Clostridioides difficile (C. difficile; formerly known as Clostridium difficile) is a gram-positive rod-shaped bacillus that is commonly involved in antibiotic-associated diarrhoea. As the bacterial spores are difficult to eradicate and easily transmitted (via faecal-oral transmission), the C. difficile infection rate is particularly high among hospitalized patients and residents in long-term care facilities.
Colonization with C. difficile occurs following antibiotic treatment of other diseases, as the bacteria is particularly resistant to antibiotics. The resulting damage to the intestinal flora promotes infection, which may be accompanied by high fever, abdominal pain, and characteristically foul-smelling diarrhoea. The most severe form of C. difficile infection is pseudomembranous colitis, which may lead to ileus, sepsis, and toxic megacolon. In most cases, however, colonization results in asymptomatic carriage rather than symptomatic infection.
Diagnosis is usually made via detection of the C. difficile toxin and/or corresponding genes in stool samples. C. difficile infections are treated with oral vancomycin or oral fidaxomicin. Following diagnosis, strict adherence to hygiene measures and patient isolation is essential, especially in hospitals and other healthcare settings.

Vomiting usually results in hypokalaemia, and hyponatremia would least likely occur as a result of it. Hyponatremia is a common postoperative finding among patients and hence serum sodium must be carefully monitored. Addison disease, SIADH, diuretic therapy can all cause hyponatremia.

Clostridioides difficile (formerly Clostridium difficile) colitis results from a disturbance of the normal bacterial flora of the colon, colonization by C difficile, and the release of toxins that cause mucosal inflammation and damage. Antibiotic therapy is the key factor that alters the colonic flora. C difficile infection (CDI) occurs primarily in hospitalized patients.
The diagnosis of C difficile colitis should be suspected in any patient with diarrhoea who has received antibiotics within the previous 3 months, has been recently hospitalized, and/or has an occurrence of diarrhoea within 48 hours or more after hospitalization. In addition, C difficile can be a cause of diarrhoea in community dwellers without previous hospitalization or antibiotic exposure

The following recommendations on Clostridium difficile infection (CDI) were released on February 2018 by the Infectious Diseases Society of America (ISDA) and Society for Healthcare Epidemiology of America (SHEA).
Diagnosis (adults)
Patients with unexplained and new-onset ≥3 unformed stools in 24 hours are the preferred target population for testing for CDI.
Use a stool toxin test as part of a multistep algorithm (i.e., glutamate dehydrogenase [GDH] plus toxin; GDH plus toxin, arbitrated by nucleic acid amplification test [NAAT]; or NAAT plus toxin) rather than NAAT alone for all specimens when there are no pre-agreed institutional criteria for patient stool submission.
Use NAAT alone or a multistep algorithm for testing (i.e., GDH plus toxin; GDH plus toxin, arbitrated by NAAT; or NAAT plus toxin) rather than a toxin test alone when there are pre-agreed institutional criteria for patient stool submission.
Do not perform repeat testing (within 7 days) during the same episode of diarrhoea and do not test stool from asymptomatic patients, except for epidemiologic studies

The use of intravenous diltiazem or verapamil is contraindicated in patients with ventricular tachycardia. The IV administration of a calcium channel blocker can precipitate cardiac arrest in such patients.
Marked hemodynamic deterioration and ventricular fibrillation have occurred in patients with wide-complex ventricular tachycardia (QRS >= 0.12 seconds) treated with IV verapamil.

Breast cancer frequently metastasizes to the skeleton, interrupting the normal bone remodelling process and causing bone degradation. Breast cancer is the commonest cause of lytic bone metastasis in women of this age, especially from amongst those options given.

Osteolytic lesions are the end result of osteoclast activity; however, osteoclast differentiation and activation are mediated by osteoblast production of RANKL (receptor activator for NFκB ligand) and several osteoclastogenic cytokines. Osteoblasts themselves are negatively affected by cancer cells as evidenced by an increase in apoptosis and a decrease in proteins required for new bone formation. Thus, bone loss is due to both increased activation of osteoclasts and suppression of osteoblasts. The clinical outcomes of bone pain, pathologic fractures, nerve compression syndrome, and metabolic disturbances leading to hypercalcemia and acid/base imbalance severely reduce the quality of life.

