further evaluate this patient by
taking a full history to ID causes of AR and
continue my examination to assess severity and
look for comorbidities.
• I would like to Ix this patient with:
– ECG, CXR, ECHO/TEE, bloods, cardiac catheterization
• Management options include:
– Asymptomatic: monitor sxs, yearly ECHO
– Symptomatic: avoid exertion, treat CCF
– Surgery: ↑ sxs, ↑ LV size, LVEF <50%,
– Surgical options: Valve replacement or valve repair
 MR

Describe findings
Causes
 Causes
• Acute
– Trauma or MI
• Valve rupture, chordea rupture
• Chronic
– Annular Calcification (Elderly)
– Mitral prolapse/degeneration (common)
– Rheumatic HD (rare)
– IE
– CTD
– Cardiomyopathy
– Congenital
– Drugs (appetite suppressants: Phen-Fen combo)
 MR
• Pulse: Irregularly irregular (Afib), normal character, sharp
up stroke and low volume
• The apex beat is displaced laterally and is hyperdynamic.
• ± thrill at mitral area and a parasternal heave
• S1 is soft/absent, split S2, loud P2 ± S3
• Pansystolic murmur, best heard at apex on full expiration
with patient in the left lateral position. The murmur is X of
out of 6 in intensity and it radiates to the axilla. ↑ with
isometric hand grip.
• These findings are consistent with…
• Furthermore the:
– Small volume pulse
– Loud S3
– Loud P2
– Signs of LVF
– Afib
– LVH**

– suggest that the MR is significant

• I would like to further evaluate this patient by taking a full
history to ask about sxs and conntinue my examination to
assess severity and look for comorbidities.
• I would like to Ix this patient with:
– ECG, CXR, ECHO/TEE, bloods, cardiac catheterization
• Management options include:
– Manage Afib + warfarin
– Watchful waiting – mild symtoms
– Medical – as per HF
– Surgical Indications:
• Severe sxs
• Asymptomatic with change in LV size or function, pulmonary HTN, new
onset Afib)
Prosthetic Valve

Describe findings
 Prosthetic Valve
• General
– Midline sternotomy scar/Left lateral scar (describe)
– NO harvest sites (check legs, wrists)
– ?TAVI scar (describe) – AV
– ?Audible click at bedside
• Hands
– Normal rate, rhythm, character and volume
• Precordium
– Aortic Valve: Normal S1, Metallic S2
• Midsystolic murmur normal
– Mitral Valve: Metallic S1, Normal S2
• “There is a normal pulse, a normal apex beat, a
normal first HS and a metallic 2nd HDS ± systolic
murmur. These findings are consistent with a
metallic AV”
• “I would like to proceed by taking a full history to
ascertain the indications for the valve”
• “ I would then like to continue with my examination
to ID any complications associated with a metallic
valve such as thromboembolism, IE, hemolysis and
bleeding 2° to warfarin”
• “Finally, I would then perform Ixs to look @ valve
function”
Hepatomegaly Causes
 Hepatomegaly
• Malignancy:
– metastatic or primary (hepatoma)
• Hepatic congestion:
– RHF, Budd-Chiari Syndrome (hepatic vein thrombosis)
• Infection:
– Mononucleosis (EBV), hepatitis viruses, malarias, schistosomiasis
• Hematological:
– Leukemia, lymphoma, myeloproliferative disorders, sickle-cell, hemolytic
anemias
• Infilatrative
– Hemochromatosis, amyloidosis
• Others:
– Fatty liver, early cirrhosis (ETOH), biliary obstruction
Splenomegaly Causes
 Splenomegaly
• Malignancy
• Infectious
– Malaria, IE, hepatitis, EBV, TB, CMV, HIV, Lyme, septicemia
• Hematological
– Leukemia, myelofibrosis, lymphoma, DIC
• Arthritis/CTD
– Sjogren’s syndrome, RA, SLE,
• Other
– Sarcoid, vasculitis, portal HTN, rheumatic fever
• If Massive think:
– Myeloid leukemia, Myelofibrosis, Malaria
Spleen vs Kidney
 Differentiating from Kidney
• Cannot get above it (rib overlies its top)
• Dull to percussion
– Kidney resonant b/c of overlying bowel
• Palpable notch (medial side)
• Extends down into RIF with insipiration
Examine Liver + Spleen
Describe
Describe
Lobar Pneumonia
Bronchopneumonia
Clinical Findings in Pneumonia
 Clinical Findings
• SOB
• Pleuritic CP
• Cough, sputum hemoptysis
• Fever, chills, sweating, aches
• ↓ chest expansion on side of pneumonia
• ↓ breath sounds
• Bronchial breathing with coarse crackles
• ↑ tactile and vocal fremitus
• Dullness to percussion
• Trachea midline
 Pneumonia
• Organisms – typical and atypical
• Ixs
• Classification
• Diagnostic Score (next slide)
• Treatment of CAP
• Treatment of HAP
• Treatment of Aspiration pneumonia
Diagnostic Score in Pneumonia
 CURB-65
• Confusion
• Urea >7
• RR>30
• BP ↓
– <90 SBP; <60 DBP
• >65 y/o
Clinical Features in COPD
 COPD
• ↓ breath sounds
• Early inspiratory crackles
• Hyperresonance
• Trachea midline
Remember Ned???
“Old Ned Has Abnormal
Pulmomaries’

O = Oxygen
N = Nebulizers
H = hydrocortisone
A = Abx + ABG
P = Picture (CXR), PT, PFTs
 COPD
• Investigations
– What does ABG look like
• Stable chronic COPD
• Exacerbation of COPD
• Diagnosis + Classification
• Management of stable COPD
• Management of COPD exacerbation
– O2 requirements; why? What drive?
• Long-term O2 requirements
• Complications of COPD
• BODE Index
O2
 Venturi Mask
• Venturi Mask
– Device to delivery a known concentration of O2
• Venturi effect
– Fixed proportion of room air enters through side pores
– O2 flow speeds up through a more restricted area
– Bigger diameter = slower the velocity

• Nasal cannula – 28%

• Venturi – up to 60%
• Non-rebreather - ~100% (bag must be inflated)
• CPAP/BiPAP
• Intubation
• Tracheotomy
 Pleural Effusion
• NB questions to ask in history
• Clinical findings
• Investigations
• Diagnostic criteria
• Classification and causes
• Treatment options
 Tension Pneumothorax
• Clinical signs
• Medical emergency - management
Air in pleural space
Causes of Pneumothorax
• Spontaneous
– Primary (idiopathic)
• Tall, thin males, smokers, rupture of subplueral bullae
• Often small and self-resolve
– Secondary (underlying lung pathology)
• COPD
• CF
• Asthma
• TB, Pneumonia
• Lung fibrosis, lung Ca, CT disorders
• Trauma
– Iatrogenic
• Central line insertion
• CPR
• Thoracentesis
• Pleural, lung, liver biopsy
• Intercostal pain blocks
– Penetrating/Blunt injury
 Pneumothorax
• Clinical signs
• DDx
• Investigations

• **CXR
– Measure interpleural distance at level of hilum
• Visible rim of >2cm btw lung margin and chest wall
Management of Pneumothorax
• 1. No intervention
– Small (<2cm rim) and no respiratory distress
• 2. Aspiration/Thoracentesis
– 16G cannula in 2nd ICS MCL (above rib)
– Aspirate <2.5L of air
– CXR to confirm resolution; repeat CXR 1/52
• 3. Chest drain
– If aspiration unsuccessful
– U/S guided seldinger technique and narrow bore tube
• 4. Surgery (pleurodesis)
– Indications:
• Persistant/recurrent pneumothorax
• Bilateral pneumothorax
• Failure to re-expand with chest drain
OSA
 Definition
How to Diagnosis
 OSA
• Definition
– Cessation of airflow during sleep
• Apnea Index
– # of apnea events/hour during sleep
• OSA = ≥15 episodes of apnea in 1 hr of sleep
Risk Factors of OSA
 Risk Factors and Associations
• Obesity • IGT and DM
• COPD • Hyperlipidemia
• Micrognathia • Hypothyroidism
• Neuromuscular disease • Acromegaly
• Alcohol • Polycythemia
• Nasal congestion
• Sleep deprivation
Symptoms/Signs of OSA
 Sxs/Signs
• Daytime sleepiness, snoring, witnessed apneic episodes, poor
sleep hygiene
• Unrefreshed sleep
• Personality and cognitive changes
• Fall asleep at wheel
• Morning HA
• PMHx:
– Weight gain, thyroid disease, acromegaly, neurological disease, HTN
• Epworth Sleepiness Scale**
– 8 questions; 0-3; max score 24
– >10  expert care should be sought
Treatment
 Treatment
• Modify risk factors
– Weight loss
– Smoking cessation
– Tx underlying medical conditions
– Sleep hygiene:
• Avoid daytime napping, avoid caffeine, reduce EtOH,
exercise regularly, maintain regular sleep pattersns,
body position up
• CPAP (gold standard)
Complications
 Complications
• Depression
• Weight gain
• ↓QoL
• Accidents (work, driving)
• Cardiac
– Cor pulmonale
– IHD
– HTN
Tx Algorithm in Asthma
• SABA
– Salbutamol (Ventolin)
Next add…
• Inhaled corticosteroid
– Fluticasone, beclomethasone
Next add…
• LABA
– Salmeterol
– *Most combined with steroids
• Seretide: salmeterol + fluticasone
• Symbicort: formoterol + budesonide
Next….
• ↑ corticosteroid or add 4th drug (theophylline, monteleukast)
Nutritional Requirements
 Requirements
• Energy
– 30kcal/kg/day
• Protein
– 1g/kg/day
• CHO
– 5g/kg/d
• Fat

