PG Cases1-40

banner-drogheda

Case #040


PG Case 40

50 year old lady, day 7 post op Hartmann’s operation for perforated diverticulitis of sigmoid colon started spiking temperature and had high WCC and CRP. CXR was done as part of septic screen. Can you appreciate the findings?

This is an erect Chest Xray taken in PA view. It shows a large right sided pleural effusion with lower lobe atelectasis and a smaller effusion on the left side. There is some perihilar atelectasis on the right side as well. The pulmonary vasculature, cardiac and mediastinal outlines appear normal. The patient had developed a lower respiratory tract infection secondary to the atelectasis and retained secretions. She was treated with IV antibiotics and aggressive chest physiotherapy.
Atelectasis is one of the most common pulmonary complications after abdominal surgery. It is usually managed with aggressive chest physiotherapy and good analgesia. If patients are hypoxemic, positive airway pressure (CPAP) may be beneficial. Those with abundant secretions may require regular suctioning. Small pleural effusions are also not uncommon after abdominal procedures. They tend to resolve spontaneously and usually no intervention is required. Occasionally they can be para-pnuemonic or secondary to a sub phrenic collections.

Case #039


PG Case 39

You are the intern on call and asked to urgently review a patient in respiratory distress post insertion of central line. On examination you noticed a large swelling around the insertion point at the neck. What is the diagnosis?

Respiratory distress secondary to haematoma formation in the neck following central line insertion.
Other complications of central line insertion include:

  • Pneumothorax
  • Infection
  • Air embolism
  • Arryhtmias
  • thrombosis

Case #037


PG Case 38

A 35 year old lady with chronic right iliac fossa pain underwent laparoscopy that showed a dilated appendix. It was converted to open surgery and an appendectomy was done, taking good margin from the base of the appendix. Can you identify the appendicular pathology on this specimen?

The picture shows a specimen of an appendicular mucocele. You can appreciate that the appendix is dilated and on opening the specimen it is filled with mucoid material. Appendicular mucoceles could be simple retention cysts due to obstruction from a faecolith or they can result from mucosal hyperplasia, mucinous cystadenoma or mucinous cystadenocarcinoma. Rupture can lead to intraperitoneal spread of neoplastic cells resulting in mucinous ascites/psuedomyxoma peritonei.
The histology result of this patient showed a low grade mucinous appendicular neoplasm with clear resection margins. It is very important to prevent spillage during surgery and therefore open approach is preferred to laparoscopic resection in case of appendicular mucoceles.

Case #037


PG Case 37

A 40 year old man was referred to surgical service after a mass was discovered in his left adrenal gland. He was diabetic and hypertensive. He also complained of weight gain, easy bruising, leg swelling and mood changes. Can you appreciate any related findings on abdominal inspection?

On abdominal inspection of this patient we can appreciate truncal/central obesity and purple striae. His signs, symptoms and investigations pointed towards cushing syndrome secondary to a cortisol secreting adrenal adenoma. He was started on metyrapone and subsequently underwent unilateral adrenalectomy.
Features of cushing syndrome include weight gain, moon facies, easy bruising, buffalo hump, abnormal hair growth, leg swelling, stretch marks, hypertension, diabetes, peptic ulcer, mood changes, paper thin skin, plethora, muscle weakness and menstrual disturbances in women. The most common cause of cushings is iatrogenic administration of high dose steroids. Excess cortisol in the body can also occur due to ACTH secreting pituitary tumor, cortisol secreting adrenal adenoma or ectopic ACTH production, for example, from a small cell lung cancer.

Case #036


PG Case 36

55 year old man presented with anemia and weight loss. CT colonography was done initially that showed an apple core appearance. Subsequently he underwent colonoscopy. Can you identify the pathology encountered?

The picture shows a circumferential stenosing tumor of the colon. The lumen was so narrow that it was not possible to pass the endoscope through it. The lesion seen on colonoscopy corresponded to the apple core appearance demonstrated by CT colonography. Multiple biopsies were taken from the tumor for tissue diagnosis. Histology confirmed it to be a moderately differentiated colonic adenocarcinoma. Since the tumor was located in the ascending colon near the hepatic flexure, the patient underwent a right hemicolectomy with a primary anastomosis between the ileum and the transverse colon.

Case #035


PG Case 35

55 year old man presented with anemia and weight loss. A CT colonography was performed. Can you identify the findings on this CT colonography image?

