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Telegram recalls (7)

1-Pic of varicocele suggestive of left sided non tender painless swelling completely reducible on lying down (it was not hernia) choice of investigation

sono

varicocele

JM P:1224

A varicocele is a varicosity of the veins of the pampiniform plexus. It is seen in 8–10% of normal males and occurs on the left side in 98% of affected patients, due to a mechanical problem in drainage of the left kidney vein. A relationship with infertility has been observed but its nature is controversial, as is whether repairing varicoceles in

subfertile men improves fertility chances. Most varicoceles are asymptomatic and incidental findings. They can cause a dragging discomfort in the scrotum. Investigation is usually not necessary but an ultrasound is useful where the diagnosis is doubtful or a neoplasm is suspected. Treatment is indicated if it is symptomatic or for infertility. Firm-fitting underpants may relieve discomfort. Surgical treatment is by venous ligation, above the deep

inguinal ring. Ligation is indicated if there is any reduction in the size of the left testis.

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2- Pic of thyroglossal cyst investigation of choice? CT

(Acc to JM I’m with FNA)

Neck lumps

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HB2.072

Thyroglossal cyst:

•Thyroglossal ducts cysts (TGDC) characteristically present as a midline neck mass at the level of the thyrohyoid

membrane, closely associated with the hyoid bone. Classically, TGDCs move with swallowing or protrusion of the

tongue.

•Differential diagnosis includes dermoid cysts, sebaceous cysts, and thyroid ectopia.

•CT of the neck with contrast and ultrasonography are the preferred imaging modalities. In a suspected case of

thyroglossal duct cyst, CT of the neck with contrast is the most preferred imaging modality

•Patients with TGDCs

should be treated surgically.

•Ectopic thyroid tissue can be confused with a TGDC. All cases of thyroid ectopia should have thyroid function tests,

ultrasonography, and a thyroid scan performed to locate additional functioning thyroid tissue.

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HB 2.121

Branchial cyct

Situated in the upper third of the neck partially covered by sternomastoid muscle. Mostly benign and a remnant of bronchogenic cleft track. Aspiration of the non-infected cyst gives typicalopalescent fluid with cholesterol crystals.

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3- Scenario of alcoholic with epigastric tenderness radiating to back.

Acute pancreatitis

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Note: diagnosis of acute pancreatitis doent need CT

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UpToDate: Patients with clinical and biochemical features of acute pancreatitis who do not improve with initial conservative therapy or who are suspected of having complicaions or other diagnoses should undergo CT scan.

4- Recall of previous mastectomy 5 yrs ago. Now palapable mass in upper outer quadrant

Patterns of relapse in breast cancer survivors

Relapse has usually 3 types: locoregional recurrence, metastasis, second primary breast tumor. Less than two year from mastectomy or breast conserving therapy (BCT) is suspected to be a metastasis and relapse in a longer time more prone to a new carcinoma.

Locoregional recurrence — Women who have undergone either mastectomy or breast conserving surgery are at risk for locoregional recurrenceLocoregional.

In general, women treated with BCT (including adjuvant RT) should proceed with a mastectomy because reirradiation is not generally an option to reduce the risk of another local recurrence. However, for women who did not previously receive RT and those treated with partial breast irradiation, re-excision may be appropriate because they may be candidates for RT.

In contrast, a local recurrence following mastectomy is usually manifest as a mass in the chest wall, regional nodal basins (ie, infraclavicular, supraclavicular, and axillary regions), or overlying skin. Treatment may involve excision of the recurrence or RT (if not previously administered). However, if relapse occurs within two years of primary treatment, distant metastatic disease is already present in 25 to 30 percent of cases. Therefore, systemic therapy is generally administered.

Metastatic disease — Although approximately 15 to 40 percent of recurrences involve the chest wall and axillary or supraclavicular lymph nodes, breast cancer has the potential to metastasize to almost every organ in the body ( . The most common sites of metastases are bone, liver, and lung. Approximately 50 to 75 percent of patients who relapse distantly do so in a single organ; the remainder will develop diffuse metastatic disease. Fewer than 5 percent of patients will manifest central nervous system (CNS) involvement as the first site of metastatic disease.