Boerhaave’s syndrome is also known as spontaneous oesophageal rupture or effort rupture of the oesophagus. Although vomiting is thought to be the most common cause, other causes include weightlifting, defecation, epileptic seizures, abdominal trauma, compressed air injury, and childbirth, all of which can increase the pressure in the oesophagus and cause a barogenic oesophageal rupture.
It usually follows excessive alcohol intake or overeating, or both, because either of these can induce vomiting.
The rupture is transmural.
A provider should suspect Boerhaave’s syndrome when a patient presents with retrosternal chest pain with or without subcutaneous emphysema when associated with heavy alcohol intake and severe or repeated vomiting. Up to one-third of patients do not present with these symptoms. The actual clinical presentation of Boerhaave syndrome will depend on the level of the perforation, the degree of leakage, and the time since the onset of the injury. Typically, the patient will present with pain at the site of perforation, usually in the neck, chest, epigastric region, or upper abdomen. Cervical perforations can present with neck pain, dysphagia, or dysphonia; intra-thoracic perforations with chest pain; and intra-abdominal perforations with epigastric pain radiating to the shoulder or back. History of increased intra-oesophageal pressure for any reason followed by chest pain should prompt consideration of this condition. Physical exam findings may include abnormal vitals (tachycardia, tachypnoea, fever), decreased breath sounds on the perforated side, mediastinal emphysema, and Hamman’s sign (mediastinal “crackling” accompanying every heartbeat) in left lateral decubitus position.

Chyle leakage is one of the most challenging complications following an esophagectomy and can lead to hypovolemia, metabolic and nutritional depletion, infection, and even death. The leakage occurs in 1.1 to 3.7% of esophagectomy patients; mortality occurs in excess of 50% of patients. Surgeons administer a lipid rich material prior to surgery to facilitate its identification if it occurs.

Patients treated with moderate-dose intravenous thrombolysis within 3 hours after the onset of stroke symptoms benefit substantially from therapy, despite a modest increase in the rate of symptomatic haemorrhage. This patient is within 3h of symptom onset of a stroke, therefore he should be urgently referred to the medical team for thrombolysis, before Aspirin is given. According to the current guidelines, in order to limit the
risk of an intracranial haemorrhagic complication, no antiplatelet treatment should be administered in the 24 hours that follow treatment of an ischemic stroke by intravenous thrombolysis.

Spleen injuries are among the most frequent trauma-related injuries. At present, they are classified according to the anatomy of the injury. The optimal treatment strategy, however, should take into consideration the hemodynamic status, the anatomic derangement, and the associated injuries. The management of splenic trauma patients aims to restore the homeostasis and the normal physiopathology especially considering the modern tools for bleeding management.

The trend in the management of splenic injury continues to favour nonoperative or conservative management. This varies from institution to institution but usually includes patients with stable hemodynamic signs, stable haemoglobin levels over 12-48 hours, minimal transfusion requirements (2 U or less), CT scan injury scale grade of 1 or 2 without a blush, and patients younger than 55 years.
Surgical therapy is usually reserved for patients with signs of ongoing bleeding or hemodynamic instability. In some institutions, CT scan–assessed grade V splenic injuries with stable vitals may be observed closely without operative intervention, but most patients with these injuries will undergo exploratory laparotomy for more precise staging, repair, or removal.

A retrospective analysis by Scarborough et al compared the effectiveness of nonoperative management with immediate splenectomy for adult patients with grade IV or V blunt splenic injury. The study found that both approaches had similar rates of in-hospital mortality (11.5% in the splenectomy group vs 10.0%), however, there was a higher incidence of infectious complications in the immediate splenectomy group. The rate of failure in the nonoperative management was 20.1% and symptoms of a bleeding disorder, the need for an early blood transfusion, and grade V injury were all early predictors of nonoperative management failure.

