M e d i c a l E d u c a t i o n CASE PRESENTATION A 60-year-old Chinese man with a past medical history of hypertension, hyperlipidaemia and previous cerebrovascular accident six years ago presented with a one-day history of acute abdominal pain and vomiting. This was associated with abdominal distension and symptoms of obstipation. He did not complain of any constitutional symptoms such as weight loss or loss of appetite. He did not report having any prior abdominal surgery. Physical examination revealed mild, central abdominal tenderness. The abdomen was distended, but no guarding or rebound tenderness was elicited. No mass or lump was felt in the hernial orifices of the groin. Abdominal radiography (Fig. 1) and contrast-enhanced computed tomography (CT) of the abdomen and pelvis (Fig. 2) were performed. What do these images show and what is the diagnosis? CMEArticle
Introduction: Many institutions still perform routine chest radiographs after tube thoracostomies despite current guidelines suggesting that this is not necessary for simple cases.We aimed to evaluate the usefulness of routine chest radiography following ultrasonographyguided catheter thoracostomies for the detection of complications of symptomatic pleural effusions in hospitalised patients. Methods:This was a retrospective review of 2,032 ultrasonography-guided thoracostomies on hospitalised patients with symptomatic effusions at a single institution from April 2012 to May 2015. The aetiology of effusions was not systemically registered, but patient demographics, procedural details and clinical outcomes were collected. Data was analysed using descriptive statistics and chi-square test. Generalised estimating equation analysis was performed to assess the relationship between chest radiography findings and complications, while controlling for age.Results: Out of 2,032 chest radiographs performed, 92.96% (n = 1,889) were normal, 5.81% (n = 118) showed pneumothorax and 1.23% (n = 25) showed catheter kinking. 99 pneumothoraces and 24 kinked catheters were detected in the first hour post procedure. 97.40% (n = 115) of patients with pneumothorax were stable or had minor complication, such as vasovagal event. 0.20% (n = 4) of patients had serious complication post chest drain insertion, resulting in cardiovascular collapse. There was no significant relationship between chest radiography results and the occurrence of complications (p = 0.244). The amount of fluid drained or side of insertion did not affect the clinical outcome of patients. Conclusion:Routine use of chest radiography after tube thoracostomy did not significantly change patient management, which is concordant with recent guidelines. Instead, adverse clinical outcomes or procedural factors should guide investigations.
IMAGES IN MEDICINEA 57-year-old woman presented with a 2-month history of an asymptomatic left neck lump. She is a non-smoker, does not drink alcohol, and has no family history of head and neck cancers. On examination, there was a 2cm left cervical level II ovoid and mobile nodule, which appeared to exhibit transmitted pulsations. Cranial nerve examination was normal nasoendoscopic and otoscopic evaluation were unremarkable.The lesion was visualised on both computed tomography and magnetic resonance imaging (MRI) scans as a well-defined 2.8 x 2.9 x 2.8cm mass just adjacent to the major vessels in the neck (Fig. 1).What is the diagnosis? A. Enlarged cervical lymph node B. Carotid body tumour C. Vagal schwannoma D. Sympathetic chain schwannoma E.Branchial cleft cyst The patient then underwent surgical excision of the lesion. Histological examination revealed a dense lesion with adjacent compressed nerve fibres containing ganglions that displayed a mixture of both cellular Antoni A and hypocellular Antoni B segments, with the latter showing vessels with surrounding hyalinisation. These findings are consistent with a schwannoma-in this case, a sympathetic chain schwannoma.Schwannomas are nerve sheath tumours consisting of Schwann cells that confer a low risk of malignant
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