This film from the CT Colonography, shows an apple core sign in the ascending colon near the hepatic flexure. It also demonstrates a tortuous sigmoid colon at the bottom.“Apple core” is used to describe findings of a short segment of irregular circumferential thickening of the large bowel that has abrupt “shouldered” margins resembling an apple core. The appearance is classically described on contrast enema studies and is mostly due to a stenosing annular colonic carcinoma.

Case #034


PG Case 34

Day 4 post Laparotomy. What is the Diagnosis?

This photo shows a complete wound dehiscence. The suture has cut through fascia and lying loose in the abdominal wound. Abdominal wound dehiscence (burst Abdomen, Fascial dehiscence) is a severe postoperative complication, with mortality rates reported as high as 45%. The incidence as described in the literature ranges from 0.4% to 3.5%.
Abdominal wound dehiscence can result in evisceration, requiring immediate treatment. It will lead to a prolonged hospital stay, high incidence of incision hernia, and subsequent reoperations underline the severity of this complication.

Case #033


PG Case 33

45 year old lady presented with RIF and lower abdominal pain. What is this structure and what is the diagnosis?

The image shows the uterus with multiple fibroids bulging from the outer surface. Her appendix was normal. This incidental finding was reviewed inta-operatively by the gynaecologist and she was managed conservatively with further follow up arranged in gynaecology OPD.

Case #032


PG Case 32

27 year old lady presents with a complaint of pain in the medial aspect of her left big toe nail. She has suffered from repeated infections at this site in the past. What is your spot diagnosis on examination?

The picture shows an in growing toe nail. The medial edge of the nail is growing into the peri-ungal skin causing pain and recurrent bacterial infections. It is sometimes associated with wearing tight fitting shoes. The patient should be encouraged to wear correctly fitting footwear and cut nails horizontally. Acute infection is treated with antibiotics, however, nail avulsion is sometimes done in the presence of gross sepsis. Wedge excision is the treatment of choice and can be carried out in local anesthetic. It involves excising the ingrowing nail edge along with the germinal matrix to avoid this part of the nail growing back. Complications include infection, bleeding and recurrence.

Case #031


PG Case 31

25 year old presented with 24 hours upper abdominal pain. What is this intra-operative finding?

The patient had a small perforated peptic ulcer. This could be managed laparoscopicaly or via small upper mid line laparotomy. In this case the patient had a small upper mid line incision were the abdominal cavity was washed and the patient had an omental patch to close the defect.


Case #030


PG Case 30 A
PG case 30 B

70 year old lady presented with non-healing breast ulcer. What is the likely diagnosis?

The Lady has advanced left breast cancer. Form the lower image you can appreciate axillary fullness. She had multiple large fixed axillary lymph nodes. She had core biopsies to establish the tumour type and receptor status (hence the bandage in the upper picture). This patient is stage 4 locally advanced breast cancer with lymph nodes involvement. Her staging scans showed liver and bony metastasis.


Case #029


PG Case 29

A 23 year old girl presented to the ED with abdominal pain and persistent vomiting. A vague mass was palpable in the epigastrium. CT scan showed a mass filling the entire stomach. Detailed history revealed that she had habit of pulling and eating her hair. Can you name the mass taken out from the stomach of this girl?

This mass of hair is called trichobezoar. The girl had habit of pulling and eating her own hair (Trichophagia). Over time the trichobezoar had become so big that it caused gastric obstruction. Very rarely, the tail of the trichobezoar extends in the small bowel. This is called Rapunzel Syndrome.The girl had to undergo laparotomy and the trichobezoar was removed through a gastrotomy made in the anterior wall of the stomach. She subsequently recovered well and was referred on to the psychiatric service.

Case #028


pg-case-028

25 year old boy presented to the ED with food bolus stuck in throat. He swallowed a piece of beef steak without chewing properly. A X ray soft tissues of neck, lateral view was taken. Can you identify the food bolus on the X ray and recall your knowledge of anatomy to identify the other marked structures?