SECOND PRIMARY BREAST TUMORS — The risk of a second breast cancer is the same whether a patient was treated by mastectomy or breast conserving therapy (BCT). For women without an inherited predisposition to breast cancer (ie, a BRCA1 or BRCA2 mutation), this risk is between 0.5 to 1.0 percent per year [ 9,10 ]. For women with a known genetic predisposition, the risk is much higher. The lifetime risk of contralateral recurrence may be as high as 65 percent for BRCA1 mutation carriers and 50 percent for BRCA2 carriers [ 11 ].

A substantial number of second primary breast cancers occur after five years, necessitating long-term surveillance for all women with a history of breast cancer [ 12,13 ]. This is especially true for hormone receptor-positive breast cancers. As an example, in National Surgical Adjuvant Breast and Bowel Project (NSABP) trial B-04, which evaluated mastectomy with and without RT, 50 percent of all contralateral breast cancers were detected after five years of follow-up.

New findings in breast exam after treatment of breast carcinoma should be approached as new findings irrespective of past history if there is a 5 or more year time interval, I’m with FNA here.

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5-Old lady vegan diet blood values showing iron defanemia. Cause...cancer

آنمی فقرآهن در خانم یایسه و اقا باید اول کولونوسکوپی بشه برا رد کانسر کولون.

6- Past hx of melanoma resction ct of brain showing calcification,...metastasis

melanoma

SURVEILLANCE AFTER TREATMENT

•The primary objective of follow-up in patients with melanoma is to identify potentially curable locoregional recurrences and second primary cancers. The incidence of a second melanoma is increased in melanoma survivors, with the cumulative risk ranging from 2 to 5 percent at periods from 5 to 20 years after initial diagnosis.

•For patients with melanoma in situ, no specific oncologic follow-up is indicated, but patients require continued dermatologic follow-up because of the risk of a second primary, particularly if atypical nevi are present.

•Most initial recurrences in patients with stage I and II primary melanomas are locoregional, particularly if a SLN biopsy was not performed or not indicated (ie, for most patients with T1a primary tumors).

•In patients who initially present with stage III disease, systemic recurrences are more common [ 36 ]. Although locoregional recurrences may be curable if detected early, distant recurrences are commonly fatal. Thus, the most important elements in the follow-up of melanoma patients are the medical history and the physical examination.

•Optimal follow-up strategy and intervals have not been determined, and there is no consensus. At a minimum, patients should undergo an annual routine physical examination, including a full skin assessment and palpation of the regional lymph nodes. More frequent visits are appropriate for patients at high risk for multiple primary lesions (ie, patients with multiple clinically atypical moles, a family history of melanoma, or excessive sun exposure), or for more extensive (ie, stage II or III) disease.

•Periodic chest x-rays were often obtained for early detection of pulmonary metastases. Chest x-rays and other radiographic studies detected recurrences in less than 10 percent of cases of early stage disease, but a higher percent of those with resected node-positive disease.

•Routine blood work including CBC, liver function tests, and LDH, were rarely the sole indicator of recurrence.

•In a subsequent study from the same group, 108 patients with positive sentinel lymph node biopsies were followed with surveillance chest x-rays every six months for five years and then annually for an additional five years [ 45 ]. Lung metastases were eventually detected in 23 cases (21 percent), but the surveillance chest x-rays detected only 11 of these, only three of whom were candidates for metastasectomy. In addition, false positive findings were identified in the lung in 19 cases. The authors concluded that serial surveillance chest x-ray were unlikely to be beneficial.

•In conclusion, the major value of the follow-up visits is to detect potentially curable recurrence, particularly locoregional. Nonetheless, CT and MRI, more recently complemented or replaced by PET/CT, is often a component of the overall follow-up for patients with stage III/IV melanoma. Additional studies are needed to define the role of imaging in the follow-up of the melanoma patient.