• *Aim: 50% CHO, 30% lipid, 10% protein, 5% vitamins,

minerals
Types of Nutritional Support

When?
 Types
• Oral
– SIPS (supplementary feeds)
• Enteral
– Functional GI tract with inability to meet nutritional
requirements orally
• E.g. Severe wasting, dysphagia, stroke, sepsis, burns
• Total Parenteral Nutrition (TPN)
– Short bowel syndrome
– Prolonged obstruction
– Bowel rest required
– Severely ill
Types of Enteral Feeding
 Types
• Gastric: nasogastric and PEG
– Percutaneous Endoscopic Gastrostomy
• Surgical placement with endoscopy
• Postpyloric: jejunostomy
– When: gastric outlet obstruction, duodenal
obstruction, severe GERD
– Confirm radiographically
– Most have 2 ports: drainage and nutrition
 Enteral Feeds
• Monitoring
– Weight
– Bloods: U&E, LFTs, total protein, albumin
• Advantages
– Cheaper then TPN
– Keeps villi intact
– Promotes peristalsis
Complications of Enteral Feeding
 Complications
• Insertion
– Hematoma, infection
• Aspiration
• Tube migration, tube blockage
• Diarrhea or Constipation
• Refeeding syndrome
– Rapid change in electrolyte balance  arrhythmias, resp
distress
– Prevention: start slow and gradually increase
• Metabolic
CI to Enteral Feeding
 CI
• Problems with GIT
– Obstruction
– Ileus
– GI bleed
– Severe diarrhea
– High output fistula
• Bowel anastomosis at risk of dehiscence is NOT a
complication (early feeding increases strength of
anastomosis)
Access for TPN
 Access
• Short term
– Central venous catheters (subclavian or internal
jugular vein)
• Long term
– Tunneled CVC (Hickman)
– PICC line (peripherally inserted central catheter)
• **risk of infection
Complications of TPN
 Complications
• Insertion
– Pneumothorax, venous thrombosis, air embolism
• Infection  Sepsis
• Atrophy of GI villi
• Metabolic
– Hyperlipidemia, hyperglycemia, electrolyte imbalance,
metabolic acidosis
• Refeeding syndrome
• Abnormal liver function, cirrhosis, GS
• Azotemia
Examine
 External Fixation Device
• Set bone # in correct anatomical configuration to
allow # to heal
• Pins are inserted through the skin into bone and held
in place by an external frame
• Indications
– Open fractures/infected fractures
• Wherein casts would not permit access for mx of soft tissue
wounds
– When ORIF is CI
– Limb lengthening
Advantages
 Advantages
• Provides rigid fixation when other forms of
immobilization are inappropriate
– Permits for mx of soft tissue wounds
• Allows for direct visualization of the limb and wound
– Wound healing, NVS, viability of skin flaps
• Associated dressing changes, skin grafting, irrigation
are possible w/o disturbing the #
• Immediate motion of proximal/distal joints
• Early patient mobilization
Disadvantages
 Disadvantages
• Meticulous pin tract care needed to prevent
infection
• Expensive
• Frame is cumbersome
• Re-fracture after frame removal
• Non-compliant patient may disturb settings
Complications
 Complications
• Pin tract infection (most common)
• Neurovascular impalement
• Muscle fibrosis or tendon rupture
• Delayed union
• Compartment syndrome
• Re-fracture
Examine Hip
X-ray features of
OA
 LOSS
• Loss of joint space
• Osteophytes
• Subchondral scelrosis
• Subchondral cysts
Treatment of OA of Hip
 Hip OA
• Non-surgical options
– Lifestyle modifications: diet, exercise, weight loss
– OT: fitting for walking device
– Analgesia: paracetamol and NSAIDs
– Steroid injections: no more than 4/yr
• Surgical options:
– Arthroplasty
• THR indications: instability, loss of mobility, severe pain, rest
pain or pain with movement
– Arthrodesis (fusion)
THR Complications
 THR Complications
• Intraoperative
– # of acetabulum or femur
– Dislocation
• Early
– Infection
– DVT and PE
– Sciatic nerve palsy
– Fat embolism
• Late
– Infection
– Loosening
– Leg-length discrepancy
– #
DVT Prophylaxis
 DVT Prophylaxis
• TEDS (thromboembolic deterrent stockings)
• LMWH SC injections (prophylaxis)
– * Start 12 hrs pre-op and continue until patient mobile or D/C
– Enoxaparin (Clexane) 40mg OD SC
– Tinzaparin (Innohep) 3500 U OD SC (4500 if high risk)
• Early mobility
Examine Shoulder
Causes of Painful Shoulder
 Painful Shoulder
• Tendon
– Adhesive capsulitis
– Tendinitis (Impingment syndrome)
– Rotator cuff tear/rupture
• Joint
– GHJ and ACJ arthritis
• Instability
– Dislocation
– Bone #
• Other: nerve lesions, referred pain, malignancy
Mx of Tendinitis/Rotator Cuff
Tear
 Mx
• Impingement Syndrome
– Eliminate aggravating activity
– PT
– Analgesia (NSAIDs)
– Subacromial steroid injection
• Rotator Cuff Tear
– Non-surgical – PT
– Surgical
• Open or arthroscopic cuff repair and subacromial decompression (if
repairable)
• Open or arthroscopic cuff debridment and subacromial decompression
Causes of Adhesive Capsulitis
 Causes
• Idiopathic
• Ass with DM and Dupuytren’s
• Chronic rotator cuff injuries
• Extrinsic causes (painful disorders leading to ↓ movements of shoulder)
– Post-hand, wrist or elbow surgery
– Referred pain
– Post-breast surgery
– Post MI
Mx of Adhesive Capsulitis
 Mx
• Non-surgical
– Analgesia
– PT
– Steroid injections
• Surgical
– Reserved for prolonged and disabling restriction!
Examine Knee
Treatment of Knee OA
 Knee OA
• Non-surgical options
– Lifestyle modifications: diet, exercise, weight loss
– OT: fitting for walking device
– Analgesia: paracetamol and NSAIDs
– Steroid injections: no more than 4/year
• Surgical options:
– Arthroscopic debridement and washout
• Meniscal tears and osteophytes can be trimmed
– Arthroplasty
• Unicompartmental or total knee arthroplastyTKR indications: instability, loss
of mobility, severe pain, rest pain or pain with movement
– Arthrodesis (fusion)
TKR Complications
 TKR Complications
• Intraoperative
– # of femur or tibia
– Vascular injuries
• Early
– Infection
– DVT and PE
– Peroneal nerve palsy
– Fat embolism
• Late
– Infection
– Loosening
– Patellar instability
– #
Examine Spine
Examine
Examine
Examine
Examine
Examine
Examine
 PVD
• Risk Factors
• Presentation of PVD
• Classification of PVD
• Physical exam  do!
• Investigations (slide)
• ABPI (slide)
• Management (slide)
– * say most obvious 1st
 Ixs
• Blood tests
– FBC
– U&E – check renal function (contrast)
– Blood glucose
– ESR
– Lipids
– Coags (monitoring)
– Homocysteine
– G&H (operation)
• Others
• BP
• ECG
• ABPI
• ECHO
• Carotid and abdo U/S
• Imaging
– CXR (preop assessment, cardioresp disease)
– Duplex scan (flow inside vessel, degree of stenosis and where lesion is)
– CT angiography
 ABPI

What is it?
How to carry out an ABPI?
Interpretation of results?
 ABPI
• Non-invasive method of determining the presence and
severity of PVD
• Examines for a fall in BP in leg arteries
• SBPleg/SBParm (take highest readings)
• How to carry out?
– Inflate cuff above ankle/arm and place doppler probe over
pulse; inflate cuff till noise from doppler disappears;
deflate cuff slowly until signal reappears
• Interpretations
– >1.2 hardening of arteries
– >0.9 normal
– <0.8 claudication
– <0.3 critical ischemia
 Mx of PVD
• Conservative
– Smoking cessation
– Optimize weight and nutrition
– Glycemic control
– Exercise program

• BMT
– Dual antiplatelet therapy
– Phosphodiesterase inhibitor  sxs reduction in
claudication
– Tx of HTN, hypercholesterolemia and DM
 Surgical Mx
• Endovascular (1st option)
— Angioplasty ± stent
— Sub-intimal angioplasty
• Open
– Bypass
• Anatomical (fem-pop) or extra-anatomical (axillo-fem)
• Name bypass where the incision is over the artery!
– Endarterectomy
• Short occlusion

• Amputation Indications
Critical Limb Ischemia
Severe claudication/rest pain
Impaired QoL
 Bypass

Vein vs graft?
Graft types and when to use each type?
 Bypass
• Vein
– If bypass goes below knee! *better patency
– Saphenous vein
• If use vein on ipsilateral side  valvotomy to destroy valves
• If use vein from contralateral side  reverse vein
• Graft
– If bypass remains above knee!

• Types of graft
– Dacron  above groin
– PTFE  below groin
Name
Name
Describe
• Site
• Size
• Direction
– Longitudinal
– Transverse
– Oblique

• Age
• Name of device
• How it works?
 Art Assist
• Intermittent compression device
• Short term
– ↑ systolic pressure and ↓ venous pressure 
↑AV gradient  improves perfusion pressure to
tissues
• Long term
– Release NO which promotes growth of new blood
vessels  collaterals
• What is this?
• What is it used for?
 Profore
• Multilayer compression bandage

• Used to tx venous ulcers ONLY!

