Orris

Clinical Case 1 A 25-year-old man presents with pain, redness, swelling, and warmth over his right lower leg. He has a fever of 38.5°C. The area has poorly defined margins. Questions: 1. What is the most likely diagnosis? 2. What organisms commonly cause this condition? 3. Outline the treatment. ⸻ Clinical Case 2 A 45-year-old diabetic man presents with severe pain in the perineum, fever, and rapidly spreading black discoloration of the skin. Questions: 1. What is the diagnosis? 2. Why is this condition dangerous? 3. What is the immediate management? ⸻ Clinical Case 3 A 30-year-old woman presents with a painful fluctuant swelling in the axilla. She has had similar episodes before. Questions: 1. What is the diagnosis? 2. What risk factors are associated with this disease? 3. How is it treated? ⸻ Clinical Case 4 A 22-year-old student develops severe throbbing pain at the tip of the index finger. The fingertip is swollen and tender. Questions: 1. What is the diagnosis? 2. What complication may occur if untreated? 3. How should it be managed? ⸻ Clinical Case 5 A 60-year-old diabetic presents with fever and a swollen painful knee. Joint movement is extremely painful. Questions: 1. What is the diagnosis? 2. Which investigation confirms it? 3. What is the treatment? ⸻ Clinical Case 6 A 14-year-old boy presents with fever and severe pain over the distal femur. The area is tender and swollen. Questions: 1. What is the diagnosis? 2. What organism is most likely responsible? 3. What treatment is required? ⸻ Clinical Case 7 A farmer presents with a slowly enlarging foot swelling with multiple discharging sinuses containing granules. Questions: 1. What is the diagnosis? 2. What causes this condition? 3. How is it managed? ⸻ Clinical Case 8 A 45-year-old woman develops redness, pain, and swelling around a surgical wound 5 days after surgery. Questions: 1. What is the diagnosis? 2. What factors increase the risk? 3. What is the management? ⸻ Clinical Case 9 A patient has temperature 39°C, pulse 120/min, respiratory rate 28/min, and a confirmed intra-abdominal infection. Questions: 1. What systemic condition is present? 2. Define sepsis. 3. Outline initial management. ⸻ Clinical Case 10 A 50-year-old woman presents with fever and a painful breast lump while breastfeeding. Questions: 1. What is the diagnosis? 2. What organism commonly causes it? 3. How is it treated? ⸻ Clinical Case 11 A 42-year-old man presents with painful swelling around the anus. Examination reveals a tender fluctuant mass. Questions: 1. What is the diagnosis? 2. What is the treatment? 3. What late complication may occur? ⸻ Clinical Case 12 A patient presents with productive cough, fever, pleuritic chest pain, and a large pleural collection seen on chest imaging. Questions: 1. What is the diagnosis? 2. Which investigation confirms the diagnosis? 3. How is it managed? ⸻ Clinical Case 13 A shepherd from a rural area presents with a large liver cyst discovered on ultrasound. Questions: 1. What is the most likely diagnosis? 2. What parasite causes it? 3. What are the treatment options? ⸻ Clinical Case 14 A patient presents with right upper quadrant pain, fever, and a liver abscess on ultrasound. He recently returned from a tropical area. Questions: 1. What is the likely diagnosis? 2. What organism causes it? 3. How is it treated? ⸻ Clinical Case 15 A 55-year-old smoker develops calf pain after walking 100 meters. The pain resolves with rest. Questions: 1. What is the diagnosis? 2. What is the underlying pathology? 3. What investigations are useful? ⸻ Clinical Case 16 A 70-year-old man suddenly develops severe pain in the left leg. The leg is pale, cold, and pulseless. Questions: 1. What is the diagnosis? 2. What are the classical signs? 3. What is the immediate management? ⸻ Clinical Case 17 A 34-year-old man presents with dilated tortuous veins along the medial aspect of the leg. Questions: 1. What is the diagnosis? 2. What complications may develop? 3. What treatment options are available? ⸻ Clinical Case 18 A woman presents with unilateral leg swelling and calf pain after a long flight. Questions: 1. What is the diagnosis? 2. What investigation confirms it? 3. Why is prompt treatment important? ⸻ Clinical Case 19 A patient presents with a chronic ulcer over the medial malleolus. Questions: 1. What type of ulcer is this? 2. What is the underlying cause? 3. How is it managed? ⸻ Clinical Case 20 A smoker aged 35 presents with foot pain, toe ulcers, and absent distal pulses. Questions: 1. What is the diagnosis? 2. What is the strongest risk factor? 3. What is the most important treatment? ⸻ Clinical Case 21 A patient develops severe abdominal pain, guarding, rigidity, and fever after a perforated duodenal ulcer. Questions: 1. What complication has occurred? 2. What investigations are required? 3. Outline management. ⸻ Clinical Case 22 A patient presents with a rapidly spreading infection of the forearm following a small puncture wound. Crepitus is palpable. Questions: 1. What is the diagnosis? 2. Which organism is commonly responsible? 3. What treatment is required? ⸻ Clinical Case 23 A child presents with a painful swollen neck mass. Ultrasound suggests necrotic lymph nodes. Questions: 1. What diagnosis should be considered? 2. What investigations are useful? 3. What treatment is indicated? ⸻ Clinical Case 24 A patient presents with fever and tenderness over a previous fracture fixation plate 8 months after surgery. Questions: 1. What is the likely diagnosis? 2. What investigations would you request? 3. What are the principles of treatment? ⸻ Clinical Case 25 A diabetic patient presents with a painful swollen toe and purulent discharge from around the nail. Questions: 1. What is the diagnosis? 2. Which organism is most common? 3. How should it be treated? ⸻ Clinical Case 26 A patient develops generalized erythema and red streaks extending proximally from an infected wound. Questions: 1. What is the diagnosis? 2. Which anatomical structure is inflamed? 3. How is it treated? ⸻ Clinical Case 27 A 25-year-old patient presents with a chronic anesthetic skin patch and thickened peripheral nerves. Questions: 1. What is the diagnosis? 2. What organism causes it? 3. What are the principles of treatment? ⸻ Clinical Case 28 A postoperative patient develops fever, tachycardia, hypotension, and confusion. Questions: 1. What serious complication should be suspected? 2. What investigations are required urgently? 3. What are the key management principles? ⸻ Clinical Case 29 A patient presents with painful swelling near the parotid gland associated with fever and purulent discharge from Stensen’s duct. Questions: 1. What is the diagnosis? 2. What factors predispose to this condition? 3. How is it treated? ⸻ Clinical Case 30 A patient presents with redness and swelling of the leg. Duplex ultrasound demonstrates thrombosis of the deep veins. Questions: 1. What is the diagnosis? 2. What is the most feared complication? 3. Outline treatment.