7-Case of husband dx chlamydia options about management of his wife

Chlamydia urethritis

JM P:1274

Incubation period

Symptoms appear 1–2 weeks after intercourse, although the incubation period can be as long as 12 weeks or as short as 5 days (compare with incubation period of gonorrhoea—about 2–3 days).

It is an underdiagnosed disorder since many cases are asymptomatic; hence the value of screening. Woman can

carry Chlamydia silently for 12 months or more.

Treatment

azithromycin 1 g (o) single dose (preferred)

or

doxycycline 100 mg (o) 12 hourly for 7 days

A second course may be required if the symptoms persist or recur (about one in five cases).

Second-line treatment is

erythromycin 500 mg qid for 7 days.

All sexual partners, even if asymptomatic, need to be treated in the same way. If a female partner has proven cervicitis the treatment must be as for PID. Sexual intercourse must be avoided until 7 days after both partners have received treatment. The importance of compliance must be stressed.

Reinfection rates are high so retest after 3 months.

Prevention

Using condoms for vaginal and anal sex provides some protection.

Screening guidelines for higher risk

All sexually active women 2 cm in diameter) or complex calculi (such as staghorn calculi)

2) Cystine stones (relatively resistant to shock wave lithotripsy)

3) Anatomic abnormalities, including horseshoe kidneys or UPJO

4) Stones within caliceal diverticula

• Ureteroscopy continues to be the treatment of choice for the majority of middle and distal ureteral stones, but also can be used to manage proximal ureteral and intrarenal calculi. In addition, ureteroscopic access is frequently useful for the management of ureteral calculi that have failed shock wave lithotripsy.

• Shock wave lithotripsy can be used to treat many renal calculi, but is not the ideal modality for the management of complex calculi, large or hard calculi, stones located in a caliceal diverticulum, or in patients with complex renal anatomy. Shock wave lithotripsy employs high energy shock waves produced by an electrical discharge or piezoelectric crystals, fragmenting the stone

• Medical therapy, for both prevention of new stone formation and facilitation of stone passage, should be considered in patients who undergo stone removal procedures

ureteral calculi

• Emergency therapy - In septic patients with obstructing stones, urgent decompression of the collecting system with either percutaneous drainage or ureteral stenting is indicated in combination with appropriate antimicrobial therapy . Definitive treatment of the stone should be delayed until sepsis is resolved. Additional indications for urgent decompression include bilateral obstruction with acute kidney injury and unilateral obstruction with acute kidney injury in a solitary kidney.

• Medical therapy - In a patient who has a newly diagnosed ureteral stone EUS

BOTH for diagnosis and staging.

عاخه اينجا خيلى تاكيد رو اينيشيال investigation كرده. عاپ تو ديت كه lab data رو اينيشيال گفته ولى واسه تصوير بردارى همون سونو رو هم خيلى گفته sensitive هست البته واسه نشون دادن biliary tract dilation. من خيلى به دلم نيست تو مريض تيپيك بزنم سونو. وگرنه سونو اول مى زنم يكم شك داشته باشم. ولى اون دقيق ترينش خيلى مهمه به نظرم. ✔️

49-At 12 week pregnancy urine culture positive for GBS.Treated with AB for 7 days whats your future plan?

A) swab at 34-37 wks

B ) penicillin during labour

C) fetal prophylactic treatment at birth

عفونت gbs در حاملگی فعلی یک ریسک فاکتور قطعی ایجاد عفونت gbs در نوزاد هست بنابراین در این کیس به هر حال باید دو ساعت قبل از زایمان پنی سیلین بدیم اما اینکه منظور سوال از future plan چی هست دیگه من نظری ندارم چون عملا هر دو گزینه باید انجام بشه.

اما با توجه به اینکه در همین بارداری یه کشت مثبت داشته شاید منظور طراح همین بوده که حتما پروفیلاکسی لازمه.

50-scenario of alcoholic patient. 3rd post operative day suddenly agitated and confused. Whats most appropriate investigation:-

Xray

CTPA

Some other options.