– Can confidently say that the ulcer underneath is a
venous ulcer b/c you cannot treat arterial or
neuropathic ulcers with compression.
Examine + Management
 Venous Ulcer
• Elevate leg
• Antibiotics
• Control exudate
• Compression bandage (Profore)
Examine + Management
 Arterial Ulcer
• Revascularization
Examine + Management
 Neuropathic Ulcer
• Clean area
• Relieve pressure
Examine
Types of Amputations
 Amputations
• Above Knee (Transfemoral)
– Benefits: better function
• Below Knee (Transtibial)
– Benefits: better mobility
• Knee Disarticulation
– Amputation through middle of knee joint
• Ankle Disarticulation (Symes)
• Partial foot amputation
• Transmetatarsal
Indications and Complications of
Amputations
• Indications (4 D’s)
– Dead (ischemic)
• PVD
– Damaged (trauma)
• Unsalvageable limbs, burns, frostbite
– Dangerous (malignancy)
– Damn nuisance (infection/neuropathy)
• Osteomyelitis, necrotizing fasciitis, charcot neuropathy
• Complications
– Psychological and social implications
– Hematoma
– Wound infection
– DVT and PE
– Phantom limb pain
– Skin necrosis
– Osteomyelitis
– Stump ulceration (from prosthesis)
Vacuum Assisted Closure (VAC)
• Foam into wound
with plastic sheet on
top  attached to
machine
• (-) pressure brings
edges together
• ↓ bacterial
• Absorbs exudate
• Removes slough
Wet vs Dry Gangrene
 Gangrene
• Definition
• Wet
• Dry
• Management
• Definition: death of tissue from poor vascular supply and
is a sign of critical ischemia. Tissues are black and may
slough
• Wet
– Tissue death + infection
• Dry
– Tissue death but Ø infection
• Management
– Consult vascular, plastics
– Take cultures
– Revascularization!
– Radical debridement ± amputation
– Antibiotics (Benzyl PCN IV)
 Dry Gangrene
• Where?
– Distal part of limb due to ischemia (toes and feet)
– Due to arteriosclerosis
• Ø infection
• Spreads slowly!
• Early signs: dull ache, cold peripheries, pallor
• Affected part: dry, shrunken and dark reddish-
black (mummified flesh!)
 Wet Gangrene
• Where?
– Occurs in naturally moist tissue and organs (mouth, bowel,
lungs, cervix)
– Areas of bedsores (sacrum, buttocks, heels)
• Bacterial infection
– Tissue swelling and fetid smell
• Develops rapidly!
• Poor prognosis (due to septicemia)
• Affected part: edematous, soft, putrid, rotten and dark
Describe
 Lymphedema
• Non-pitting
• Enhanced skin creases
• Hard skin
Emergencies

Management
 Management for all Emergencies
• Recognize emergency
– “This is a surgical emergency. I would resuscitate
the patient by…”
• Call for help
• Initial Resuscitation
– Airway
• Give supplemental O2 (high flow, non-rebreather bag)
• Assess patency (ask patient a question)
• Establish patent airway
– Jaw thrust, chin lift, Guedel, NPA, endotracheal intubation
 Cont…
• Breathing (ensure adequate ventilation!)
– O2 saturations
– Inspection
– Palpation
– Auscultation
 Cont…
• Circulation
– Assess level of shock (clammy, CRT)
– Vitals
– IV access (2 large bore – grey/brown)
– Take bloods
– Resuscitation fluids
 Cont…
• Disability
– Neurological status using GCS
– Pupils
– BM glucose
• Environment
– Expose patient adequately
• Assess response to initial measures
• Emergency Ixs (*omit if surgical emergency e.g. AAA)
– Simple bedside
– Blood tests
– Imaging
• Additional Monitoring (CVP, urinary catheter)
• Definitive Treatment
• “This is a surgical emergency”
• “I would resuscitate the patient, ensuring the patient’s
airway is patent and provide high-flow supplemental
O2 with a non-rebreather mask. I would then ensure
the patient is breathing adequately. I would then insert
2-large bore IVs into the antecubital fossas and draw
blood for emergency ixs. I would begin the patient on
fluid resuscitation. To guide fluid replacement, I would
like to assess the patient’s volume status through
clinical examination, vital signs and urinary output.
Thus, the patient will need to be catheterized and a
fluid balance chart should be implemented.”
• “At this point I would call for senior help”
6 P’s
 6 P’s
• Pain
• Pallor
– White  mottled  non-blanching mottled 
fixed staining
• Pulselessness
• Polar
• Paraesthesia
• Paralysis
Acute Limb Ischemia

Management
 Management
• ABCDE
• Emergency Ixs
• Additional monitoring
• Call for help
• Assess for severity (6 P’s)
• Definitive treatment
 Acute Limb Ischemia
• Etiology + how to differentiate cause
• Management according to cause
• Post-op complication to look out for
 Scenario
• A man was found collapsed in the street. He
has a pulsatile expansile mass on abdominal
examination. How would you manage him?
 Emergency Management
• Recognize emergency
• Call for HELP
• Initial resuscitation
– 2 large IVs + draw blood (esp Xmatch)
– Give O- blood (if desperate)
– Maintain BP <90 mmHg (permissive hypotension)
• DO NOT GIVE FLUIDS unless BP <60
• Emergency Ixs – none; straight to theater
– Abx: cefuroxime 1.5g + metronidazole 500 mg IV
• Additional monitoring
– CVP line + urinary catheter
• Definitive treatment
– Immediate surgery to cross-clamp the aorta proximal to the
rupture and control bleeding
 AAA
• Definition of aneurysm
• Etiology of aneurysm (6)
• RFs
• Classification of aneurysm
– Type, Shape, Location
• Ixs of AAA
• Management (non-ruptured)
• Indications for surgery
• Types of surgery + requirements + complications
Complications of AAA
 Complications
• Rupture
• Dissection
• Embolization leading to trash foot
• Fistula formation
– Abnormal connection between 2 epithelial
surfaces
Causes of Post-Operative Fever
 Causes
• <24h
– Physiological response to surgery
• <3 days
– Atelectasis
• >3 days
– Pneumonia, wound infection, UTI, line infection
• > 5 days
– PE or DVT
Management of Patient with
Post-Op Fever
 Management
• Assess urgency
• Initial resuscitation (examination!)
– Auscultate chest, examine abdo, look at wound,
examine legs (DVT)
• Ixs
– Septic Screen (FBC, blood cultures, urine dipstick,
CXR
• Definitive treatment
Status Epilepticus Mx
• Seizure >30min
or repeated
seizures without
intervening
consciousness
• ABCs
– Open and maintain airway
– 100% O2
– IV access and take bloods
• FBC, U&E, LFT, BM glucose, Ca, anticonvulsant levels, ABG, tox screen
– Fluid resuscitation
• Lay in recovery position
• Glucose 50mL 50% IV (unless glucose normal)
• ±Thiamine 250mg IV (if suspect EtOH)
• Lorazepam 2-4mg IV bolus; 2nd dose if no response
If fits continue….
• Phenytoin IV infusion
• Diazepam IV infusion
Describe + give DDx
 DDx
• Pulmonary Edema
– LVF
– ARDS
– Fluid overload
• Asthma/COPD
• Pneumonia

• Above 3 are hard to distinguish between! Ok to treat all

simultaneously
– Salbutamol nebs, Furosemide IV, amoxcillin
Symptoms and Signs
 Symptoms and Signs
• SOB
• Orthopnea, PND
• Pink frothy sputum
• Distressed, sitting up and leaning forward
• Pale, sweaty, cool peripheries, clammy
• Tachycardia, hypotensive
• Raised JVP
• Fine lung crackles
• Cardiac wheeze
Management

BEFORE Ixs!!
• ABC
– IV lines + draw bloods
• Vitals
• Cardiac monitoring
• “LMNOP”
– (Lasix) Furosemide 40-80 mg IV slowly
– Morphine 2.5-5 mg IV
– Nitrates (Ø if SBP <90)
• Start nitrate infusion if BP >100 mmHg
– 100% O2 + salbutamol nebs (if unsure of dx)
– Position  Sit patient upright
– ** Consider CPAP
Ixs
• FBC, U&E, blood cultures
• BNP
• Cardiac enzymes (troponins)
• ABG
• CXR
• ECG  ?MI or arrhthymias
• ECHO
 Cerebral Edema
• Vasogenic
– ↑ capillary permeability  tumor, trauma, ischemia, infection
• Cytotoxic
– Cell death from hypoxia

• Brain swelling quickly results in ↑ ICP

• Causes
– Tumors
– Head injury
– Hemorrhage (subdural, extradural, SAH, ICH)
– Infection (meningitis, encephalitis, abscess)
– Hydrocephalus
Symptoms/Signs
 Sxs/Signs
• Headache
• Drowsiness and irritability
• ∆ in consciousness
• Vomiting
• Pupillary changes (constriction then dilatation)
• Vitals: ↓ HR and↑ BP (Cushing’s response)
• Papilloedema (unreliable)
Investigations
 Ixs
• FBC, U&E, glucose, blood cultures, coags,
serum osmolality
• CXR
• CT brain
Treatment
• ABC
• Brief history and exam if possible
• Elevate head of bed
• If intubated, hyperventilate to ↓PaCO2
– *this causes cerebral vasoconstriction and reduces ICP
ASAP
• Mannitol
• Dexamethasone
• Fluid restrict to <1.5L/day
• Monitor closely
• Tx cause
Urinary Retention
• Tender
• Containing
~600 mL
Acute Urinary Retention Causes
 Causes
• Prostatic obstruction
• Urethral stricture
• Anticholinergics
• Post-op (pain, anaesthetics)
• Constipation
• Infection
• Cauda equina syndrome
• Carcinoma
Ixs and Mx
 Ixs and Mx
• FBC, U&E, PSA
• MSU
• Renal and bladder U/S

• Catheterization

• Urine output
– >0.5ml/kg/hr = ~30-35 ml/hr in 70kg man
– >400 ml/day
Catheter not draining…now what
• ?Blocked
– Flush and withdraw 20mL of sterile 0.9% NaCl with a bladder
syringe
– ± 3-way catheter if clot retention
• ?Slipped
– If flush enters but cannot be withdrawn
– Deflate balloon, advance and re-infalte, then flush and withdraw
again
• ?Renal hypoperfusion (dehydrated)
– Fluid challenge 250 ml STAT
– Check vitals and ↑ rate of IV fluids if necessary
• ?ARF
– Pre-renal failure
– Nephrotoxic drugs
 Post-Op Oliguria