1 hyoid bone, 2 thyroid cartilage, 3 trachea, 4 food bolus, 5 epiglottis
The oesophagus has 3 constrictions in its vertical course, the first constriction is at 15 cm from the upper incisor teeth, where the oesophagus commences at the cricopharyngeal sphincter; this is the narrowest portion of the esophagus and approximately corresponds to the sixth cervical vertebra. The food bolus was stuck at this level in this particular patient. The second constriction is at 23 cm from the upper incisor teeth, where it is crossed by the aortic arch and left main bronchus. The third constriction is at 40 cm from the upper incisor teeth, where it pierces the diaphragm; the lower esophageal sphincter (LES) is situated at this level.
Treatment usually involves OGD and either to push the food bolus down into the stomach or take it out piece meal. Possible complications of the procedure include perforation, bleeding and aspiration.

Case #027


PG-Case-027

A 47 year old male presented to ED with one day history of colicky abdominal pain, abdominal distention, vomiting and absolute constipation. He has background history of open appendectomy, done 25 years ago. A PFA was done for him. What is the most likely diagnosis looking at the PFA?

The PFA (plain film abdomen) shows multiple dilated loops of small bowel. Given the history, it would be consistent with a diagnosis of small bowel obstruction due to adhesions. Adhesions due to previous surgery would be the most common cause of small bowel obstruction followed by hernias, tumours and crohn’s disease. Small bowel can be identified on the X ray by central position in the abdomen and valvulae conniventes which are mucosal folds that cross the full width of the bowel. In contrast, large bowel will be peripheral in position in the abdomen (transverse and sigmoid colon may be variable), will show haustra and may contain faeces.This gentleman was treated conservatively with “drip and suck”. He was made NPO, nasogastric tube was inserted with intermittent suction, IV fluids were administered. Hourly urine output was monitored with a catheter to access adequacy of resuscitation. IV fluids should account for pre-existing fluid deficit, ongoing losses and maintenance volume. His electrolytes were also closely monitored and replaced. He gradually improved and did not require an operation.

Case #026


pg-case-026

68 year old man presented to ED with large ulcerating, painless mass from the left upper chest present for 12 months. Can you guess the diagnosis?

Pleomorphic Undifferentiated Sarcoma or previously malignant fibrous Hystiocytoma. A histiocytoma is a tumour consisting of histiocytes.PUS is regarded as the most common soft tissue sarcoma of late adult life. It occurs more often in Caucasians than in those of African or Asian descent and is a male-predominant disease.
Metastasis is common to lungs (90%) bone and liver.
Essential Imaging include CT TAP for staging and MRI of the lesion, however biopsy is required for definitive diagnosis.
Treatment consists of surgical excision (ranging between tumour excision to limb amputation) and some cases radiation.

Case #025

pg-case-025

You are called by the medical team who are concerned about the findings on this CXR. What is the diagnosis?

This erect chest x-ray nicely demonstrates Chilaiditi syndrome, one of the causes of pseudopneumoperitoneum and occurs when bowel gas is interposed between the liver and the hemidiaphragm resulting in pain. Gas in this position may be misinterpreted as true pneumoperitoneum resulting in further imaging, investigation and treatment that is not required.
This condition is named after Dr Demetrius Chilaiditi (1883), Greek radiologist who described the radiographic findings in 1910 3; Vienna, AustriaPain distinguishes Chilaiditi syndrome from colonic interposition.
X-ray features that suggest a Chilaiditi syndrome (termed the Chilaiditi sign) include:

  • gas between liver and diaphragm
  • rugal folds within the gas suggesting that it is within the bowel and not free


Case #024


pg-case-024


A 33 year old man presented with left flank pain radiating to the groin. Urine dipstick showed 3+ blood. Can you identify the cause on the PFA?

The PFA shows a ureteric calculus at the vesicoureteric junction (marked by the arrow). CT KUB done subsequently showed a 7mm calculus at the vesicoureteric junction causing proximal hydroureter and hydronephrosis. Sometimes phleboliths in the colon can give similar appearance. If the ureteric stone is less than 5mm it is usually managed conservatively as there are good chances for it to pass spontaneously. However stones larger than that and causing obstruction need to be removed by the urologist. Distal ureteric stone like this one can be removed by ureteroscopy.


Case #023


pg-case-023


52 year old man presented to the ED with history of right upper quadrant pain for the past 2 days, associated with nausea and vomiting. On examination he was very tender in the right upper quadrant. His bloods revealed a high CRP and WCC. Abdominal ultrasound was done for him. Can you appreciate the findings on the ultrasound abdomen?