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Here are comprehensive answers to all 30 clinical cases, drawn from Bailey & Love's Surgery, Tintinalli's Emergency Medicine, Andrews' Diseases of the Skin, Robbins Pathology, Schwartz's Principles of Surgery, and other authoritative textbooks in the medical library.

Clinical Cases: Infections and Vascular Surgery

Case 1 - Right Lower Leg: Pain, Redness, Swelling, Poorly Defined Margins

1. Most likely diagnosis: Cellulitis Cellulitis is a spreading infection of the subcutaneous tissue. The key distinguishing feature here is the poorly defined margins - this separates cellulitis from erysipelas (which has sharp, well-demarcated borders). The systemic fever (38.5°C) confirms active infection.
2. Common causative organisms
  • Streptococcus pyogenes (Group A Streptococcus) - most common
  • Staphylococcus aureus (including MRSA)
  • In special circumstances: Aeromonas hydrophila (freshwater exposure), Vibrio vulnificus (saltwater), aerobic gram-negative bacilli (diabetics and immunocompromised), non-group A beta-haemolytic streptococci (elderly)
3. Treatment
  • Mild/moderate (no systemic toxicity): Oral antibiotics - amoxicillin-clavulanate, flucloxacillin, or co-amoxiclav; mark the advancing edge with a skin marker to monitor progression
  • Severe/spreading (systemic toxicity, fever): IV antibiotics - benzylpenicillin + flucloxacillin, or IV co-amoxiclav; if MRSA suspected, use vancomycin or daptomycin
  • Elevate the limb, analgesia, and rest
  • Blood cultures if severe systemic toxicity (yield is low but worthwhile)
  • Duration typically 5-7 days; switch to oral once improving