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در مورد alcohol withdrawal چيزى كه گايدلاين ميگه اينه :

- ديازپام خوراكى

- اگه همكارى نميكرد ديازپام رقيق شده يا ميدازولام IV

- اگه مريض خيلى آژيته بود و IV نميشد گرفت ميدازولام IM

- اگه مريض علائم سايكوتيك شديد هم داشت droperidol OR haloperidol IM (كه البته گفته بين اين دو هالوپريدول بهتره چون كمتر باعث كاهش seizure threshold ميشه)

alcohol withdrawal syndromes

|Syndrome | Clinical findings | Onset after last drink |

|Minor withdrawal |Tremulousness, mild anxiety, headache, |6 to 36 hours |

| |diaphoresis, palpitations, anorexia, GI upset; | |

| |Normal mental status | |

|Seizures |Single or brief flurry of generalized, |6 to 48 hours |

| |tonic-clonic seizures, short post-ictal period;| |

| |Status epilepticus rare | |

|Alcoholic hallucinosis |Visual, auditory, and/or tactile hallucinations|12 to 48 hours |

| |with intact orientation(sensorium rmains | |

| |normal, not delirious) and normal vital signs | |

|Delirium tremens |Delirium, agitation, tachycardia, hypertension,|48 to 96 hours |

| |fever, diaphoresis | |

JM P: 209

Treatment of Delirium tremens

• Hospitalisation

• Correct fluid and electrolyte imbalance with IV therapy

• Treat any systemic infection

• Thiamine (vitamin B1 300 mg IM or IV daily for 3–5 days, then thiamine 300 mg (o) daily

• Diazepam 5 mg by slow IV injection (over several minutes) every half hour until symptoms subside or diazepam

20 mg (o) every 2 hours (up to max. 100 mg daily) until symptoms subside. This dose is usually required for 2–3

days, then should be gradually reduced till finished.

If psychotic features (e.g. hallucinations and delusions)

• add haloperidol 1.5–5 mg (o) bd, titrated to clinical response

Other types of delirium:

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51- scenario of 55 yrs old patient undergoing hip replacement surgery. Postoperative management was asked.

LMWH for 7 days

Warfarin for 1 month

Warfarin for 3 months

اينم high risk هست چون خود elective arthroplasty فقط ٥ امتياز داره حالا بابت سنش هم يك امتياز ميگيره و چون بيش از ٧٢ ساعت احتمالا bed rest ميشه، ٢ امتياز هم از اين ميگيره...

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52-25 years old female for ECT next day, today in morning develops restlessness. Next?

A. Zolpidem

B. Diazepam

C. amitryptilin

D. setraline

E. Na valproate

53- scenario of ankylosing spondilitis . Asked what will help you to diagnose:

HLA

Xray spine

Some other options

Ankylosing spondylitis

JM P:374

This usually presents with an insidious onset of inflammatory back and buttock pain (sacroiliac joints and spine) and stiffness in young adults (age 3 months

• Associated morning stiffness >30 minutes

• Awoken with pain during second half of night

• Improvement with exercise and not relieved by rest

• Limitation of lumbar spine motion in sagittal and frontal planes

• Chest expansion ↓ relative to normal values

• Unilateral sacroiliitis (grade 3 to 4)

• Bilateral sacroiliitis (grade 2 to 4)

Treatment uptodate:

•We recommend use of an NSAID as initial therapy.

•We recommend an exercise program for all patients.

•We suggest NOT using systemic glucocorticoids. We suggest intraarticular glucocorticoids for persistent

peripheral joint involvement, enthesitis at sites other than the Achilles tendon, and for pain of sacroiliitis.

•Traditional nonbiologic DMARDs (eg, sulfasalazine , methotrexate , leflunomide , or penicillamine ) are ineffective

for those with axial disease.

•For patients with axial disease who do not respond to NSAIDs we recommend an anti-TNF agent.

•In patients with predominantly peripheral arthritis who do not respond adequately to NSAIDs and for whom a

TNF inhibitor is unavailable or is contraindicated, we recommend sulfasalazine (alternatively methotrexate),

unless there are contraindications (eg, allergy to sulfonamide antibiotics) to this drug.

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