The ultrasound picture shows stones in the gallbladder along with thickening of the gall bladder wall, which would be consistent with a diagnosis of acute cholecystitis. The thin arrow points towards stones in the gall bladder lumen and the thick arrow shows the acoustic shadows casted by the calcium containing stones. The astericks indicate the thickened wall of the gall bladder. Cholelithiasis along with thickened gallbladder wall and pericholecystic fluid are sonographic evidence to prove the clinical diagnosis of acute cholecystitis.


Case #022


pg-case-022


A 30 year old man presented to the ED after a road traffic accident with dyspnea. A life-saving procedure was performed in the ED. Can you identify the finding on the chest X ray and imagine what the initial problem would have been?

The chest X ray shows a chest tube in situ and some sub cutaneous emphysema on the left side. The man initially presented to the ED with a tension pneumothorax, from the road traffic accident. Urgent left sided chest intubation was done at that time in the ED. A gush of air came out on opening the pleural cavity for chest tube insertion. The patient received regular chest physiotherapy and good analgesia in the hospital. This chest X ray is three days post chest intubation and shows that the lung is completely expanded. The chest tube was subsequently removed as its purpose had been served.


Case #021


pg-case-021a
pg-case-021b


46 year old man with complaint of vague left lower limb pain especially on standing or walking for long time, presented to the surgical outpatients. What is the most likely diagnosis on inspection?

The picture shows varicose veins of the lower limb, one of the common presentations to the surgical outpatients. Varicose veins occur do to incompetence of venous valves. Secondary causes of varicose veins include pelvic masses like pregnancy, fibroid, ovarian tumour etc or pelvic venous abnormality like after pelvic surgery, irradiation or previous DVT.
Complications include eczema, excoriation, phlebitis, lipodermatosclerosis, ulceration or bleeding. Colour Duplex is done to define anatomy and site of incompetence. Treatment options include surgery involving, saphenofemoral or saphenopopliteal junction ligation, stripping of great saphenous vein and stab avulsion. Microsclerotherapy, foam sclerotherapy, endovascular laser therapy or endovenous radiofrequency ablation are other treatment options.

Case #020


pg-case-020a
pg-case-020b

A 60 year old diabetic man presented to the ED with severe right upper quadrant pain associated with nausea. He was clinically septic. After confirmation of diagnosis on USG abdomen he was initially managed conservatively with IV antibiotics. His condition further deteriorated rather than improving during the next 24 hours. Decision was made to perform laparoscopic surgery for definitive treatment of his condition. Can you identify the gangrenous structure in these pictures that were taken during the laparoscopic surgery?

The pictures show a gangrenous gall bladder with the omentum wrapped around it, as seen at laparoscopy. The omentum was separated and cholecystectomy was performed. It was difficult procedure as tissues were very friable and oedematous but it was completed laparoscopically. The patient improved dramatically in a few days after his surgery.
Gallstones can cause acute cholecystitis. Gangrenous gall bladder is the most common complication of acute cholecystitis. It occurs particularly in older people, diabetics and those who delay in seeking medical treatment. These patients present with sepsis along with other signs and symptoms of acute cholecystitis. Perforation can follow leading to pericholecystic abscess or generalized peritonitis. Laparoscopic cholecystectomy has been shown to be safe in the acute stage but if surgery is deemed very high risk, radiology guided percutaneous cholecystostomy can help settle the acute inflammation and definitive surgery can be carried out later on at an elective setting.

Case #019


pg-case-019
pg-case-019b

A 35 year old lady presented with vague left upper quadrant pain for past 4 -5 months. A mass was palpable in the left hypochondrial region. She gives history of blunt abdominal trauma 6 year ago. No intervention was required at that time. CT abdomen was done to investigate the palpable mass. Can you identify the finding on CT images?

The axial and coronal sections on CT scan demonstrate a large calcified splenic cyst, most likely traumatic in nature. Splenic cysts are rare. Only 25% are non parasitic. Of these, about 80% are secondary to trauma. They mostly present as an incidental finding or with non specific symptoms due to mass effect such as vague abdominal pain, shoulder tip pain, hydronephrosis, reflux symptoms or palpable lump in the left upper quadrant. Splenic cysts greater than 5 cm and causing symptoms may require surgery. Surgical options include partial or total splenectomy, cystectomy, decapsulation or fenestration of cyst. Laparoscopic approach is favorable if expertise is available.


Case #018


pg-case-018

A worried 18yF attends breast clinic re: a smooth lump in her breast which changes size with her cycle. What is the most common dx? When do we treat?