Boerhaave syndrome classically presents as the Mackler triad of chest pain, vomiting, and subcutaneous emphysema due to oesophageal rupture, although these symptoms are not always present.
The classic clinical presentation of Boerhaave syndrome usually consists of repeated episodes of retching and vomiting, typically in a middle-aged man with recent excessive dietary and alcohol intake.
These repeated episodes of retching and vomiting are followed by a sudden onset of severe chest pain in the lower thorax and the upper abdomen. The pain may radiate to the back or to the left shoulder. Swallowing often aggravates the pain.
Typically, hematemesis is not seen after oesophageal rupture, which helps to distinguish it from the more common Mallory-Weiss tear.
Swallowing may precipitate coughing because of the communication between the oesophagus and the pleural cavity.

Answer: Thoracotomy

Cardiac arrest after penetrating chest trauma may be an indication for emergency thoracotomy. A successful outcome is possible if the patient has a cardiac tamponade and the definitive intervention is performed within 10 minutes of loss of cardiac output.
EMERGENCY “CLAM SHELL” THORACOTOMY

Indication:

Penetrating chest/epigastric trauma associated with cardiac arrest (any rhythm).

Contraindications:
Definite loss of cardiac output for greater than 10 minutes.

Any patient who has a cardiac output, including hypotensive patients.

Aortic transection was the underlying cause of death in this patient.

Aortic transection, or traumatic aortic rupture, is typically the result of a blunt aortic injury in the context of rapid deceleration. This condition is commonly fatal as blood in the aorta is under great pressure and can quickly escape the vessel through a tear, resulting in rapid haemorrhagic shock and death. A temporary haematoma may prevent the immediate death. Injury to the aorta during a sudden deceleration commonly originates near the terminal section of the aortic arch, also known as the isthmus. This portion lies just distal to the take-off of the left subclavian artery at the intersection of the mobile and fixed portions of the aorta. As many as 80% of the patients with aortic transection die at the scene before reaching a trauma centre for treatment.

A widened mediastinum may be seen on the X-ray of a person with aortic rupture.

Other types of thoracic trauma include:
1. Tension pneumothorax and pneumothorax
2. Haemothorax
3. Flail chest
4. Cardiac tamponade
5. Blunt cardiac injury
6. Pulmonary contusion
7. Diaphragm disruption
8. Mediastinal traversing wounds

The passage of extremely loose and watery stools is characteristic of Vibrio cholera infection. Most of the other gastroenteric infections do not produce such watery motions.

Vibrio cholerae is a Gram-negative, comma-shaped bacterium. It’s natural habitat is brackish or saltwater. Some strains of V. cholerae cause the disease cholera.

Transmission occurs through the ingestion of contaminated water or food. Sudden large outbreaks are usually caused by a contaminated water supply. Outbreaks and endemic and sporadic cases are often attributed to raw or undercooked seafood.

Symptoms of the disease include sudden onset of effortless vomiting and profuse watery diarrhoea. Correction of fluid and electrolyte losses are the mainstay of treatment. Most cases resolve shortly afterwards, and therefore, antibiotics are not generally indicated.

Answer: Excision biopsy of a lymph node

Hodgkin lymphoma is an uncommon cancer that develops in the lymphatic system, which is a network of vessels and glands spread throughout your body. In Hodgkin lymphoma, B-lymphocytes (a particular type of lymphocyte) start to multiply in an abnormal way and begin to collect in certain parts of the lymphatic system, such as the lymph nodes (glands). The affected lymphocytes lose their infection-fighting properties, making you more vulnerable to infection. The most common symptom of Hodgkin lymphoma is a painless swelling in a lymph node, usually in the neck, armpit or groin.
A histologic diagnosis of Hodgkin lymphoma is always required. An excisional lymph node biopsy is recommended because the lymph node architecture is important for histologic classification.

