Station 1: Respiratory
Saira Ghafur, Parminder K Judge, Richard Kitchen, Samuel Blows, Fiona Moss in The MRCP PACES Handbook, 2017
Search for a cause for the effusion: Connective tissue disease: Features of rheumatoid arthritis butterfly facial rash indicative of systemic lupus erythematosus (SLE)Cardiac disease: Raised JVP and ankle swellingLung cancer: Clubbing, wasting, Horner’s syndrome, radiation scars, tattoos, lymphadenopathy, previous drain site scarsLiver disease: Leuconychia, palmar erythema, spider naevi, gynaecomastia, parotid swelling, ascitesRenal disease: Arteriovenous fistulae, scars from neck lines, peritoneal dialysis catheters, renal transplant
Orthopaedics and Trauma, including Neurosurgery
Kaji Sritharan, Samia Ijaz, Neil Russell, Tim Allen-Mersh in 300 Essentials SBAs in Surgery, 2017
A 65-year-old gardener with a history of gout presents to the emergency department with a painful left knee. He is complaining of being unable to flex his knee without severe pain. On examination, he has a very red and swollen knee. It has a tense effusion, and any passive movement causes extreme pain. You note that he has a temperature and on further questioning find out that he pricked his knee on a rose thorn a few days ago. You suspect a septic arthritis. The most appropriate next step is: Take him to theatre immediately to wash out the knee.Aspirate the effusion and send it for urgent Gram stain and microscopy.Admit him to the ward and arrange for analgesia and antibiotics.Send him home with a course of antibiotics.Organise an ultrasound scan to confirm the effusion.
Answers
Andrew Schofield, Paul Schofield in The Complete SAQ Study Guide, 2019
Fluid in the pleural space is known as a pleural effusion. The fluid may be a transudate or an exudate. Transudates are commonly caused by cardiac failure, cirrhosis or renal failure. Exudates have high protein content and are commonly due to infection, inflammation or malignancy. Examination of the chest classically reveals reduced chest expansion on that side, a ‘stony dull’ percussion note and reduced breath sounds. Small effusions may be seen on a chest X-ray as blunting of the costophrenic angle. Larger effusions are seen more clearly as a fluid level/meniscus in the lung fields. A diagnostic aspiration is performed to determine the nature of the effusion. Drainage may be required if the effusion is causing symptoms. If pleural effusions are recurrent, pleurodesis may be necessary. This involves the installation of an irritant, such as talc, into the pleural space to cause local inflammation and fusion of the pleura to the chest wall. Persistent collections may require surgical intervention.
Daptomycin for the successful treatment of postoperative methicillin-resistant Staphylococcus aureus empyema: a case report
Published in Journal of Chemotherapy, 2021
Yusuke Yagi, Michiro Iizuka, Moemi Okazaki, Kohei Jobu, Yasuyo Morita, Mitsuhiko Miyamura
Although two sets of blood culture on POD 9 proved negative, MRSA was detected in pleural effusion cultures, and therefore anti-MRSA drugs were administered. We initially considered VCM for anti-MRSA treatment; however, LZD was considered to be more appropriate given the overall status of the patient and the tissue penetration of LZD into the pleural space. Although the renal function of the patient showed a slight decrease, as his PLT count was normal, we judged that the use of LZD would be appropriate, and intravenously administered the standard dose of 600 mg twice a day. Pleural drainage to perform intrathoracic lavage with saline was continued repeatedly until POD 16, and the patient’s fever subsequently improved. Administration of LZD was continued until POD 20; however, the treatment proved ineffective in controlling the patient’s fever, left dorsal pain, and elevated WBC and CRP levels. Furthermore, computed tomography of the chest revealed the persistence of pleural effusion, although at a reduced level.
Our current understanding of and approach to the management of lung cancer with pulmonary hypertension
Published in Expert Review of Respiratory Medicine, 2021
Gaelle Dauriat, Jerome LePavec, Pauline Pradere, Laurent Savale, Dominique Fabre, Elie Fadel
In patients without known PH, the echocardiographic findings can indicate high pulmonary pressure. The right ventricular systolic pressure can be estimated from the doppler measurement of tricuspid regurgitation velocity. The size and function of the two ventricles should be assessed, as well as the influence of the right ventricle (RV) on filling of the left ventricle (LV). A pericardial effusion should be sought. Echocardiography may overestimate RV pressure, notably in patients with COPD [38]. The overestimation is most marked in severe PH, with an up to 20% difference from catheterization and an ability to estimate systolic PAP in less than half the patients [38,68]. Chest CT assist in diagnosing PH. Pulmonary artery enlargement with a ratio of the diameter of the pulmonary artery over the diameter of the aorta greater than 1 strongly supports PH in patients with COPD or other diseases of the lung parenchyma [69–71]. In a retrospective study in 237 patients, pulmonary artery enlargement predicted cardiopulmonary complications after pulmonary resection for lung cancer [72].
Rapidly destructive coxopathy due to dialysis amyloidosis: a case report
Published in Modern Rheumatology Case Reports, 2021
Shiho Nakano, Arata Nakajima, Masato Sonobe, Manabu Yamada, Hiroshi Takahashi, Yasuchika Aoki, Kensuke Terai, Hiroyuki Hiruta, Koichi Nakagawa
A 61-year-old male who had been on dialysis for seven years due to diabetic nephropathy felt left hip pain for the first time one year before. Thereafter the pain increased, and he visited our hospital as he had difficulty walking. He was 181 cm tall and weighed 98 kg; his body mass index was 29.9 kg/m2 so he was considered obese. He had not received medical treatment for inflammatory arthritis or gastrointestinal disorders despite long-term haemodialysis. The standing radiograph at the first visit showed collapse of the femoral head and joint space narrowing. Posterior pelvic tilt was also observed (Figure 1(A)). One month later, progress of the collapse and flattening of the femoral head were evident on the standing radiograph (Figure 1(B)). Magnetic resonance imaging (MRI) of the hip revealed bone marrow edoema of the acetabulum and sclerosis of the subchondral bone of the femoral head (Figures 2(A,B)). The bone marrow edoema extended from the femoral head to the proximal femur. Joint fluid effusion was also evident (Figure 2(B)). Biochemical analyses for the blood disclosed an elevated C-reactive protein (CRP) of 5.91 mg/dl but the white blood cell count (WBC) was 8910/μl. Joint fluid cultures were negative for general bacteria, tubercle bacillus, and nontuberculous mycobacteria.