In this age group, the most common diagnosis is fibroadenoma, a benign condition. Ultrasound is preferred over mammography to examine the dense glandular breast tissue in this age group. Symptoms may be managed by cycle control (eg. With an oral contraceptive), simple analgesia and evening primrose oil.. Patients should be reassured that these lesions are not malignant and should only be excised when large as the resultant scar tissue could make the interpretation of mammograms later in life more difficult. No follow up is required. Elective excision is usually offered when fibroadenomata are greater than 3 cm.


Case #017


pg-case-017

Remember the method for describing an ulcer that the Consultant Vascular Surgeon taught you? Test yourself with this & come up with a dDX?

pg-case-017-answer


Case #016


pg-case-016

You are called to a 44yM day 1 post laparotomy who is hypotensive, somnolent and has pinpoint pupils and shallow respirations. What is the likely Dx and Rx?

There are many reasons for post-operative hypotension, including hypovolemia and sepsis. In this instance, however, the patient had been prescribed intravenous morphine as a Patient-Controlled Analgesia (PCA) regimen. The case describes some of the effects of morphine overdose (others being itch from histamine release by mast cells, and nausea from the action of morphine on receptors in the chemoreceptor trigger zone, and constipation and vomiting due to the inhibition of peristalsis).
The treatment is administration of naloxone; however the patient should continue to be monitored as the half-life of naloxone is shorter than that of circulating morphine.


Case #015


pg-case-015

A 54yoM company director presents with a 2/7hx of RIF pain, fever & this CT is ordered by the ED. He asks you about the treatment options.

While acute appendicitis is more commonly a disease of childhood, it has a second peak of incidence in late adulthood, and should remain a differential diagnosis in the febrile patient with RIF pain, anorexia, nausea and usually a leucocytosis and an elevated CRP. While the traditional treatment of non-perforated (simple) appendicitis has been appendicectomy via open or laparoscopic technique, the antibiotic treatment of appendix abscess and of appendicitis in those not fit for an operation has taught us that a proportion of patients can be treated with antibiotics instead of operation and that only a small minority (15%) have recurrent appendicitis requiring operation.


Case #014


pg-case-014

A 14yo has sudden excruciating pain in his left hemiscrotum. The left testis is found to lie high in an otherwise normal-looking scrotum. Likely Dx?

This boy has a sudden painful hemiscrotum,and there is no penile discharge or inguinal lymphadenopathy. Blood and urine laboratory tests are normal. It is likely, given the history and age profile, that this represents a testicular torsion. Torsion most commonly occurs in males between age 10-25 yrs, although a few cases occur in infancy.
Severe pain of sudden onset, with the testis high lying and tender with a thickened tender spermatic cord. Erythema of the scrotum occurs after 6 hours. By way of differential diagnosis, elevation of the testis partly relieves the pain of epididymo-orchitis in the older patient.


Case #013


pg-case-013

This 19yoM restrained passenger was brought to the ED following an RTA. Initially stable but complaining of left shoulder pain, he became hypotensive in the CT scanner. What’s the diagnosis?

This axial image from an abdominal CT scan shows a Grade IV splenic injury, with hemoperitoneum (free blood within the abdominal cavity) and injury to the splenic hilum. This is a life-threatening injury. The patient is in haemorrhagic shock and requires immediate transfer to the operating theatre for splenectomy.
Bonus: Following splenectomy, patients must be vaccinated against the encapsulated organisms (pneumococcus, meningococcus and Haemophilus influenzae).


Case #012


pg-case-012

This clinical image was taken during a procedure on a 56yM who had been previously been admitted with LIF abdo pain. What’s the diagnosis?

This is a photograph taken during a colonoscopy. The lumen of the sigmoid colon is clearly visible, as are the haustrae of the bowel wall. Numerous accessory lumens are seen in the bowel wall, representing the neck of outpouchings known as “diverticulae”. It is likely the patient in the scenario had an episode of acute diverticulitis, a common condition in this age group. Stay tuned for a radiologic image from this man in a later tweet.


Case #011

pg-case-011
pg-case-011-b

A 70 year old man was referred by his GP with recent onset fresh bleeding PR. He had also noticed change in his bowel habit towards the need to go more frequently. He had no history of weight loss or family history of bowel cancer. An urgent full colonoscopy was done for him. This lesion was encountered in the descending colon. What is your opinion about the lesion on gross morphology and what would be treatment for it.