Case 2 - Perineum: Severe Pain, Fever, Black Discoloration, Rapid Spread

1. Diagnosis: Fournier's Gangrene (a specific form of necrotizing fasciitis of the perineum/genitalia)
2. Why it is dangerous
  • It is a rapidly progressive necrotizing infection involving the deep fascia
  • Progression from redness to central blue-black discolouration and gangrene can occur within 24-48 hours
  • It is typically polymicrobial (aerobic + anaerobic synergy: beta-haemolytic streptococci, staphylococci, coliforms, enterococci, Pseudomonas, Bacteroides)
  • The anaerobic component produces gas, causing crepitus and subcutaneous emphysema
  • Mortality can reach 20-40% even with optimal treatment
  • Diabetes is a major risk factor for delayed presentation and worse outcomes
  • Septic shock, multi-organ failure, and extensive tissue destruction can occur rapidly
3. Immediate management
  1. Surgical emergency - urgent wide radical debridement of all necrotic tissue; leave no necrotic tissue behind (re-look and re-debride in 24-48h)
  2. Broad-spectrum IV antibiotics covering polymicrobial flora: e.g. piperacillin-tazobactam + metronidazole + an aminoglycoside
  3. Aggressive resuscitation with IV fluids
  4. ICU admission for monitoring
  5. Hyperbaric oxygen therapy as adjunct where available (reduces anaerobic burden)
  6. Wound reconstruction after infection controlled (split-skin grafting, flaps)

Case 3 - Recurrent Axillary Fluctuant Swelling

1. Diagnosis: Hidradenitis Suppurativa (HS) A chronic, recurrent condition characterized by follicular occlusion, folliculitis, and secondary infection, culminating in painful abscesses, sinus tracts, and scarring in apocrine gland-bearing areas (axillae, groins, perineum). - Bailey and Love's Surgery
2. Risk factors
  • Female sex (affects 4 women for every 1 man)
  • Obesity
  • Smoking (strongly associated)
  • Genetic predisposition (variable penetrance)
  • Sex hormone influence (onset at puberty, often resolves at menopause)
  • Associated organisms: Staphylococcus aureus and Propionibacterium acnes
3. Treatment
  • Lifestyle: Stop smoking; lose excess weight; antiseptic soaps, tea tree oil, non-compressive clothing
  • Medical: Topical clindamycin; oral antibiotics (tetracycline, doxycycline, or combination clindamycin + rifampicin); antiandrogen therapy; biologics (adalimumab - the only FDA-approved biologic for moderate-severe HS)
  • Surgical: Incision and drainage for acute abscesses; radical excision of affected skin and subcutaneous tissue in chronic/severe cases; reconstruction to avoid contracture

Case 4 - Painful Fluctuant Fingertip Swelling

1. Diagnosis: Felon (pulp space infection of the fingertip) A felon is a closed-space infection of the distal pulp of the finger. The enclosed fibrous septa create high compartment pressure rapidly.
2. Complications if untreated
  • Osteomyelitis of the distal phalanx (most important)
  • Flexor tendon sheath infection (tenosynovitis) - spreading proximally
  • Septic arthritis of the DIP joint
  • Ischaemic necrosis of the pulp due to raised compartment pressure compromising blood supply
  • Chronic pain and permanent loss of fingertip sensation/function
3. Management
  • Surgical incision and drainage under digital block or general anaesthetic; a high lateral incision parallel to the nail avoids the weight-bearing and sensitive volar pad
  • Thorough irrigation of all loculations
  • Leave wound open or loosely packed to allow drainage
  • Oral antibiotics post-drainage (flucloxacillin or co-amoxiclav covers S. aureus)
  • Swab for culture and sensitivity
  • Elevation and analgesia
  • Daily dressing changes

