A 49 year old man undergoes laparoscopic cholecystectomy for acute cholecystitis. After surgery he develops shoulder tip pain.
What is the likely cause?
Correct Answer D: When the gallbladder is removed there is a high chance of irritation of the nearby diaphragm. The C3,C4,C5 nerves innervate the diaphragm. (‘C3C4C5 keep the diaphragm alive’).
These nerves innervate the dermatome region of the shoulder and if irritated can cause pain in the shoulder.
A 45-year-old woman presents with a problem on her toe. She first noticed an ulcer under her toe a year ago that has progressed to the present state. Physical exam reveals an ischemic ulcer on the second toe in a patient with critical limb ischemia. The surrounding skin is cool to touch.
What would you do next?
Correct Answer C: Arterial ulceration is due to a reduced arterial blood supply to the lower limb. The most common cause is atherosclerotic disease of the medium and large sized arteries. Other causes include diabetes, thromboangiitis, vasculitis, pyoderma gangrenosum, thalassaemia, and sickle cell disease, some of which may predispose to the formation of atheroma. Arterial ulceration typically occurs over the toes, heels, and bony prominences of the foot. Increasing the peripheral blood flow by, for example, reconstructive surgery or angioplasty is the intervention most likely to affect the healing process in arterial ulceration. Operative indications for chronic ischaemia include non-healing ulceration, gangrene, rest pain, and progression of disabling claudication. The patient should stop smoking, and control of diabetes, hypertension, and hyperlipidaemia should be optimized. Patients may find benefits from sleeping in a bed raised at the head end. Patients should follow simple advice on foot and leg care. Walking is beneficial. Patients with rest pain or worsening claudication, or both, and a non-healing ulcer should be referred to a vascular surgeon (choice C); opioid analgesia may be necessary during the wait for surgery.
→ It is not appropriate to debride arterial ulcers (choice A) as this may promote further ischaemia and lead to the formation of a larger ulcer.
→ Infection, which is not seen in this patient, can cause rapid deterioration in an arterial ulcer, and treatment with systemic antibiotics (choice B) should be started.
→ Vasoconstrictive drugs such as non-selective beta-blockers (choice D) should be avoided.
→ This case describes arterial ulceration, not a fungal infection (choice E).
A 45-year-old female came to you for a routine medical check up. You found two stones in the gall bladder. She has no active diseases and no symptoms.
What would you like to do?
Correct Answer A: This is a case of asymptomatic cholelithiasis (gallstones). Most gallstones (60-80%) are asymptomatic. Vital signs and physical examination findings in asymptomatic cholelithiasis are normal. These are generally patients with an incidental finding of gallstones. Asymptomatic gallstones are often found incidentally on plain radiographs, abdominal sonograms, or CT scan for workup of other processes.
Surgical treatment of asymptomatic gallstones without medically complicating diseases is discouraged. The risk of complications arising from interventions is higher than the risk of symptomatic disease.
→ Cholecystectomy (surgical removal of gallbladder) is not indicated.
→ Cholecystostomy, the establishment of an opening into the gallbladder, usually for external drainage of its contents is also not indicated in this patient.
→ Approximately 25% of patients with asymptomatic gallstones develop symptoms within 10 years. For asymptomatic gallstones, medical therapies are rarely used because they require long-term therapy, may have adverse reactions or complications, and recurrence of gallstones is relatively common (25% within 5 years).
A 68 year old male suffers sudden mid abdominal pain. He is pale and diaphoretic but elicits no intensity of pain during abdominal palpation.
What is the most likely diagnosis?
Correct Answer A: Acute mesenteric ischemia is a sudden blockage of blood flow to part of the intestines, which may lead to gangrene and perforation (puncture). At first, the person has severe abdominal pain, usually developing suddenly, but the abdomen is only slightly tender when the doctor presses it. This pain out of proportion to tenderness is a very important clue in the diagnosis.
It can be caused by an arterial embolism, which is a blood clot or piece of atherosclerotic plaque material that travels from its origin in the heart or aorta to lodge in the smaller arteries that supply blood to the intestines. If the person has typical presentation, he/she will be taken right to surgery. At surgery, the blood vessel blockage can sometimes be removed or bypassed but sometimes the affected intestine must be removed.
Cecal volvulus would present as pain in the right lower quadrant. Diverticulitis presents most commonly in elderly patients as pain in the left lower quadrant, both in the history and during physical exam.
Appendicitis would be the right lower quadrant and would elicit tenderness to palpation, in particular at Mcburney’s point. Colon cancer would present as hematochezia, weight loss and positive family history.
A 79-year-old white male presents with a 4-hour history of acute abdominal pain. He indicates that the pain is severe and intermittently screams with discomfort. The abdomen is soft with minimal diffuse tenderness. There is no abdominal guarding or localized tenderness. Bowel sounds are Hypoactive and vital signs are unremarkable. There is no psychiatric history or history of prior abdominal surgery.
Which one of the following is the most likely diagnosis?
Correct Answer A: Mesenteric ischemia is a manifestation of atherosclerotic disease. The elderly and those with vascular disease are at risk. The pain is normally disproportionate severe when compared to physical findings, which are often minimal.
Perforated peptic ulcers often present with abdominal guarding, if not the characteristic board-like rigidity. Appendicitis, cholecystitis, and diverticulitis typically present with abdominal tenderness or guarding in the characteristic locations. Findings may be more subtle in the elderly, as the apparent pain is usually proportionately less; the elderly tend to have a higher pain tolerance than younger patients.
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