The picture shows a neoplastic lesion in the descending colon which is broad based and nearly circumferential. The black discoloration of the mucosa around the lesion in the second picture is due to tattooing. The lesion was too large to be snared endoscopically. Therefore multiple biopsies were taken to get the histological diagnosis. Although such a large, fungating lesion would be very highly suspicious for a carcinoma, the histology for this particular lesion showed it to be tubulovillous adenoma with low grade dysplasia. Colonic adenomas, over time, can develop high grade dysplasia and eventually carcinoma in situ leading to invasive cancer. To prevent it from becoming a malignant lesion, it is essential to remove it completely. As it was not amenable to endoscopic resection, he underwent left hemicolectomy with primary anastomosis.


Case #010

pg-case-010

A 32 year old man underwent laparotomy for small bowel obstruction. The cause was found to be an adhesion extending from this structure almost 2 feet from the ileocaceal junction. Can you identify the structure.

This is a Meckel’s diverticulum. Meckel’s diverticulum is the most common congenital anomaly of the gastrointestinal tract, remanent of vitteline duct. The rule of 2 describes the essential features. It occurs in about 2% of the population, is found about 2 feet from the ileocecal valve, and is about 2 inches long. Approx 2 percent of patients develop a complication over their lifetime, and the male to female ratio is 2:1. It is often clinically silent, particularly in adults. Meckel’s diverticulum can present with gastrointestinal bleeding or acute abdominal pain related to bowel obstruction, Meckel’s diverticulitis, or perforation. It can sometimes harbor ectopic gastric mucosa. Diverticulectomy or segmental small bowel resection is done depending upon the pathology.


Case #009

pg-case-009

22 year old girl with history of hemolytic anemia and recurrent episodes of right upper quadrant pain underwent laparoscopic surgery. Can you identify the specimen and explain the cause of the pathology.

This is specimen of the gall bladder of the young girl suffering from hemolytic anemia, opened up to show black pigment stones.
Gall stones can present with recurrent attacks of upper abdominal pain (biliary colic), acute cholecystitis, chronic cholecystitis, mucocele, empyema, obstructive jaundice, cholangitis, pancreatitis or they may remain asymptomatic. Gall stones can be:

  • Pure cholesterol stones (10%)
  • Pure pigment stones (10%), are of two types:
  1. Black, associated with hemolytic disease
  2. Brown, associated with chronic cholangitis and biliary parasites
  • Mixed (80%), most common usually multiple

Investigation of choice for detecting stones in gall bladder is ultrasound and treatment is laparoscopic cholecystectomy.

Case #008

pg-case-008

45 year old lady presented with gradually enlarging swelling on her neck for the last two year. It was initially asymptomatic but now she had been experiencing dysphagia and difficulty breathing especially on lying down. She underwent surgery after investigations and failed non surgical treatment. What surgery, do you think, was done and can you identify and describe the gross morphology of the specimen.

She underwent total thyroidectomy. This is a fresh specimen of a multinodular goiter. Her pre-op investigations had showed euthyroid status and no suspicious features for malignancy were seen on ultrasound. The pathology report confirmed multinodular colloid goiter. She had no post operative complications of hypoparathyroidism or recurrent laryngeal nerve paralysis. The patient was advised to take lifelong thyroid hormone replacement (eltroxin).
Surgery is indicated in multinodular goiter for symptoms of local compression, enlarging dominant nodule, recurrent laryngeal nerve palsy, hyperthyroidism and cosmesis.

Case #007

pg-case-007
pg-case-007b

A 30 year old man presents with slowly enlarging multiple swellings on his scalp. He first noticed them about a year ago. Few months back one of them got painful and red. He had to take antibiotics for it to settle. Otherwise they don’t cause him any pain but he finds them unsightly and is very concerned. What is the most likely diagnosis?

This man had multiple sebaceous cysts on his scalp. Differential diagnosis on inspection only could be lipomas, however they would be less common on the scalp. Sebaceous cysts are also known as epidermal cysts, trichilemmal cysts or pilar cysts. They occur in the hair bearing parts of the body most commonly on the scalp, scrotum, neck and back. They are slow growing and are not painful. Pain, erythema and tenderness are signs of infection. If not settled with antibiotics, infected cysts can form an abscess which may require surgical incision and drainage. Treatment for non infected sebaceous cysts is complete excision with an ellipse of overlying skin containing the punctum, usually done under local anesthesia.