Nurse calls to say that hourly urine

output <30ml…how do you manage?
• ABCs
• Vitals
• History and Examination
– Hands: skin tugor, prolonged CRT, cool/clammy
– Abdomen: ?distended bladder
– Drains: ?large output
• Read surgical notes
• Check fluid balance chart
– Oliguria abrupt or gradual?
– Drain/stoma output?
– Fluid intake?
• Investigations
– FBC, U&E, fluid challenge
• Call for help
 Treatment

• Post-renal (stone, BPH)

– Insert urinary catheter or check pre-existing not blocked
• Renal: call for expert help!
• Pre-renal
– Fluid challenge
– 250 ml STAT bolus IV and assess response (vitals, urine
output)
– If unresponsive  repeat fluid challenge again
– If unresponsive  insert CVP line to accurately assess
fluid volume status (normal values 3-7 cm/H2O)
 CVP Monitoring
• Patient underfilled
– CVP will rise in response to a fluid challenge…then
fall back down to the original value quickly
• Patient normovolemic
– CVP will rise substantially and will fall back down
over a longer period of time
• Patient well filled
– CVP will rise substantially but will not fall
 Ganglion
• Inspection
– Site
– Size
– #
– Shape
– Color
– Transillumination
• Palpation
– Tenderness
– Temperature
– Edge
– Consistency
– Fluctuance
– Compressibility
– Pulsatility
– Mobility
• Auscultation
 Cardiac Arrest
• If saved….
– GCS <8  ICU, induced coma, therapeutic
hypothermia
– GCS>8  cath lab
 Abdo Incisions
• Any patient with incision – ask to cough or lift
head!!!
• Indication for Pfannestieal
– Low C-section
– Bladder carcinoma
– Hysterectomy
– Fibroids
– Prostate
– Pubic symphsis surgery
– Laporascopic colectomy – need to get specimen out
 Types of Stomas
• Gastrostomy
• Jeunostomy
• Ileostomy
– End ileostomy: total colectomy with permanent end ileostomy
– Loop ileostomy: to defunction distal bowel
– Output: 500 ml to 1 L/day
• Colostomy
– End colostomy
• Proximal end: stoma
• Distal end: resected (APR), closed (Hartmann’s), exteriorized (mucous fistula)
– Loop colostomy
– Outpout: 100 – 300 ml/day
 Indications for Ileostomy
• Temporary
– Protect ileo-rectal anastomosis
– Persistent low intestinal fistula
– Right colonic trauma
– Preliminary to construction of ileo-anal reservoir
• Permanent
– Total colectomy (panproctocolectomy
– FAP syndrome
– Severe CD
 Indications for Colostomy
• Temporary
– Protect distal anastomosis
– Defunction a diseased segment (e.g. Chron’s
perineum)
– 1° anastomosis not possible following resection of
bowel (e.g. perforation, sepsis, ischemia)
• Permanent
– APR
1 3

2 4
 Complications of Stomas
• Psychological and sexual!!
• Early
• Ischemia
• Obstruction/blocked/stenosed
• Retraction
• Skin irritation (excoriation)
• Prolapse
• Late
• Parastomal hernia
• Leak
• High output
• Electrolyte changes (ileostomy)
• Stones
 Mucous Fistula
• Can be the 2nd of the two stomas in a double
barrel ostomy (2 distinct stomas made) or
• 2nd stoma when a single ostomy is created

• Non-working stoma (does not pass feces)

• Purpose: discharge of mucous or gasses from
the non-functioning portion of the colon and
rectum
 Loop Ostomy
• Both the proximal and distal openings of the
bowel are brought through the same hole in
the abdominal wall
• Proximal – drains feces
• Distal – mucous fistula

• Rod to support stoma in place

– temporary 4-10 days
Raised Amylase Levels
 Raised Amylase
• Acute pancreatitis
• Severe uremia
• Mesenteric ischemia
• DKA
• PUD
• Renal failure
Raised LDH levels
 Raised LDH levels
• MI
• Pulmonary embolism
• Liver disease
• Tumor necrosis/Tumor lysis syndrome
• Hemolysis
• Pancreatitis
Abx Prophylaxis in Surgery

GUH
• Choice of agent
– Depends on procedure and potential pathogens
• Timing
– 30-60 mins before skin incision
• Duration
– Single dose
– Exceptions
• prolonged surgeries >3 hrs
• Blood loss/fluid replacement
• Who
– High-risk operations (larege bowel, urological)
– High-risk patients (DM, renal failure, etc)
– Prosthetic implant surgery
– Patients with MRSA (ADD teicoplanin IV)
 Classification of Surgical Procedures
• Clean
– No breach of respiratory, GIT or GUT
– Non-traumatic
– No inflammation
–  prophylaxis NOT usually recommended
• Clean-contaminated
– Breach of respiratory, GIT or GUT
– Non-traumatic
–  prophylaxis NEEDED
• Contaminated
– Major break in aseptic technique
– Gross spillage from a viscus
– Dirty, traumatic wounds
– Pus from any source
–  Treatment course 5-7 days may be needed
Surgery Procedure 1st line Abx 2nd line

GIT surgery Upper GIT, GB, lower Co-Amoxiclav IV 1.2g Cefuroxime IV 1.5g
GIT, PEG, hernia + Metronidazole IV
repair 500mg
Breast surgery Any breast surgery Flucloxacillin IV 1g Cefuroxime IV 1.5g

Reconstruction Co-amoxiclav IV 1.2g

Urological See GUH Handbook Gentamicin IV 3mg/kg

surgery Add amoxicillin IV 1g (TURP)
*Ciprofloxacin for TRUS and PCNL
Cardiothoracic CABG, valve surgery Cefuroxime IV 1.5g q8h
surgery
Vascular Surgery Cefuroxime IV 1.5g q8h + Metronidazole IV 500mg q8h

