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ANXIOUS MOTHER (PERFORATED APPENDIX) STEM - You are a surgical SHO on call for emergency general surgical admissions. A 10-year-old girl Sarah was brought by her neighbour as an emergency with peritonitis, Her mother was at work when she was told that her daughter is in hospital. The child Sarah, is febrile and extremely ill, A perforated appendix is suspected and she is being resuscitated by your registrar before being taken to the operating theatre. You've just arrived in the hospital for your shift and haven't seen the patient. Your consultant, Mr, Mann is on his way from home, and will perform the operation, She became anxious when she realize that Mr. Mann is the same surgeon who operated upon her husband and couldn't save his life. Considering this communication skills station, you are asked to talk to this anxious mother and answer her queries. Doctor: Hello, good evening, I'm Dr. Z, one of the surgical doctors. Am I talking to Sarah's mother? *Patient: It's not a good evening for me, doctor, at all. What's going on here? All of you have taken my child for an operation even without letting me know. How is this even possible?* Doctor: I was told to speak with you about your child condition. Can we please have a seat so that we can discuss about everything a bit more detailed? Could you first tell me what do you know so far? *Patient: My child had fever from yesterday; but still I went to my work. I have no clue, doctor. It's all happened because of not being in home.* Doctor: First, you don't have to feel guilty because this could happen anyway. Your daughter was brought by your neighbour complaining of tummy pain. Our initial investigation revealed the suspicion of acute appendicitis. She was managed by our registrar and received some TV fluids and antibiotics. We are now waiting for theconsultant who will operate upon her. *Patient Are you sure that my daughter has acute appendicitis?* Doctor: We are suspecting acute appendicitis as this is common condition and also her signs and symptoms denotes this. But we cannot be certain 100% until we open and see. Usually we do a keyhole first, then look for it. Then after observation we complete the procedure. if it ruptures and case general infection of your tummy, or if this failed, we need to convert it to open appendectomy by giving a small incision over right lower tummy. *Patient: Is it dangerous, doctor?* Doctor: In children specifically, there is less fat inside the abdomen, so perforation can be particularly dangerous. In such case your child may go to a higher care area called HDU. But Mr. Mann is a very good surgeon, I can assure you that your childis in very good hands. We will be looking after her but there are still some concerns. *Patient: Will the wound be disfiguring?* Doctor: A small horizontal wound will leave a little scar, but we may need to expand the wound and this may leave a bigger scar. We will try to make as little scar as possible. / As she is a girl, it's conecrning, but still we will try to make it as short as possible. *Patient: Is there any other problem that could occur?* Doctor: Yes, probably severe infection can block the reproductive tubes in young girls, so future sub fertility may happen. *Patient: Do you mean that she can’t get pregnant in the future?* Doctor: I understand your apprehension, no need to worry because she has another fine working tube on the other side. *Patient But Mr, Mann did operation for my husband, and he died,* Doctor: I am so sorry to hear that. Please accept my sincere condolences. May I ask when and how he died? *Patient: Mr. Mann did operation for him because he had colon cancer and he died few weeks after the operation at home.* Doctor I am so sorry to hear that again. I think those are two different situations. I think your husband died from the cancer not the surgery and Mr. Mann one of best surgeon we have in the hospital who has a vast experience on this, we will take good care of your daughter. *Patient: Can I change the consultant?* Doctor: Of course, you can because it's within your rights. But it’s time consuming as the new consultant will study the case from the beginning. As i's a suirgical emergency it will have a deleterious impact on your child health. So, I will not recommend you do that. *Patient: Can I see her?* Doctor: Obviously, you can see her. But she will be kept in observational room just after the operation. Once she regains her consciousness, you can definitely see her. Do you have any other concerns? *Patient: I just need to be everything ok for my child.* Doctor: Of course, my team is trying our best. Lets summarize what we have been through here. Your child has been brought here by your neighbour complaining of tummy pain. Our initial investigation revealed acute appendicitis and we are now waiting for the consultant to operate upon her, and I’ve explained the risks and benefits of this operation. We all are here to help and support you and to dive you a hand at any time. Should there be any concerns, please don’t hesitate to contact me at any moment. I will leave my bleep number at the nurse station. Thank you so much for your co-operation.

