Abdominal Aortic Aneurysm - What to do and When

AAA - Abdominal Aortic Aneurysm - Mx

>= 55 mm -> non-urgent repair


Symptomatic -> urgent repair


< 40 mm -> US or CT every 2 years


>= 40 mm but < 50 mm    -> US or CT every 12 months


>= 50 mm but < = 54 mm -> US or CT every  6 months


AAAs < 50 mm -> increase in diameter ~ 4 mm/year


Monitor and Rx CVD- particularly BP and lipid levelsStatins -> decrease risk of mortality after repair


Refs include Ferri's Clinical Advisor 2015

In Case of Skin Cancer

In case of melanoma or non-melanoma skin cancer
- check local/draining lymph nodes

In case of melanoma
- refer to local melanoma unit

Ix Urinary Tract Disease

Renal
- function - eGFR
- damage - urinary albumin:creatine ratio ;( MAU)
- structure - US scan; CT urogram

Bladder
- urine - mcs; phase-contrast microscopy (renal or non-renal RBCs?); cytology
- cystoscopy

In Case of any Cancer - Keys to Mx

1. (Tissue) Dx

2. Staging

3. Counselling

SOA: What to Consider

Swelling of the ankles generally presents as such


Important causes of SOA include organ failure (heart; liver; kidney)

• But such conditions are generally well-documented in the patient's PHx or present with symptoms or signs other than SOA alone
• SOB
• Raised liver enzymes
• Reduced eGFR

Think

1. Uni- or bi-lateral?
2. Pitting or non-pitting?
3. Painful or not?
4. Tender or non-tender?
5. JVP ?elevated

Bilateral
=> Hot environment
=> Relative immobility (permanent; temporary - sitting; travel)
=> Obesity
=> Menstrual (mid-cycle)
=> Chronic venous insufficiency
=> Medication
Calcium antagonists
Glitazones
C.steroids (systemic)
NSAID
COCP (combined oral contraceptive pills)

=> Organ failure (low serum albumin => liver or kidney; normal level => cardiac)

Unilateral
=> inflammation or infection


Pitting edema
=> excess interstial fluid

Pain
=> inflammation or infection or clot (superficial phlebitis; DVT)

Tenderness
=> inflammation or infection or clot (superficial phlebitis; DVT)


JVP raised
=> cardiac




Ix to consider initially

• Urinalysis - office dipstick test; urine for mcs; MAU
• Serology - UCEs; eGFR; LFTs
• Haematology - FBC; CRP
• Imaging - US scan leg veins; CXR; EchoC

Ear Drops in case of Perforated Drum

Ciprofloxacin

• Equally effective as aminoglycoside drops, but not ototoxic
• Would be prudent to consider their use before potentially ototoxic alternatives

In case of otitis externa

• Consider that ear drum could be perforated before Rx ear drops

What Can Present in a Myriad of Ways?

If patient Hx (or Dx) proves tricky, always consider

• Mental illness
• Endocrine dysfunction
• Anaemia
• Chemicals (Drugs: Rx; OTC; recreational | Environmental)
• Viruses; Vector-born disease
• Auto-immune disease
• A para-neoplastic syndrome

Ix to consider in such circumstances

• Serology - CRP; LFTs; TSH; fasting BSL; infection serology; RF; ANA; (PSA)
• Haematology - FBC; ESR
• Imaging - CXR; abdo/pelvic US or CT scan; brain CT/MRI scan; (mammogram)
• Clinical tool - K10 questionnaire