Case 5 - Diabetic with Hot, Swollen, Painful Knee

1. Diagnosis: Septic Arthritis Hot, acutely swollen joint with pain on any movement in a diabetic patient is septic arthritis until proven otherwise.
2. Investigation that confirms it: Joint aspiration (arthrocentesis) with synovial fluid analysis and culture
  • Synovial fluid WBC >50,000/mm³ with >90% neutrophils is strongly suggestive
  • Gram stain (positive in ~50%) and culture are definitive
  • Blood cultures should also be taken (bacteraemia is common)
  • X-ray to exclude fracture/other pathology
3. Treatment
  • IV antibiotics immediately after cultures taken - do not wait for results if clinical suspicion is high
    • Empirical: flucloxacillin (MSSA cover); vancomycin if MRSA risk or penicillin allergy
    • In diabetics/elderly: cover gram-negative organisms (add ceftriaxone or piperacillin-tazobactam)
  • Joint drainage: Repeated needle aspiration daily (or arthroscopic washout if no improvement within 48-72h; or open arthrotomy for hip/shoulder)
  • Duration of antibiotics: typically 4-6 weeks (initially IV, then oral)
  • Physiotherapy once infection controlled

Case 6 - 14-year-old: Fever, Severe Pain Over Distal Femur

1. Diagnosis: Acute Haematogenous Osteomyelitis The metaphysis of long bones (distal femur, proximal tibia) is the classic site in children and adolescents. The rich metaphyseal blood supply with sluggish capillary flow predisposes to bacterial seeding.
2. Most likely organism: Staphylococcus aureus S. aureus is the most common cause at all ages. In children, Streptococcus pyogenes and S. pneumoniae are also seen. In neonates, Group B Streptococcus and gram-negatives are important. Salmonella should be considered in sickle cell disease patients.
3. Treatment required
  • IV antibiotics for at least 6 weeks total (IV initially then oral switch when clinical improvement and falling CRP)
    • Empirical: IV flucloxacillin ± fusidic acid; adjust based on culture
    • MRSA: vancomycin or teicoplanin
  • Surgical drainage if: subperiosteal abscess present, no response to antibiotics in 48-72h, or fluctuant swelling present
  • WBC, CRP, ESR to monitor response; MRI is the most sensitive investigation for early diagnosis
  • Aggressive treatment reduces risk of chronic osteomyelitis

Case 7 - Farmer with Foot Swelling and Discharging Sinuses with Granules

1. Diagnosis: Mycetoma (Madura Foot / Maduromycosis)
2. Cause Mycetoma is a chronic granulomatous subcutaneous infection caused by either:
  • Actinomycetoma (caused by filamentous bacteria): Nocardia brasiliensis, Actinomadura madurae, Actinomyces israelii - most common in Africa/India
  • Eumycetoma (caused by true fungi): Madurella mycetomatis, Scedosporium apiospermum Organisms enter via traumatic inoculation (thorn prick, soil exposure). The hallmark triad is: progressive subcutaneous swelling + sinus tracts + grain discharge (colour of grains indicates the organism). - Andrews' Diseases of the Skin
3. Management
  • Diagnosis: Grain examination (colour/shape), histology, culture, PCR; X-ray/MRI for bone involvement
  • Actinomycetoma: Combination antibiotics - co-trimoxazole (trimethoprim-sulfamethoxazole) plus amikacin; or dapsone + streptomycin; long-term (months to years)
  • Eumycetoma: Antifungals - itraconazole or voriconazole (long-term, often years); poor response to medical therapy alone
  • Surgery: Wide excision or amputation may be needed for large/unresponsive lesions, especially eumycetoma