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S — Situation “Hello, it’s David, the SHO on Ward 4G. I’m calling about Mrs Eleanor Thompson, DOB 15/06/1942, who is post-operative day 2 following a right mastectomy with axillary lymph node clearance. She has developed new right axillary swelling, discomfort, and mild shortness of breath, and I’m concerned about a possible early postoperative complication.” B — Background “She has moderate COPD, mild left ventricular failure, and hypertension. Her surgery two days ago was uneventful with 150 mL blood loss, and a drain was inserted. Since yesterday, her temperature has been slowly rising from 36.9 to 37.2 today. Importantly, the drain has had no output today, and the axilla appears swollen and mildly tender. Her daughter is requesting discharge today due to family childcare pressures, but given the clinical changes I feel this is unsafe.” A — Assessment “On examination, she has a swollen right axilla, mild tenderness, and no drain output. Her pain is controlled, and observations are otherwise stable apart from very mild temperature rise. Her bloods today show: WCC 10.2, Hb 11.5, platelets 230. My concern is a postoperative seroma, haematoma, or possibly early infection, or a blocked drain. Given her comorbidities and mild SOB, I also want to rule out cardiopulmonary causes.” R — Recommendation “I’d like you to review her urgently, please. I’d appreciate guidance on whether to: Attempt drainage (needle aspiration) or re-site/flush the drain, Start empirical antibiotics, Arrange ultrasound of the axilla, And confirm whether you agree she should not be discharged today. Could you please come to review her on Ward 4G, or advise on the next immediate steps?”

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@evehiclefan@mathstodon.xyz Contents (NAVEL) Femoral Nerve, Femoral Artery, Femoral Vein, Femoral canal (Empty space), Lymphatics

@florianecaffart @Photosaurus hi hi merci !

Spinal Stenosis Doctor Instruction: Your next patient is a 51-year-old woman called Rebecca, presenting with lower back pain. Please take a history and perform an appropriate examination. Patient History: Rebecca, a 51-year-old female, nurse You have always been having lower back pain for the past few years, but this has been getting gradually worse. The pain is dull and intermittent. Very often, the pain can diffuse and radiate towards the buttocks, back of the thighs, and feet - when this happens, the pain feels like a burning or cramping sensation. It can be associated with weakness in both legs. The symptoms can be triggered or worsened by sitting down, standing straight and walking downhill. It goes away after a few minutes after being at rest. Bending forward improves symptoms. You tried paracetamol, which only helped a little with pain. If you walk for more than 50 yards, you will start noticing numbness and weakness in your legs. No previous injury/trauma. Waterworks normal. The bowels are working normally. No other abnormal sensations or weaknesses. No incontinence. No stiffness. No fever. No weight loss. No night sweats. Ideas, Concerns, Expectations: You think because you often have to bend your back due to work, the pain may be caused by poor posture. You are concerned because it is starting to affect your ability to work in the hospital as a nurse. You would like to see if you can get stronger painkillers and possibly have a scan of your back. Past Medical History: Obesity, hypercholesterolemia, acromegaly, T2DM. No past relevant surgical history. Drug History: Atorvastatin, metformin NKDA. Family History: Father has ankylosing spondylitis. Social History: You work as a senior nurse in a local hospital. You smoke around ten cigarettes daily for over ten years but don't drink alcohol. Live with husband in a semi-detached house. Independent. Examination Findings: Lower spinal tenderness on palpation at L4-5 region. Complete motor and sensory neurological examinations are normal. Features of acromegaly e.g. enlarged hands, feet and facial features. Lower limb vascular examination is normal. No cervical