Features of Hodgkin lymphoma include the following:

Asymptomatic lymphadenopathy may be present (above the diaphragm in 80% of patients)

Constitutional symptoms (unexplained weight loss [>10% of total body weight] within the past 6 months, unexplained fever >38º C, or drenching night sweats) are present in 40% of patients; collectively, these are known as B symptoms

Intermittent fever is observed in approximately 35% of cases; infrequently, the classic Pel-Ebstein fever is observed (high fever for 1-2 week, followed by an afebrile period of 1-2 week)

Chest pain, cough, shortness of breath, or a combination of those may be present due to a large mediastinal mass or lung involvement; rarely, haemoptysis occurs

Pruritus may be present

Pain at sites of nodal disease, precipitated by drinking alcohol, occurs in fewer than 10% of patients but is specific for Hodgkin lymphoma

Back or bone pain may rarely occur

A family history is also helpful; in particular, nodular sclerosis Hodgkin lymphoma (NSHL) has a strong genetic component and has often previously been diagnosed in the family.

Significant facial fractures may have an intracranial effect. Computerised tomography (CT) scan of the head allows delineation of the injury extent, and a 3D reconstruction of images can be done. An Orthopantomogram (OPT) provides good images of mandible and surrounding bony structures but cannot give intracranial details. X-ray of the skull lacks the details important in modern practice.

Craniomaxillofacial (CMF) injuries in the UK are due to:
1. Interpersonal violence (52%)
2. Motor vehicle accidents (16%)
3. Sporting injuries (19%)
4. Falls (11%)

Staphylococcus epidermidis tends to colonise plastic devices (such as the breast implant in this scenario) and forms a biofilm which allows colonisation with other bacterial agents. It is extremely difficult to eradicate the infection once established, and the usual treatment is removal of the device.

Staphylococcus epidermidis is a gram-positive facultative anaerobic bacterium. It is part of the normal human flora, typically the skin flora, and less commonly the mucosal flora. It is also one of the most frequently detected pathogens in infections following implant surgery.

Pinworm infection is caused by a small, thin, white roundworm called Enterobius vermicularis. Although pinworm infection can affect all people, it most commonly occurs among children, institutionalized persons, and close-contacts. Pruritus is the main symptom, as there is a lack of tissue invasion. It is rare for individuals to have any signs of systemic sepsis. Pinworm infection is treatable with over-the-counter or prescription medication, but reinfection, which occurs easily, should be prevented

As a reconstructive option after extensive surgery, pedicled musculocutaneous flaps offer several advantages in the setting of previous radiotherapy. Rotational skin flaps will comprise of irradiated tissue and thus won’t heal well.

This wound should be managed by primary closure as there is minimal associated tissue loss and the surgery is minor and uncontaminated.

Primary wound closure is the fastest type of closures, and is also known as healing by primary intention. Wounds that heal by primary closure have a small, clean defect that minimizes the risk of infection and requires new blood vessels and keratinocytes to migrate only a small distance. Standard methods of suturing are usually sufficient for primary wound closure.

Various definitions of massive blood transfusion (MBT) have been published in the medical literature such as:

– Replacement of one entire blood volume within 24 h

– Transfusion of >10 units of packed red blood cells (PRBCs) in 24 h

– Transfusion of >20 units of PRBCs in 24 h

– Transfusion of >4 units of PRBCs in 1 h when on-going need is foreseeable

– Replacement of 50% of total blood volume (TBV) within 3 h.

Streptococcus bovis (S. bovis) bacteria are associated with colorectal cancer and adenoma. S. bovis is currently named S. gallolyticus. 25-80% of patients with S. bovis/gallolyticus bacteraemia have concomitant colorectal tumours. Colonic neoplasia may arise years after the presentation of bacteraemia or infectious endocarditis of S. bovis/gallolyticus. The presence of S. bovis/gallolyticus bacteraemia and/or endocarditis is also related to the presence of villous or tubular-villous adenomas in the large intestine.