Ortho and Cefuroxime IV 1.5g q8h

Trauma *Add Metronidazole IV 500mg q8h if open #
Urology
Massive Hematuria

Management
• ABC
• IV + fluids
• Bloods ASAP
– FBC, U&E, coags + x-match
• Minimal bleeding
– Irrigation with triple lumen catheter
• Major bleeding
– Cystoscopy  coagulate bleeding sites
• Refractory bleeding
– Intravesicle irrigation with 1% aluminum K sulphate
– Intravesicle injection with 1% silver nitrate
– Embolization and ligation of iliac arteries
 Bladder Ca
• Risk Factors
• Types
• Presentation
• Investigations
• Staging
• Treatment
• F/U
• Prognosis
 Renal Stones
• Presentation
• Types of stones
• Areas of obstruction
• Investigations for initial presentation
• Investigations for recurrent presentation
• Treatment
– Admit if…
– Medical
– Interventional
Describe
Describe
Describe
 Dialysis Access
• AV Fistula
• Prosthetic graft
• CVC
Types AV Fistula
Describe
 Scleroderma
• Sclerodactyly
• Tight shiny skin
• Loss of skin folds
• Digital flexion contractures
• Calcinosis
• Depigmentation (salt and pepper skin)
• Ulcers and scars over PIJs
Describe
• Microstomia with angular creases and
tightness of facial skin with telangiectasia on
cheek
• Swelling of hands (early edematous phase in
Scleroderma)
• Dilated capillary loops
• Scruffy cuticles
 Coup de Sabre
• Linear indentation of forehead
Describe
 SLE
• Malar Butterfly Rash - Scaly erythematous
rash over the malar eminences with nasolabial
fold sparing
• Discoid Rash on arms
Describe
 Dermatomyofibrosis
• Eye – heliotrope rash
• Hands – Gottren’s papules and periungal
telangiectasia
 Ankylosing Spondylitis
• Posture – flattened lumbar lordosis, severe
dorsal kyphosis, protruding abdomen and
flexed knees
• Xray: Bamboo Spine
Dark brown/black marks in eye
DDx
Ascites
 Causes of Ascites
• Without portal HTN
– Malignancy
– Infections (esp TB)
– ↓albumin (eg nephrosis, malnutrition)
– CCF; pericarditis
– Pancreatitis
– Myxoedema
• With Portal HTN
– Cirrhosis
– Budd-chiari syndrome
– IVC or portal vein thrombosis
– Portal nodes
Pancreatitis
 Acute Pancreatitis
• Etiology
• Investigations
• Treatment
• Complications
 I GET SMASHED
• Idiopathic
• Gallstones
• Ethanol
• Trauma/surgery/tumours
• Steroids
• Micro: mumps, coxsackie, varicella
• Autoimmune: SLE, PAN, Crohn’s
• Scorpion bite
• Hypercalcemia, hyperlipidemia, hypothermia
• ERCP
• Drugs: azathioprine, metronidazole, furosemide, salicylates,
acetaminophen
 GLASGOW (PANCREAS)
• PaO2 <8kPa
• Age >55y
• Neutrophils (WBC>15)
• Ca <2mmol
• Renal function (Urea >16)
• Enzymes (LDH>600, AST>200)
• Albumin <32
• Sugar >10
 Complications
• Early
– Shock
– ARDS
– Renal failure
– DIC
– Sepsis
– Hypocalcemia
– Hyperglycemia
• Late
– Pancreatic necrosis
– Psedocyst
– Abscess
– Bleeding
– Thrombosis
– Fistulae
– Recurrent pancreatitis
Bowel Obstruction
 SBO Etiology
• Outside the wall
– Adhesions
– Hernia
– Volvulus
– Neoplasm
• Inside the wall
– Neoplasm
– Strictures
– Congenital malformation
– CF
• Inside the bowel
– Gallstone
– Feces
– Meconium
– Foreign body
– Intussusception
 LBO Etiology
• CRC
• Diverticulitis
• Volvulus
• IBD
• Fecal impaction
• Foreign body
• Adhesions
• Hernia
• Intussusception
• Extrinsic mass
 Small vs Large BO
• Small
– Vomit earlier
– Less distension
– Pain higher
– Central gas shadows & no gas in LB on PFA
– Valvulae conniventes
• Large
– Pain more constant
– Gas proximal to blockage but not in rectum
– Haustra
Appendicitis
 Acute Appendicitis
• Presentation
• Signs
• DDx
• Treatment
• Open vs Laparoscopic
• Complications
 Ddx
• Ectopic
• Renal stone
• Mesenteric adenitis
• Cystitis
• Cholecystitis
• Diverticulitis
• Salpingitis/PID
• Crohn’s disease
• Perforated ulcer
 Signs
• McBurney’s sign
– Tenderness 1/3 from ASIS to umbilicus
• Rovsing’s sign
– L abdo pressure causes McBurney’s point tenderness
• Psoas sign
– Pain on passive hyperextension of hip
• Obturator sign
– Flexion and external or internal rotation causes pain
 Open Vs Laparoscopic
• Open
– Quicker
– Less $$
– Less chance of abscesses
• Laparoscopic
– Less pain
– Shorter hospital stay
– Quicker return to work
– Less cost to society
– Good if diagnosis in doubt
 Complications
• Infection
• Mass
• Abscess
• Perforation
Diverticulosis
 Diverticulosis
• Definition
• Risk factors
• Presentation
• Complications
• Classification
• Management
 Risk Factors
• Age
• Low fibre
• Obesity
• Physical inactivity
• Ehler’s Danlos, Marfans, PCKD
 Complications
• Perforation
• Abscess
• Obstruction
• Fistula
• Hemorrhage
• Stricture
 Hinchey Classification
• 1 – peri-diverticular abscess within mesocolon
• 2 – distant abscess
• 3 – generalized purulent peritonitis
• 4 – generalized fecal peritonitis
Hernias
 Hernia
• Definition
• Types
• Exam
 Types
• Inguinal
– Direct
– Indirect
• Femoral
• Ventral/epigastric
• Incisional
• Umbilical
• Uncommon types
– Spigelian
– Lumbar
– Richter’s
– Littre’s
– Obturator
 Examine Inguinal Hernia
• Goals:
– Confirm its a hernia
– Differenitate inguinal from femoral
– Determine if direct or indirect
• Standing or laying flat
• Inspection
– Scars
– Ask patient to cough (look for impulse)
– Get the patient to reduce it if possible
• Palpation
– Identify anatomy (pubic tubercle, ASIS, inguinal ligament)
– Ask to cough again and determine if above/below ligament
– Reduce the hernia and try to control it at the deep ring
– If controlled on cough impulse it’s an indirect hernia
• Ask to complete by examining the scrotum for other lumps and examine
the other side
 Anatomy of Inguinal Hernias
• Midinguinal point
– Halfway along ASIS & midline
– Location of femoral artery
• Midpoint of the inguinal ligament
– Halfway along inguinal ligament (between pubic tubercle & ASIS)
– Location of deep inguinal ring
• Inguinal canal
– Floor = inguinal ligament
– Roof = transversalis & internal oblique
– Ant = external oblique aponeurosis
– Post = transversalis fascia & conjoint tendon
• Hesselbach’s triangle
– Inferior = inguinal ligament
– Lateral = inferior epigastric artery
– Medial = rectus sheath
 Contents of Inguinal Canal
• 3 arteries
– Vas deferens artery9
– Testicular artery
– Cremasteric artery
• 3 nerves
– Ilioinguinal nerve
– Cremaster nerve
– Autonomic nerves
• 3 other structures
– Vas deferens
– Pampiniform plexus
– lymphatics
 Anatomy of Femoral Hernias
• Femoral Canal
– Anterior = inguinal ligament
– Medial = lacunar ligament & pubic bone
– Lateral = femoral vein & iliopsoas
– Posterior = pectineal ligament & pectineus
Colorectal Carcinoma
 Colorectal Carcinoma
• Presentation
• Risk Factors
• Investigations
• Staging
• Treatment
• Screening
 Presentation
• L sided
– Bleeding or mucous PR
– Tenesmus
– Mass on DRE
– Altered bowel habit
– Obstruction
• R sided
– Weight loss
– Anemia
– Abdo pain
 Risk Factors
• Age
• Polyps
• Family History
• Personal History of CRC
• IBD
• Diet
• DM
 Investigation
• FBC
• FOBT
• sigmoidoscopy
• Barium enema or colonoscopy
• LFTs
• CT/MRI (staging)
• CEA (marker)
 Staging
• Duke’s
– A = confined to mucosa/submucosa
– B = invasion of muscle wall
– C = regional lymph nodes
– D = metastases
• TNM
– T1 = submucosa
– T2 = muscularis
– T3 = subserosa
– T4 = beyond visceral peritoneum
– N0 = 0 nodes
– N1 = 0-3 nodes
– N2 = >4 nodes
– N3 = LN along vascular trunk
– M0
– M1
 Treatment
• Surgical excision with adequate margins (2-5cm)
– R hemicolectomy
– L hemicolectomy
– Transverse colectomy
– Sigmoidectomy
– Anterior Resection
– Abdominal Perineal Resection
– Totoal Mesorectal Excision
– Hartmann’s Procedure
• Excision of lymphatic drainage (based on vascular
supply)
Examine this patient with a RLQ mass
• Approach
• DDX of RLQ mass
• Investigations
Stomas
 Stoma
• Inspection
• Palpation
• Summary

• What are the complications of a stoma?

• What factors would you consider in choosing
a stoma site?
 Stoma
• Inspection
– Site
– Covering
– Appearance
• Healthy? Relation to skin? Number of lumens?
– Surrounding skin
– Contents of bag
– Describe the rest of the abdomen
• Palpation
– Open the bag and examine with gloved finger
• Say that you would like to examine the rest of the
abdomen to look for clues as to why the stoma was formed
• Would also like to complete the examination with a DRE
 Complications
• Early
– Ischemia/necrosis
– Obstruction/stenosis
– Retraction
– Skin irritation
– Prolapse
• Late
– Parastomal hernia
– Leak
– High output
– Stones
• Psychological & sexual complications
 Site
• Assess both standing and lying
• Avoid
– Bony prominences
– Umbilicus
– Old wounds/scars
– Skin folds/creases
– Waistline
Peripheral Edema
 Peripheral Edema
• Abnormal accumulation of fluid beneath the
skin that causes swelling

• On examination
• Etiology
• Pitting vs Non-pitting
 Exam
• Determine level
• Generalize or localized
• Measure circumference
• Describe level to which edema extends
• Other signs?
– JVP
– Pulmonary crackles
– Pain
– Tenderness
– Skin discolouration
– Ulceration
 Pitting Edema
• Bilateral
– Implies systemic disease
– Dependent
– Causes
• RHF
• Hypoalbuminemia (liver failure, nephrotic syndrome)
• Venous insufficiency
• Vasodilators
• Pelvic mass
• pregnancy
• Unilateral
– Causes
• DVT
• Inflammation
• Bone or muscle pathology (tumour, necrotizing fasciitis, trauma)
• Compartment syndrome
• Trauma
• Arthritis
• Baker’s cyst
 Non-Pitting Edema
• Causes
– Lymphedema
– Lipoedma
– Myxedema
DVT
 DVT
• Etiology
• Wells Critera
 Virchow’s Triad (risk factors)
• Endothelial damage
– Trauma
– Surgery
• Stasis
– Immobility
– Obesity
– CHF
– Chronic venous insufficiency
• Hypercoagulability
– Acquired
• Malignancy
• Hormaonal (OCP, HRT, pregnancy)
• Trauma/surgery
– Inherited
• Coagulopathy (Factor V leiden, Protein C/S deficiency, ATIII deficiency)
• Homocysteine, antiphospholipid Ab
 Presentation
• Warm
• Tender
• Swollen
• Red
• Mild fever
• Pitting edema
• Homan’s sign

• DDx
– Cellulitis
– Ruptured Baker’s cyst
 Well’s Criteria
• Pretest clinical probability score
– Active Ca (1)
– Paralysis, paresis or recent immobilization (1)
– Major surgery or recently bedridden >3d (1)
– Local tenderness along deep venous system (1)
– Entire leg swollen (1)
– Calf swelling >3cm (1)
– Pitting edema (1)
– Collateral superficial veins (1)
– Alternative dx as or more likely than DVT (-2)
• ≥3 points = high pretest probability; treat as suspected DVT  venous
doppler
• 1-2 points = intermediate; treat as suspected DVT  venous doppler
• ≤0 points = low probability; do D-dimers
 DVT Treatment
• LMWH + warfarin
– Enoxaparin: 1.5mg/kg
– Tinzaparin: 175u/kg
• Long-term warfarin with INR 2-3
– 1 DVT & transient RFs: 3 months
– 1 DVT & no cause found: 6 months
– Recurrent DVTs: lifelong treatment
 DVT Prevention
• Stop OCP 4wks pre-op
• Mobilize early
• LMWH
– Enoxaparin 20-40mg
– Tinzaparin 3500 units
• TEDS
• Intermittent pneumatic pressure
Pulmonary Embolism
 PE
• Presentation
• Risk factors
• Wells Criteria
 Presentation
• Collapse 2w post-op
• Acute SOB
• Pleuritic CP
• Hemoptysis
• Pre-syncope/syncope
• Cough
• Tachycardia
• Tachypnea
• Pyrexia
• ↓SpO2
• ±hypotension
• RV failure
 Investigations
• ECG
– Sinus tachy
– RAD, RBBB
– S1Q3T3 (rare)
• CXR
– Hampton’s hump = atelactasis & infarct (wedge)
– Westermark’s sign = distal oligemia + dilated pulm artery
• Bloods
– ABG
– FBC
– Clotting
– U&E
 Well’s Criteria
• Clinical signs of DVT (3)
• Alternative Dx less likely (3)
• Previous Hx DVT/PE (1.5)
• Tachycardia (1.5)
• Recent immobility/surgery (1.5)
• Hemoptysis (1)
• Ca (1)