tenderness or restricted movement. Gait normal. No cauda equina syndrome features. Peripheral pulses and ABPI normal. Differentials: Lumbar spinal stenosis - likely to be due to degenerative changes Osteoarthritis of the spine To rule out cauda equina syndrome Ankylosing spondylitis/spondylolisthesis Rule out peripheral arterial diseases Other causes of back pain: spinal tumour, disc herniation, trauma, fracture, and epidural abscess. Investigations: Imaging: XR Lumbar spine (may show degenerative changes/spondylolisthesis) MRI Spine. Alternatively, CT myelography/spine when MRI is not available or unsuitable. Consider ABPI / CT angiogram to exclude peripheral arterial disease where intermittent claudications are present. Special tests: Consider electromyographic (EMG) walking test - increased F latency values in lumbar spinal stenosis Consider electromyographic paraspinal mapping Management: Conservative: Exercise Weight loss if overweight Physiotherapy e.g. exercises that minimally stress the back, such as walking, swimming, or bicycling. Exercise may also strengthen the paraspinal muscles. NSAIDSs e.g. naproxen, celecoxib +/- PPI cover / antacids Paracetamol Medication for neuropathic pain e.g. amitriptyline, gabapentin, pregabalin. Consider oral steroids for acute exacerbation of painful symptoms. Activity modification e.g. limit heavy lifting/prolonged sitting/repetitive bending/twisting of the back. Consider deep heat therapy with massage to relieve spasms associated with back pain Surgical: Consider decompression surgery +/- fusion e.g. laminectomy ( removal of the lamina from affected vertebra) followed by physiotherapy Consider interspinous distraction procedure to reduce backward movement of the spine. Consider epidural injections with local anaesthetic and corticosteroids under specialist guidance for short/long-term pain relief. Viva Questions: Explain the pathophysiology of spinal stenosis. Spinal stenosis is the narrowing of the spinal canal, which holds the spinal cord and nerves. It's often due to age-related disc degeneration, arthritis, and thickened ligaments. This narrowing can compress the spinal cord and nerves, leading to pain, numbness, and weakness. Factors like herniated discs and inflammation worsen the compression. Treatment involves pain management, physical therapy, and sometimes surgery to relieve pressure on the nerves and spinal cord. At what level of the spine does spinal stenosis occur most commonly? Spinal stenosis most commonly occurs in the lumbar (lower back) region of the spine. This is because the lumbar spine bears the most weight and undergoes significant movement, which can contribute to degenerative changes over time. Lumbar spinal stenosis can result in compression of the spinal cord and nerve roots, leading to symptoms such as lower back pain, leg pain, numbness, and weakness. However, spinal stenosis can also occur in the cervical (neck) and thoracic (mid-back) regions of the spine, albeit less frequently. What are the causes of spinal stenosis? Degeneration of spinal structures due to aging. Disc degeneration and herniation. Osteoarthritis and bone spurs. Thickened ligaments. Congenital factors and genetics. Injuries and trauma. Tumors or abnormal growths. These factors narrow the spinal canal, compressing nerves and causing stenosis symptoms. What are the risk factors of spinal stenosis? Age: Risk increases with aging. Genetics: Family history matters. Congenital: Narrow canal from birth. Injuries: Past spine trauma or surgery. Lifestyle: Heavy lifting, certain jobs. Obesity: Excess weight strains spine. Diseases: Arthritis, diabetes, etc. Scoliosis: Abnormal spine curvature. What are the red flag symptoms/signs of back pain? Neurological Issues: Weakness, numbness, or tingling. Bladder/Bowel Problems: Loss of control. Severe Pain: Unbearable or unrelenting. Fever: Along with back pain. Unexplained Weight Loss: Rapid and unintended. Cancer History: Especially if pain is new. Night Pain: Worse at night. Trauma: After injury or accident. Age Over 50: New-onset pain. Steroid Use: Especially long-term.