Answer: Hemopericardium

Hemopericardium refers to the presence of blood within the pericardial cavity, i.e. a sanguineous pericardial effusion. If enough blood enters the pericardial cavity, then a potentially fatal cardiac tamponade can occur. There is a very long list of causes but some of the more common are:
-ruptured myocardial infarction
-ruptured left ventricular aneurysm
-aortic dissection
-pericarditis
-trauma
-blunt/penetrating/deceleration
-iatrogenic, e.g. pacemaker wire insertion
-cardiac malignancies
-ruptured coronary artery aneurysm
-post-thrombolysis

Cardiac tamponade is a clinical syndrome caused by the accumulation of fluid in the pericardial space, resulting in reduced ventricular filling and subsequent hemodynamic compromise. The condition is a medical emergency, the complications of which include pulmonary oedema, shock, and death.
Symptoms vary with the acuteness and underlying cause of the tamponade. Patients with acute tamponade may present with dyspnoea, tachycardia, and tachypnoea. Cold and clammy extremities from hypoperfusion are also observed in some patients. Other symptoms and signs may include the following:
Elevated jugular venous pressure

Pulsus paradoxus

Chest pressure

Decreased urine output

Confusion

Dysphoria

Necrosis and ulcers of the colon are a feature of infection with enteroinvasive E. coli (EIEC). It presents with a dysentery-type illness similar to shigellosis.

E. coli have different strains that cause a wide range of conditions. The four main types are:

1. Enteropathogenic E. coli—cause watery diarrhoea, vomiting, and low-grade fever

2. Enteroinvasive E. coli—cause dysentery, large bowel necrosis, and ulcers

3. Enterotoxigenic E. coli—cause traveller’s diarrhoea

4. Enterohaemorrhagic E. coli 0157:H7—cause haemorrhagic colitis, haemolytic uremic syndrome, and thrombotic thrombocytopenic purpura

The combination of a high reticulocyte count and severe anaemia indicates aplastic crisis in patients with sickle cell anaemia. Another differential can be that of a transient aplastic crisis due to parvovirus. This is less likely as it causes reticulocytopenia rather than reticulocytosis.

Parvovirus B19 infects erythroid progenitor cells in the bone marrow and causes temporary cessation of red blood cell production. People who have underlying haematologic abnormalities such as sickle cell anaemia are at risk of cessation of red blood cell production if they become infected. This can result in a transient aplastic crisis. It is more common in people of African, Indian, and Middle Eastern backgrounds. Typically, these patients have a viral prodrome followed by anaemia, often with haemoglobin concentrations falling below 5.0 g/dL and reticulocytosis.

Answer: The burn area is extremely painful until skin grafted

Third-degree burns destroy the epidermis and dermis. Third-degree burns may also damage the underlying bones, muscles, and tendons. The burn site appears white or charred. There is no sensation in the area since the nerve endings are destroyed. These are not normally painful until after skin grafting is done since the nerve endings have been destroyed.

One of the most serious post-ERCP complications is cholangitis leading to subsequent septicaemia. Enteric bacteria enter the biliary tree by the hematogenous route or following endoscopic or radiologic manipulation. Improperly disinfected endoscopes and accessories may also introduce infection into the biliary tree. The most common organisms responsible for infection after ERCP are the Enterobacteriaceae (especially Escherichia coli and Klebsiella species), alpha-haemolytic streptococci, Pseudomonas aeruginosa, Enterococcus, and Staphylococcus epidermidis. In most patients with acute cholangitis, a single organism is isolated from blood cultures.

Acute cholangitis is a clinical syndrome characterized by fever, jaundice, and abdominal pain that develops as a result of stasis and infection in the biliary tract. It is also referred to as Charcot’s Triad. Cholangitis was first described by Charcot as a serious and life-threatening illness; however, it is now recognized that the severity can range from mild to life-threatening.