• 0-2 = low probability  D-dimer to R/O

• 2-6 = intermediate probability CTPA/VQ
• >6 = high probability  CTPA/VQ
 Respiratory Failure
• Types
• Etiology
 Types 1 RF
• Hypoxemic, normal or ↓CO2
– Low O2
– Diffusion impairment
– V/Q mismatch
– Shunts
– Diffusion/ventilation mismatch
 Type 2 RF
• Hypercapnic
– ↑CO2 production
– Alveolar hypoventilation
– Hypoventilation
 Etiology
• Airway Obstruction
– Asthma, COPD, bronchiectasis, CF, bronchiolitis,
upper airway obstruction
• Abnormal parenchyma
– Pulmonary fibrosis, pneumonia, pulmonary edema,
ARDS, pleural effusion
• Hypoventilation
– CNS disorder (drugs, ICP, spinal cord injury, sepsis)
– Neuromuscular (GBS, MG, muscular dystrophy)
– Chest wall (kyphoscoliosis, obesity)
 ARDS
• Acute onset
• Bilateral infiltrates on CXR
• PCWP < 18 or no evidence of ↑ L atrial
pressure
• PO2/FiO2 ≤200
 Acute Lung Injury
• Acute onset
• Bilateral infiltrates on CXR
• PCWP < 18 or no evidence of ↑ L atrial
pressure
• pO2/FiO2 >200 and < 300
Shock
 Shock
• Definition
• Types
• Signs
• Management
 Shock
• Inadequate organ and tissue perfusion with
oxygenated blood to meet their metabolic needs
• Types
– Hypovolemic
– Cardiogenic
– Obstructive
– Septic
– Anaphylactic
– Neurogenic
 Signs
• Tachycardia
• Hypotension (late sign)
• Narrowed pulse pressure
• Oliguria
• Cutaneous vasoconstriction
• Tachypnea
• Altered mental status
 Management
• ABC
• IV access
• Raise foot of bed
• ID & treat underlying cause
• IV Fluids
• Monitor response
• Ix
– FBC, U&E, ABG, glucose, CRP, cross-match, coag,
cultures (blood & urine), ECG, CXR, lactate, ECHO, CT,
US...
 ABGs
• Taking a sample
 ABG
• pH: 7.35-7.45
– <7.35 = acidosis
– >7.45 = alkalosis
• Bicarbonate (major buffer)
– CO2+H2O ↔ H2CO3 ↔ HCO3- + H+ ↔ H2O +
CO2
– Catalyzed by carbonic anhydrase
• Inhibited by acetazolamide
 Anion Gap
• Measured cations & anions
– Na – (Cl + HCO3)
– Normal = 10-18 mmol/L
• Gap represents unmeasured anions (proteins,
phosphate, sulphate)
• ↑AG
– Additional unmeasured anions in blood
– Ketoacids, lactic acid
• ↓ AG
– Usually hypoalbuminemia causing retention of other
anions
– Liver cirrhosis, nephrotic syndrome, hemorrhage
 Base Excess
• ±2mEq
• Measure of metabolic alkalosis or acidosis
 Normal Values
• pH = 7.35-7.45
• HCO3 = 22-28
• PaO2 = 10.5-13.5kPa
• PCO2 = 4.5-6.0kPa
• Base deficit/excess = ±2
• Anion gap = 10-18
 Disorders
• Metabolic acidosis
– low pH, low HCO3
• Respiratory acidosis
– Low pH, high CO2
• Metabolic alkalosis
– High pH, high HCO3
• Respiratory alkalosis
– High pH, low CO2
 High AG Metabolic Acidosis
• MUDPILES
– Methanol
– Uremia
– DKA
– Paraldehyde overdose
– Infection/ischemia/isoniazid
– Lactic acidosis
– Ethylene glycol/ethanol
– salicylates
– Others: aspirin, cyanide
 Approach to ABG
• Look at pH
• Look at pCO2
• Look at HCO3 for metabolic effect
• Look at buffers (base excess)
• Practice Problem 1
• ABG's:  pH 7.31   PCO2 55 mm Hg   HCO3- 28 mEq/L
• Practice Problem 2  
• ABG's:  pH 7.31   PCO2 55 mm Hg   HCO3- 35 mEq/L
• Practice Problem 3
• ABG's:  pH 7.31   PCO2 35 mm Hg   HCO3- 20 mEq/L
• Practice Problem 4
• ABG's:  pH 7.31   PCO2 25 mm Hg   HCO3- 20 mEq/L
• Practice Problem 5
• ABG's:  pH 7.48   PCO2 25 mm Hg   HCO3- 28 mEq/L
• Practice Problem 6
• ABG's:  pH 7.48   PCO2 25 mm Hg   HCO3- 20 mEq/L
• Practice Problem 7
• ABG's:  pH 7.48   PCO2 45 mm Hg   HCO3- 33 mEq/L
• Practice Problem 8
• ABG's:  pH 7.48   PCO2 55 mm Hg   HCO3- 33 mEq/L
• ANSWER 1
• bicarbonate, 24 - 28 mEq/L pH is too low - acidosis;  PCO2 is too high, would cause
acidosis or correct alkalosis; HCO3- is normal, neither causing nor correcting
imbalance high PCO2 is correllated with low pH, which is consistent with patient's
report because PCO2 is causing the problem, this is respiratory acidosis; because
bicarbonate is normal, there is no compensation possible cause: cardiac arrest
Practice Problem 2
• ABG's: pH 7.31 PCO2 55 mm Hg HCO3- 35 mEq/L
• pH – low = acidosis
• PCO2 – high = respiratory acidosis
• HCO3 - high = renal compensation
•  
• Practice Problem 3
• ABG's: pH 7.31 PCO2 35 mm Hg HCO3- 20 mEq/L
• pH – low = acidosis
• PCO2 – normal; no compensation
• HCO3 - low = metabolic acidosis
•  
• Practice Problem 4
• ABG's: pH 7.31 PCO2 25 mm Hg HCO3- 20 mEq/L
• pH – low = acidosis
• PCO2 – low = respiratory compensation
• HCO3 - low = metabolic acidosis
• Practice Problem 5
• ABG's: pH 7.48 PCO2 25 mm Hg HCO3- 28 mEq/L
• pH – high = alkalosis
• PCO2 – low = respiratory alkalosis
• HCO3 - normal; no compensation
•  
• Practice Problem 6
• ABG's: pH 7.48 PCO2 25 mm Hg HCO3- 20 mEq/L
• pH – high = alkalosis
• PCO2 – low = respiratory alkalosis
• HCO3 - low = renal compensation
•  
• Practice Problem 7
• ABG's: pH 7.48 PCO2 45 mm Hg HCO3- 33 mEq/L
• pH – high = alkalosis
• PCO2 – normal; no compensation
• HCO3 – high = metabolic alkalosis
•  
• Practice Problem 8
• ABG's: pH 7.48 PCO2 55 mm Hg HCO3- 33 mEq/L
• pH – high = alkalosis
• PCO2 – high = respiratory compensation
• HCO3 – high = metabolic alkalosis
Diabetes
 Diagnosis
• A syndrome caused by a decrease or total lack of
insulin or diminished effectiveness of circulating
insulin

• Classic symptoms + random BM ≥11.0mmol/L

• FBG ≥ 7.0 mmol/L
• OGTT ≥ 11.0mmol/L
• HbA1c ≥ 6.5%

• Types?
 OGTT
• Fast over night
• Give 75g glucose in water to drink in the
morning
• Measure venous plasma glucose before and 2
h after
 Risk Factors
• Age
• Abdominal obesity/overweight
• First degree relative
• Race/ethnicity
• History of IGT of IFG
• HTN
• Dyslipidemia
 Treatment
• MDT!!!
• Lifestyle modifications
• Pharmacological
• Insulin
• Weight loss agent
 Hypoglycemics
• Biguanide (ie metformin)
– Sensitize tissues to insulin
– ↓ hepatic glucose production
• Insulin secretagogue (sulfonylureas – glyburide, glicalazide,
glimepiride)
– Stimulate insulin release
• Insulin
• Thiazolidinediones (ie rosiglitazone, pioglitazone)
– Sensitize tissue to insulin
– ↓FFA release
• DPP-IV inhibitors & Incretin mimetics
– Inhibit degredation of incretins (↑ insulin, inhibits glucagon & delays
gastric emptying)
• α-glucosidase inhibitor (ie acarbose)
– ↓ GI carb absorption
 Other Meds to Consider
• Anti-hypertensives
• Statins/fibrates
• Aspirin
• ACE inhibitors
• ARBS
 Targets
• HbA1c <6.5-7%
• BP < 130/80 or <125/80 if microalbuminemia
• Cholesterol <5mmol/L
• HDL >1mmol/l
• TG < 1.5mmol/l
 Complications
• Vascular Disease
• Retinopathy
• Nephropathy
• Neuropathy
• DKA/HONK
• Hypoglycemia
 Macrovascular
• Major risk factor for atherosclerosis
• MI
• Stroke
• PVD
• Address other risk factors
 Diabetic Retinopathy
• Leading cause of blindness
• DM1 > DM2 (40% vs 20%)
• Risk factors
– Duration of diabetes
– Poor metabolic control
– Pregnancy
– HTN
– Nephropathy
– Others: smoking, obesity, hyperlipidemia
• Intensive metabolic control
– Delays onset
– Slows progression
– Decreases rate of conversion to proliferative changes
– Decreases need for laser treatment
 Diabetic Retinopathy
• Background retinopathy/Non-proliferative
– Microaneurysms (dots)
– Hemorrhages (blots)
– Hard exudates
– Retinal edema
• Pre-proliferative
– Venopathy
– Cotton wool spots (infarcts)
– Flame shaped hemorrhages
– Intra retinal microvascular abnormalities
– Venous shunts & beading (signs of retinal ischemia)
• Proliferative (immediate panretinal photocoagulation)
– Neovascularization
– Fibrous scarring
– Vitreous hemorrhage
– Retinal detatchment
• Maculopathy (↓ acuity)
• Cataracts
• Rubeosis iridis
s
 Screening
• Visual acuity
• Fundus examination

