International surgical boards

2021-12-27 17:43:16 Question

29 year old female patient presents with sudden very severe occipital headache and vomitting, the patient is distressed and irritable, she said this happened after a period of straining as she had constipation, soon after admission she lost ability to speak and developed weakness, fundoscopy shows the above finding.

What is the most likely diagnosis in this condition?.

How would you like to confirm your suspicion?. Open / Comment

2021-12-26 19:45:22 Open / Comment

2021-12-25 07:12:02 Differentiating between primary and secondary Raynaud's phenomenon

Raynaud's phenomenon can be primary with no underlying disease process, or secondary to diseases especially connective tissue disease like SLE.

Features that support secondary Raynaud's phenomenon include (1)Male gender, (2) age above 25 years at onset,(3)No family history, (4) Presence of capillary nailfold abnormalities.

The nailfold capillary loops can be easily examined by putting a drop of oil on nailfold and you can use even an ophthalmoscope and look at the capillaries, when there is giant capillaries, areas of abscent capillaries (capillary fallout) or bushy branching capillaries, and microbleeds all points to secondary Raynaud's phenomenon.

Above fig shows the abnormalities of capillary nailfold in secondary Raynaud. Open / Comment

2021-12-24 12:50:49 Open / Comment

2021-12-24 12:46:36 Open / Comment

2021-12-24 12:44:43 Open / Comment

2021-12-24 09:11:30 Atlantoaxial subluxation in rheumatoid arthritis

This is a common complication that usually occur in longstanding poorly controlled rheumatoid arthritis.

Atlantoaxial stability is largely derived from the transverse ligament of the odontoid process.

Odontoid process of the axis is like a key and hole, where it articulate with the atlas (see figure above), the odontoid process is held in place against the arch of atlas by the transverse ligament.

In rheumatoid arthritis there is erosion of the transverse ligament, leading to movement of the odontoid process and hence compression of spinal cord.

This should be suspected in any patient with RA that develop occipital headache, paraesthesias or electric shock like pain in the upper limbs.

Longstanding disease can cause tetraparesis with upper motor neuron signs, operative fixation at this point carry poor prognosis and should be done earlier.

Sudden death from cord section may also occur from minor trauma or manipulation. Open / Comment

2021-12-24 06:55:04 Rheumatoid foot

Describes deformities occuring in the foot from longstanding uncontrolled rheumatoid arthritis.

Hallux valgus: describes deviation of the big toe at the metatarsophalangeal joint.

Hammer toe: describes flexsion at the proximal interphalangeal joints of the toes, a similar deformity at the distal interphalangeal joints is called Mallet toe.

Dorsal subluxuation at metatarsophalangeal joints: This causes exposure of the metatarsal heads, weight bearing causes secondary callosities over the metatarsal heads.

Calceneovalgus: this is an eversion deformity, it is usually associated with rupture of the posterior tibialis tendon, with resultant flat foot.

Rheumatoid nodules: these are basically granulomas, formed of a centre of fibrinoid material, surrounded by mononuclear cells.

N.B above fig shows the notorious deformities of the foot. Open / Comment

2021-12-24 06:41:58 Rheumatoid hand

This term is usually used to describe long-standing manifestations of RA in the hand, these are uncommon nowadays that treatment is successful.

Swan neck deformity : describes hyperextension at PIP with flexsion at DIP.

Boutonniere deformity: describes flexsion at PIP and extension at DIP.

Z-deformity of thumb: describes flexsion at interphalangeal joint, extension at MPJ and and flexsion at carbometacarpal joint.

Dorsal ulnar subluxation: describes posterior displacement of ulnar head at distal radio-ulnar joint, this can contribute to rupture of the 4th and 5th extensor tendons.

Trigger finger: describes a position as if pulling a trigger of a gun, this results from rheumatoid nodules forming on the flexor tendon sheath, shrinkage of this sheath forces the fingers into triggering position.

Ulnar deviation: describes deviation of fingers toward the ulnar side, mostly at MTP joints.

Muscle wasting

PIP=proximal interphalangeal, DIP= Distal, MTP= Metacarpophalangeal. Open / Comment

2021-12-23 10:17:45 Bones, stones, abdominal groans, and psychic moans

These feature point to one thing, excessive mobilisation of calcium from the bones to the blood.

The term "bones" refer to the bony pain due to heavy bone demineralisation and/or neoplastic infiltration of bones.

The resulting hypercalcemia causes severe smooth muscle contractions of intestine causing pain, hence "abdominal groans", and surely, they will deposit in kidneys, and thats the "stones".

At the surface on neurons, sodium channels are present, when these open sodium influx occur leading to an action potential, normally small amount of calcium is present on these channels, guarding these channels and controlling rate of Na influx, when calcium is so high, these calcium "guards" will increase around the Na channel, preventing Na influx and reducing neuronal excitation, causing depression and lethargy, and hence "the psychic moans".

These features classically occur in primary hyperparathyroidism and in multiple myeloma "see fig above". Open / Comment