Risk factors for post-ERCP infection include the use of combined percutaneous and endoscopic procedures, stent placement in malignant strictures, the presence of jaundice, low case volume, and incomplete or failed biliary drainage. Patients who are immunocompromised are more likely to experience an infectious complication.

Prevention and/or reduction of the risk of post-ERCP infectious complications can be achieved by judicious use of preprocedural antibiotics and intraprocedural steps, such as minimizing or avoiding contrast injection in patients with known biliary obstruction or cholangitis, endoscopic decompression, including the placement of a biliary stent when complete drainage cannot be achieved, and prompt percutaneous drainage if endoscopic drainage is not possible or incomplete. Prophylactic preprocedural antibiotics should be given to patients with jaundice and suspected mechanical obstruction. In addition, patients with sclerosing cholangitis, pancreatic pseudocysts, and those who are immunocompromised should also receive preprocedural antibiotics

Answer: Thoracotomy in theatre

A high CVP of 13 indicates cardiac tamponade. Cardiac tamponade is a clinical syndrome caused by the accumulation of fluid in the pericardial space, resulting in reduced ventricular filling and subsequent hemodynamic compromise. The condition is a medical emergency, the complications of which include pulmonary oedema, shock, and death.
A pericardiotomy via a thoracotomy is mandatory for lifesaving cardiac decompression in acute traumatic cardiac tamponade in cases of ineffective drainage due to clot formation within the pericardial space. Wherever possible a patient needing surgery for penetrating chest trauma should be moved to an operating theatre where optimal surgical expertise and facilities are available.

There is strong evidence to support haemostatic resuscitation in the setting of massive haemorrhage due to trauma. This advocates the use of 1:1:1 ratio.

Uncontrolled haemorrhage accounts for up to 39% of all trauma-related deaths. In the UK, approximately 2% of all trauma patients need massive transfusion. Massive transfusion is defined as the replacement of a patient’s total blood volume in less than 24 hours or the acute administration of more than half the patient’s estimated blood volume per hour. During acute bleeding, the practice of haemostatic resuscitation has been shown to reduce mortality rates. It is based on the principle of transfusion of blood components in fixed ratios. For example, packed red cells, FFP, and platelets are administered in a ratio of 1:1:1.

A flail chest segment may lacerate the underlying lung and create a flap valve. Tension pneumothorax can, therefore, occur by intubation and ventilation in this situation.

Tension pneumothorax is a life-threatening condition that develops when air is trapped in the pleural cavity under positive pressure, displacing mediastinal structures and compromising cardiopulmonary function. The development of a tension pneumothorax can be life-threatening during mechanical ventilation, since with each breath, the pressure within the pneumothorax becomes greater, compromising both ventilatory and cardiovascular function.

Signs and symptoms of tension pneumothorax include:
1. Chest pain that usually has a sudden onset, is sharp, and may lead to feeling of tightness in the chest
2. Dyspnoea and progressive hypoxia
3. Tachycardia
4. Hyperventilation
5. Cough
6. Fatigue

On examination, hyper-resonant percussion note and tracheal deviation are typically found.

CXR shows:
1. Lung collapse towards the hilum
2. Contralateral mediastinal deviation
3. Diaphragmatic depression and increased rib separation
4. Increased thoracic volume
5. Ipsilateral flattening of the heart border

Management options for tension pneumothorax include
immediate needle decompression followed by definitive wide-bore chest drain insertion (without waiting for CXR results).

Nasal injuries can be challenging to manage and where there is tissue loss, it can be difficult to primarily close them and obtain a satisfactory aesthetic result. Debridement together with a rotational skin flap would produce the best results.

A rotation flap is a semi-circular skin flap that is rotated into the defect on a fulcrum point. It provides the ability to mobilize large areas of tissue with a wide vascular base for reconstruction. Rotation flaps may be pedicled or free. Pedicled flaps are more reliable but are limited in the range of movement. Free flaps have increased range but carry greater risk of breakdown as they require vascular anastomosis.