• Annual review
– If normal fundus or mild retinopathy
• Referral to ophthalmologist
– Large hard exudates
– Reduced visual acuity
• Early referral
– Hard exudates or hemorrhages near fovea
– Maculopathy
– Proliferative retinopathy
• Urgent referral
– Proliferative retinopathy
– Pre-retinal or vitreous hemorrhage
– Rubreosis iridis
– Retinal detatchmetn
 Diabetic Maculopathy
• Focal exudate
– Tx: focal laser
• Diffuse edema
– Tx: Anit-VEGF Ranibizumab
– Responds poorly to grid laser
• Ischemic type
– Tx: tight glucose & blood pressure control
– NEVER laser
 Nephropathy
• ↑GFR
• Diffuse thickening of glomerular BM
• Microalbuminuria
– Early renal disease
– Albumin:creatinine >3
• Asymptomatic early on  HTN, edema,
uremia
• Tx: ACE inhibitor or ARB
 Neuropathy
• Symmetric sensory polyneuropathy
– Neuropathic deformity: pes cavus, claw toe, loss of arch,
rocker bottom sole
• Mononeuritis multiplex (CN III & VI)
• Amyotrophy
– Painful wasting of quads and other pelvifemoral muscles
– Autonomic neuropathy
• Postural hypotension
• Gastroparesis
• Urine retention
• Erectile dysfunction
• diarrhea
 Long Term Management
• ABCDEF’s of DM
– ASA
– ACEI or ARB
– BP control
– Cholesterol control
– Diabetic control
– Education
– Exercise
– Eyes
– Foot exam/neurologic
– Fat reduction
– Smoking
– Screen of cardiovascular disease
 HONK
• Insulin levels insufficient to prevent hyperglycemia but
enough to prevent ketosis
• Hyperglycemia, hyperosmoloality & dehydration

• Insidious - Unwell for days

• Not acidotic
• No ketones
• Very high glucose
• Risk of clotting
• Dehydrateion
• ↓LOC
Ankylosing Spondylitis
 Ankylosing Spondylitis
• A seronegative spondyloarthropathy with
prominent involvement of the sacro-iliac
joints and spine, peripheral oligoarthritis, and
multiple extra-articular manifestations

• M>F
• Onset in late teens or early adulthood
 Presentation
• Inflammatory low back/butt/thoracic pain
– Early AM stiffness >30 min
– Improves with exercise
– Localized tenderness
– Night pain
• Extra-articular manifestations
– MSK: achilles tendinitis, plantar fasciitis
– CVS: aortitis (AR)
– Resp: upper lobe fibrosis
– Eyes: uveitis/iritis
– Rare: Amyloidosis (hepatosplenomegaly, renal
enlargement, proteinuria), Cauda equina syndrome,
osteoporosis
 On Exam
• Question mark posture
• Stiffness (ankylosis)
• ±swollen joints
• Tender SI joint
• Movement ↓ in 3 planes
– Schober’s test
– Floor-finger distance
– Chest expansion
– Rotation: thoracic & neck
– Lateral flexion: lumbar & neck
– FABER test
– Head to wall distance
 Extra-articular features
• Uveitis (painful red eye)
• Enthesitis (achilles & plantar fascia)
• Aortic regurgitation
• Pulmonary fibrosis

• Signs of IBD
 Investigations
• FBC
• U&E
• LFT
• CRP/ESR
• RF (negative)
• ECG
• Arthrocentesis
• X-Ray
 X-Ray
• Babmoo spine (syndesmophytes)
• Squaring of vertebral bodies
• Whiskering
– New bone, soteitis at tendon and ligament
insertion

• Sacroillitis
 Treatment
• Non-pharmacologic
– PT, OT
– Massage, TENS, heat packs
– Good posture
– Healthy lifestyle
• Pharmacologic
– Symptomatic
• NSAIDS ± PPI
– Disease modifying
• Corticosteroids
• Methotrexate
• Sulfasalazine
• Anti-TNF: adalimumab, infliximab, etanercept
• Surgery
– Joint replacement
– Correction of spinal deformitiy
Scleroderma
 Scleroderma
• A chronic, progressive autoimmune
connective tissue disease associated with
inflammation, microvascular disease and
tissue fibrosis
 Types
• Systemic Scleroderma
– Diffuse cutaneous
– Limited cutaneous (CREST)
– Systemic sclerosis
• Limited/Localized Scleroderma
– Linear
– Morphea
 Diagnosis
• Major or ≥2 minor

• Major
– Sclerodermatous change proximal to MCP
• Minor
– Sclerodactyly
– Digital pitting scars of fingertips or loss of finger
pulp
– Bibasilar pulmonary fibrosis
 Clinical Features
• Cutaneous
• Vascular
• Pulmonary
• Cardiac
• Gastrointestinal
• Renal
• Neuro
• MSK
• Others
 Investigations
• FBC  anemia
• U&E  renal failure
• ESR/CRP
• LFTs  baseline, biliary cirrhosis
• ANA (60-90%)
• CK
• Urine dipstick  proteinuria
• ECG, ECHO
• OGD/Colonoscopy/Barium Swallow
• CXR
• PFTs
• Anti-centromere (CREST)
• Anti-Scl70 (systemic sclerosis)
• Nailfold capillaroscopy
 Treatment
• Non-Pharmacological
– PT, lifestyle management, emolients for skin
• Pharmacological
– System based depending on symptoms/severity
– Skin: emolients,
– GI: PPI, Abx, metoclopramide
– Renal: ACEi/ARB
– Raynaud’s: warm hands, smoking cessation, CCB
– Resp: corticosteroid, azathioprine
– Pulm HTN: sildenafil, bosentan
Gout
 Gout
• Rheumatologic condition associated with
elevated uric acid levels and characterized by
recurrent attacks of inflammatory arthritis,
tophi, renal stones and urate nephropathy
 Ddx
• Septic arthritis
• Pseudogout
• RA
 Ix
• Joint/tophi aspiration
– Microscopy
– Culture
– WCC
• FBC
• U&E
• CRP/ESR
• Uric acid
• ± 24h urine uric acid excretion
• Fasting lipids
• Glucose
• TFTs
• LFTs
 Treatment
• Acute
– NSAIDs
– Colchicine
– Oral/intrarticular steroids or ACTH
– Start allopurinol (never alone)
• Prevent Recurrence
– Lifestyle (EtOH, weight, meat)
– Allopurinol (xanthine oxidase inhibitor)
– Febuxostat
– Uricosurics
 Etiology
• ↓ excretion
– Renal impairment
– Alcohol
– Drugs
• Cyclosporine, thiazides, loop diuretics, ASA, nicotinic acid
• ↑ production
– Metabolic syndrome
– ↑metabolism
• EtOH, HUS, Psoriasis
– Neoplastic
• Myeloproliferative disorders, chemo (tumour lysis)
Rheumatoid Arthritis
 RA
• A chronic systemic inflammatory disease
characterized by symmetrical deforming
polyarthritis.
 Presentation
• Symmetrical swollen, painful & stiff small joints of the
hands and feet
• Worse in morning
• Fluctuates

• Swollen MCP, PIP, wrist or MTP joints

• Joint deformity: ulnar deviation of fingers, dorsal wrist
subluxation
• Boutonniere and swan neck deformities or z deformity
• May have hand extensor tendon rupture
 Extra-articular
• Nodules: elbows & lung
• Lymphadenopathy
• Vasculitis
• Fibrosing alveolitis, obliterative bronchiolitis
• Pleural & pericardial effusion
• Raynaud’s
• Carpal tunnel syndrome
• Peripheral neuropathy
• Splenomegaly (Felt’s syndrome with neutropenia)
• Episcleritis, scleritis, scleromalacia, keratoconjuncitivitis
• Osteoporosis
• Amyloidosis
 Investigations
• RF
• Anti-CCP (more specific)
• Anemia of chronic disease
• Platelets (↑)
• ESR
• CRP
 X-RAY Findings
• Soft tissue swelling
• Juxta-articular osteopenia
• Joint space narrowing
• Bony erosions
• Subluxation
 Diagnosis
• 4 out of 7
– Early morning stiffness (>1h for >6/52)
– ≥3 joints involved
– Symmetrical arthritis
– Arthritis of hand joints
– Rheumatoid nodules
– +ve rheumatoid factor
– Radiological changes
 Management
• Non-pharmacological
– PT, OT, smoking cessation, exercise, weight loss, diet
• Pharmacological
– NSAIDS for symptom control
– Steroids to induce remission
– DMARDs
• Methotrexate
• Sulfasalazine
• Hydrochloroquine
– Biologics
• TNF-α: infliximab, etanercept, adalimumab
• Rituximab
• Surgical
Sarcoidosis
 Sarcoidosis
• Non-infectious granulomatous multisystem
disease of unknown cause
– Non-caseating granulomas