Case 8 - Post-op Redness and Swelling Around Wound at Day 5

1. Diagnosis: Surgical Site Infection (SSI) Surgical wound infection typically presents 4-7 days post-operatively with the classic features of inflammation at the wound: redness, pain, swelling, warmth, and discharge.
2. Risk factors
  • Patient factors: Diabetes mellitus, obesity, smoking, malnutrition, immunosuppression (steroids, chemotherapy, HIV), advanced age, MRSA colonisation
  • Surgical factors: Emergency surgery, prolonged operating time (>2h), poor tissue handling, excessive diathermy, haematoma, dead space, use of drains
  • Environmental factors: Break in sterile technique, inadequate skin preparation, contaminated instruments
3. Management
  • Open the wound to release pus/exudate (lay open the infected portion)
  • Wound swab for culture and sensitivity
  • Dressing - moist wound healing; regular changes
  • Antibiotics if: cellulitis spreading beyond wound edges, systemic sepsis, or immunocompromised patient (flucloxacillin or co-amoxiclav empirically)
  • Address underlying risk factors
  • Debridement of necrotic tissue
  • Delayed primary closure or secondary intention healing once clean

Case 9 - Fever 39°C, Tachycardia, Tachypnoea, Confirmed Intra-abdominal Infection

1. Systemic condition: Sepsis (previously called SIRS progressing to sepsis)
2. Definition of Sepsis (Sepsis-3, 2016) Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. It is identified clinically by an acute change in SOFA (Sequential Organ Failure Assessment) score ≥2 points in the context of confirmed or suspected infection. The older SIRS criteria (temperature >38°C or <36°C, HR >90, RR >20, WBC >12,000 or <4,000) identify systemic inflammation but not necessarily sepsis. Septic shock = sepsis + vasopressor requirement + lactate >2 mmol/L despite fluid resuscitation.
3. Initial management (Sepsis-6 bundle - within 1 hour)
  1. Administer high-flow oxygen
  2. Take blood cultures (before antibiotics if possible - 2 sets)
  3. Give IV broad-spectrum antibiotics (e.g. piperacillin-tazobactam + metronidazole for intra-abdominal source)
  4. IV fluid resuscitation - 30 mL/kg crystalloid bolus for hypoperfusion
  5. Measure serum lactate (if >4 mmol/L: high risk)
  6. Measure urine output - insert urinary catheter; aim >0.5 mL/kg/hour
  • Control the source of infection surgically if indicated (e.g. drain abscess, repair perforation)
  • Vasopressors (noradrenaline) if hypotension persists after fluid resuscitation
  • ICU level care if septic shock develops

Case 10 - Breastfeeding Woman with Fever and Painful Breast Lump

1. Diagnosis: Puerperal (Lactational) Mastitis, possibly progressing to Breast Abscess Mastitis = infection of breast tissue occurring during lactation. If a fluctuant mass is present, abscess formation has occurred.
2. Most common organism: Staphylococcus aureus Enters via cracked nipples. MRSA is an increasing concern.
3. Treatment
  • Mastitis (no abscess):
    • Continue breastfeeding (or regular expression) to prevent milk stasis
    • Antibiotics: flucloxacillin 500 mg QDS for 10-14 days (or erythromycin if penicillin-allergic)
    • Analgesia (paracetamol/ibuprofen)
    • Warm compresses
  • Breast abscess:
    • Ultrasound-guided needle aspiration (preferred - repeated if needed, causes less scarring)
    • If large or not resolving: incision and drainage under anaesthesia; radial incision to avoid damage to ducts
    • Antibiotics post-drainage
    • Wound left open and packed; dressing changes

Case 11 - Tender Fluctuant Perianal Mass

1. Diagnosis: Anorectal (Perianal) Abscess
2. Treatment Surgical emergency - Incision and Drainage (I&D) under anaesthesia. The abscess is opened and drained; do not close primarily. Antibiotics are generally not required post-drainage in immunocompetent patients unless there is surrounding cellulitis.
  • Four types based on anatomical space: perianal (most common), ischiorectal, intersphincteric, supralevator
3. Late complication: Anal Fistula (Fistula-in-Ano) Approximately 30-50% of anorectal abscesses develop into a fistula-in-ano. The abscess originates from an infected anal gland (cryptoglandular theory), and a persistent track between the anal canal and the skin persists. Fistula requires surgical treatment: fistulotomy (for superficial fistulas) or seton placement (for complex/high fistulas to preserve sphincter function).