Case #006

pg-case-006-b

45 year old gentleman presented with one year history of gradually enlarging pre-auricular swelling. What is the most likely diagnosis on inspection.

This is a parotid swelling most likely pleopmorphic adenoma. Parotid if the largest salivary gland situated at the angle of the mandible. The facial nerve runs through the gland and divides in into superficial and deep lobes. Pleomorphic adenoma accounts for 80% of benign parotid tumors. FNA can be done to rule out malignancy. Treatment is superficial conservative parotidectomy, which involves removal of superficial lobe of parotid gland saving the facial nerve.



Case #005

pg-case-005

A 45 year old man presented with dyspeptic symptoms and epigastric pain. He had an OGD. Can you pick up the finding?

The picture shows a benign gastric ulcer at the pyloric region. It does not show any evidence of recent bleed. Rapid urease test was positive indicating presence of H. pylori. Treatment includes triple therapy with PPI, clarithromycin and amoxicillin or metronidazole for atleast 7 days. Topical antacids (gaviscon, sucralfate) may provide symptomatic relief. Advice to abstain from smoking, alcohol and NSAIDs.



Case #004

pg-case-004

A 78 year old man presented with 8 months history of a lesion on his cheek, gradually increasing in size. What is your diagnosis on inspection of the lesion. Explain.

This is a typical Basal Cell Carcinoma with rolled pearly edge and ulcerated centre. BCCs grow slowly with local infiltration and destruction of surrounding tissues, therefore are also called rodent ulcers. Lymphatic and haematological spread are rare. It occurs most commonly on the face. Treatment involves surgical excision with 2-5mm margins.


Case #003

pg-case-003

A 24yoF was the restrained driver in an RTA. Her abdominal pain worsened over 2 days and a laparoscopy was performed.

This photograph shows a still image captured during laparoscopy in a female driver who had worsening abdominal pain 2 days following admission. A laceration to the serosa of the cecum was noted in the right lower quadrant of the abdomen, where its attachment to the abdominal wall (Jackson’s veil) was avulsed due to a sudden deceleration in a restrained driver…remember that the seat-belt fixes you in space but your internal viscera will move to dissipate the energy, and are at risk at places where they are fixed, such as the cecum in this lady, and also her small bowel at the Ligament of Treitz (see bonus picture below; can you remember from anatomy where that is?).
pg-case-003-b


Case #002

pg-case-002

A 56yF presents to the ED with RUQ abdo pain, rigors & jaundice. Following stabilisation and initial investigations, the pictured test was performed.

This photograph shows a fluoroscopic image acquired during Endoscopic Retrograde Cholangio-Pancreatogography (ERCP), a diagnostic and therapeutic study. During ERCP, the Sphincter of Oddi is cannulated and radiopaque dye can be injected to visualise the biliary tree. Multiple faceted filling defects are shown in the dilated common bile duct; these most-likely represent gallstones impacted in the distal CBD, a condition called choledocholithiasis.
Bonus: The triad of RUQ abdo pain, fever with rigors & jaundice is known as Charcot’s triad and is associated with ascending cholangitis, an infection secondary to obstructive biliary stasis in choledocholithiasis and other conditions.



Case #001

pg-case-001

2 hours after biopsy of a lung nodule, your patient complains of shortness of breath and has an SaO2 of 85% on room air. Look at the pic. What do you do?

The most likely diagnosis shown in this erect chest radiograph is a right-sided tension pneumothorax. The next step in the management of this patient is to perform a needle decompression thoracostomy with a 18 gauge needle in the second intercostal space, mid-clavicular line on the affected side (Right). Following this, the definitive treatment for this patient’s pneumothorax is to place a thoracostomy tube / chest drain on the right side.
The main steps in placing a chest tube are:
Explain the procedure and, where possible, obtain informed patient consent
Patient supine, right arm flexed at elbow and abducted above head,
Sterile prep and drape
Anatomic landmarks – 4th or 5th intercostal space, anterior axillary line
Local anaesthesia – bupivicaine or lidocaine with adrenaline
5cm skin incision with scalpel.
Muscle-splitting blunt dissection down to parietal pleura, which is pierced with a firm push
Chest drain is placed over a trocar/on a large clamp into pleural space and aimed cephalad
Drain connected to underwater seal and sutured to the skin
Supplemental Oxygen
Post-procedure chest X-ray