• 50% asymptomatic
 Presentation
• Lung
• Skin
• GI
• Lymphadenopathy/Splenomegaly
• Eye
• Kidney
• CNS
• Heart
• MSK
 Lung
• SOB
• Non-productive cough
• Fine crackles (upper lobe fibrosis)
• ±wheeze
 Skin
• Erythema nodosum
• Maculopapular rash
• Lupus pernio
• Cutaneous sarcoid (granulomas)
 Others
• GI - ↑LFTs
• Eye – uveitis, glaucoma, cataracts, ptic
neuropathy
• Kidney – interstitial nephritis, renal failure
• CNS – meningeal, hypothalamus,
encephalopathy
• Heart – arrhythmia, SCD
• MSK - arthralgia
 Pulmonary Manifetations
• BHL
• Pulmonary infiltrates
• Nodules
• Obstructive/restrictive pattern or both
• Interstitial pneumonitis & fibrosis
• Bronchiectasis
• Honeycomb lung
• Cor pulmonale
 Staging
• 1: bihilar lymphadenopathy
• 2: BHL + infiltrate
• 3: infiltrate without BHL
• 4: end stage lung
Review Optho Session
Cataract
Define
 Define
• Lens Opacity
Causes
 Causes
• Age
• Drugs
– Steriods
– Amiodarone
• Diabetes
• Myotonic dystrophy
• Dermatitis (atopic)
• Congenital: retinitis pigmentosa / down’s / rubella
Young patient with Unilateral cataract
Young paitent with unilateral cataract
• Trauma
• Occular surgery
• Chronic uveitis
• Fuch’s uveitis
– Triad: herterchromia , cataract, keratosis on cornea
Young Patient: Bilateral Cataract
 Young Patient: Bilateral Cataract
• Diabetes
• Retinits Pigmentosa
Symptoms + Signs
 Symptoms + Signs
Symptoms
-< visual acuity
-Glare
-Colour vision decreases: white  yellow

Signs
- Loss of red reflex
Loss of red reflex
 Loss of red reflex
• Cataract
• Vitreous haemorrhage
• Retinal detachment
• Posterior capsule fibrosis
Cataract Surgery
 Cataract Surgery
• ECCE
• Phaeoemulsification
Complications of cataract surgery
 Complications of cataract surgery
Serious
•Choridal haemorrhage
•Retinal detachment
•Endophalmitis
– Bacillus aureus
– S. Epidermidis

Other
- Stitch abscess
- Lens dislocation
- Iris prolapse
- Rupture posterior capsule
Congenital Cataract
causes
 Congenital Cataract
causes
• Down’s syndrome
• Metabolic ds
• IUI – rubella / CMV / toxoplasmosis….
 Congenital cataracts IX
• Urine
• Torch test
 Congenital cataracts Mx
• Bilateral dense
• Bilateral partial
• Unilateral dense
• Unilateral partial
 Lens displacement
• Marfans
• Homocysteninuria
• Marfans UP

• Homocysteninuria DOWN
Glaucoma
Define
 Define
• Optic Neuropathy with disc cupping
Two features
• Visual field defects
• > IOP
Normal IOP + raised IOP
• Normal 10 – 22
• Average 15

• > IOP > 22

Pathogenesis
• > IOP
• Ischaemia
• Axonal loss
• Visual field defects
 Types
• POAG
• Secondary
• Congenital
 POAG
Define
Define
•Pressure > 22
•Cupping + visual loss
•Angle of lens normal

Angle measured with Goniscopy

POAG risk factors
• Age
• Race
• Fmhx
• MYOPIA
• Retinal ds: retinitis pigmentosa
• > IOP
 POAG clinical signs
• > IOP
• Optic disc cupping
• Visual field deficits
• > IOP
• Optic disc cupping
• Visual field deficits
POAG Mx
• Medical
– Prostaglandin analogues (> outflow)
– BB (< production)
– Carbonic anhydrase –ve (< production)

• Lazer
– Trabeculoplasty

• Surgical
– Trabeculectomy
Prostaglandin anologues
•SE: > Eyelash length / iris hyperpigmentation

Surgery failure
•Fibrosis
•Fistula blockage
NORMAL TENSION GLAUCOMA

OCCULAR HYPERTENSION
 Secondary Glaucoma
• What it and what causes it
Secondary glaucoma pathophysiology
• > IOP
• Blockage of trabecular meshwork

Causes:
- Blood
- Inflammatory cells
- Pseudoexfoliative material
- Angle recession
- Rubeosis iriditis
 Secondary Glaucoma
Pseudoexfoliative Glaucoma
•Material deposited on anterior chamber + angle
•This loss of material = zonules

Zonules hold lens in place…….

……huge risk of lens dislocation with CATARACT surgery
 Secondary Glaucoma
Neovascular Glaucoma = Rubeosis Iriditis

•Causes = retinal ischaemia

– DM
– Venous blockage

New blood vessels grow into angle of lens

Management??????????????????
Mx = PRP LAZER
RETINAL SURGERY = vitrectomy
 Phagolytic glaucoma
• Hyper mature cataracts leak protein blocking
angle
 Traumatic glaucoma
• Red cells block angle

Tx:
• Medical drops
• Surgical evacuation of blood
 Angle recession Glaucoma
• Blunt trauma to eye closes angle

NOTE: special considerations here is………

• Risk of glaucoma for many years so…….
……….must be followed up for many years
DIABETIC RETINOPATHY
• DM1 ….40%
• DM 2….20%
Risk factors
• Duration
• Poor metabolic control
• Pregnancy
• Hypertension
• Nephropathy
Benefits of intensive metabolic control
• Delays onset
• Slows progression
• Decreases rate of conversion
• Decreases need for lazer
Pathogenesis
• Microvascular occlusion
• Retinal capillary ischaemia
• Neovascularisation

Neovascularisation
• Micro-aneurysms
• Leak  retinal oedema
• Hard exudates
• BACKGROUND
• MACULOPATHY
• PRE-PROLIFERATIVE
• PROLIFERATIVE
• ADVANCED DIABETIC DISEASE
BACKGROUND
• Micro-aneurysms

• Haemorrhages

• Retinal oedema

• Hard exudates
 Background management
• Annual review
Maculopathy
• Focal exudative

• Diffuse exudative

• Ischaemic type
Tx maculopathy
• Focal  focal lazer

• Diffuse  anti VEGF (ranibizumab = lucentis)

• Ischaemic
• NEVER LAZER!!!!!
• Glucose control + blood pressure
PRE- Proliferative
• Venopathy
• Cotton wool spots
• Flame haemorrhage
• IRMA

Intra-retinal micro-vasc abnormalities

Pre-Proliferative mx
• Tight control of DM + HTN
Proliferative
• NVD
• NVE
• Vitreous haemorrhage
 Proliferative Mx
• PRP lazer
ADVANCED
• Pre-retinal haemorrhage

• Vitreous haemorrhage
Advanced Tx
• Vitrectomy

Note: 20% change of visual loss (complete)

 Screening
Visual acuity
Fundus exam ………………..…use topicamide 1% / phenylepherine 10%

•All DM > 12 yo
• Annual
– Background

• Early referral
– Background close to fovea
– Maculopathy
– Pre-Proliferative

• Urgent
– Proliferative
– Haemorrhage
– Rubeosis Iridis
– Retinal detachment
RETINAL vascular DisORdeRs
 Venous
• central retina vein occlusion (crvo)
• Branch retinal vein occlusion (brvo)
Causes of venous occlusion
• Diabetes
• Hypertension
• > viscosity
• > IOP
Sn
• Sudden onset of loss of vision

• Signs
– Tortuosity
– Flame haemorrhages
– Retinal oedema
– Cotton wool spots
 Prognosis
• Better for BRVO as develop collaterals within 6
months

• CRVO: poor prognosis due to macula ischaemia

 Rubeosis Iridis
• 100 day glaucoma
• PRP
 Central retinal artery occulsion
• CAUSES 3
1. Atherosclerosis
2. Embolism
3. Giant Cell Arthritis
Clinical features
• Sudden profound loss of vision
• RAPD
• Retinal cloudiness
• Cherry red spot on macula
 Hypertensive retinopathy
• Systemic > 140 / 90
• HALL MARK =
• Hallmark = SEGMENTAL arterial narrowing
 Clinical picture
• Arterial narrowing
• Vascular leakage
• Haemorrhage  oedema  hard exudates
• Swelling of optic nerve head = papilloedema
• Arteriosclerosis
– AV nipping
– Copper wiring
– Silver wiring
 Keith wagner scale of HTN
• Silver wiring
• AV nipping
• Cotton wool / haemorrhage / exudates
• Papilloedema
Thyroid
Ddx white reflex
 Ddx white reflex
• Congenital cataract
• Retinoblastoma
Ddx new onset floaters
 Ddx new onset floaters
• Retinal detachment
• Vitreous haemorrhage
• Severe Iritis
Ddx flashing lights
 Ddx flashing lights
• Migraine
• Retinal detachment
• Occipital lobe ischaemia
Ddx Painful red eye
 Ddx Painful red eye
• Uveitis
• Corneal infection
• Acute closed angle glaucoma
DDx haemorrhagic retinopathy
 Ddx Haemorrhagic retinopathy
• Diabetic
• HTN
• Retinal vein occlusion
Ddx Swollen ON head
 Ddx Swollen ON head
• > ICP
• HTN
• ON
• Central retina vein occlusion
Ddx painless loss of vision
 Ddx painless loss of vision
• Vitreous haemorrhage
• Optic nerve occlusion
• GCA (ischaemic optic neuropathy)

• Retinal detachment
• Retinal artery occlusion / Retinal vein occlusion
• Papilledema
• Amarousis fugax
Sudden loss of vision in young
 Sudden loss of vision in young
• Optic neuritis
• Retinal detachment
• Central serous retinopathy
Sudden loss of vision in elderly
 Older
• Vascular causes: GCA / thrombosis / embolism
• Retinal haemorrhage
• Vitreous haemorrhage
• Stroke
• Wet MD
Gradual onset in vision loss
 Gradual loss of vision
• Cataract
• Glaucoma
• Presbyopia
• Retinopathy  DM / HTN
• Optic neuropathy
Transient loss of vision
 Transient loss of vision
• Child = > ICP
 
• Young = Acephalic migraine

• Elderly = Amaurosis Fugax