Case 12 - Productive Cough, Fever, Pleuritic Pain, Large Pleural Collection

1. Diagnosis: Empyema Thoracis (Pyothorax) Pus or infected fluid in the pleural space. Commonly develops as a complication of pneumonia (parapneumonic effusion that becomes infected), but also post-surgery or trauma.
2. Confirmatory investigation: Pleural fluid aspiration (thoracocentesis) and analysis
  • Diagnostic criteria for empyema (Light's criteria for exudate, plus):
    • Grossly purulent fluid
    • Positive Gram stain or culture of pleural fluid
    • pH <7.2, glucose <2.2 mmol/L, LDH >1000 IU/L (complicated parapneumonic criteria)
  • Chest CT scan helps define loculations
3. Management
  • Antibiotics: IV broad-spectrum (cover streptococci, staphylococci, anaerobes); e.g. co-amoxiclav + metronidazole; tailor to culture
  • Drainage:
    • Simple/free-flowing: intercostal chest drain (large bore)
    • Loculated: chest drain + intrapleural fibrinolytics (alteplase + DNase) - MIST2 trial supports this
    • Chronic/organized empyema: Video-assisted thoracoscopic surgery (VATS) decortication
  • Nutritional support (chronic empyema is catabolic)

Case 13 - Rural Shepherd with Large Liver Cyst

1. Diagnosis: Hydatid Cyst (Cystic Echinococcosis)
2. Causative parasite: Echinococcus granulosus A cestode (tapeworm). Dogs are the definitive host; sheep are intermediate hosts. Humans are accidental intermediate hosts, acquiring infection by ingesting food/water contaminated with dog faeces containing tapeworm eggs. Oncospheres migrate via portal circulation to the liver (most common: 60-70%) or lungs.
3. Treatment options
  • PAIR (Percutaneous Aspiration, Instillation, Re-aspiration): Now the treatment of choice for uncomplicated cysts (WHO stages CE1 and CE3a); under ultrasound guidance; hypertonic saline instilled to kill scolices; performed with albendazole cover
  • Surgery: Still required for large cysts, cysts communicating with biliary tree, inaccessible cysts, or failed PAIR; techniques include cystectomy or pericystectomy; pre- and post-operative albendazole is mandatory
  • Medical (albendazole alone): For small CE1 cysts and inactive cysts; variable response; used as adjunct to all interventions to prevent secondary seeding
  • Avoid aspiration without protection (risk of anaphylaxis and seeding if cyst ruptures)

Case 14 - Tropical Traveller with Fever, RUQ Pain, Liver Abscess

1. Diagnosis: Amoebic Liver Abscess
2. Causative organism: Entamoeba histolytica A protozoan parasite. Common in tropical/developing regions. Transmission is faecal-oral. The trophozoites invade the colonic mucosa and travel via portal circulation to the liver, where they produce a solitary (usually right lobe) "anchovy sauce" pus abscess. Blood cultures are typically negative (unlike pyogenic abscess).
3. Treatment
  • Metronidazole 400-800 mg TDS for 5-10 days - drug of choice (highly effective); this treats the tissue amoebae
  • Followed by a luminal agent to eradicate intestinal carriage: diloxanide furoate 500 mg TDS for 10 days
  • Drainage: Most amoebic abscesses resolve with medical therapy alone; drainage indicated if: very large (>5 cm), left lobe (risk of rupture into pericardium), no response to metronidazole in 72h, or uncertain diagnosis
  • Serological tests (E. histolytica antibodies) are positive in >90% of amoebic abscesses

Case 15 - Smoker with Calf Pain at 100 Metres, Relieved by Rest

1. Diagnosis: Intermittent Claudication due to Peripheral Arterial Disease (PAD) Fontaine Stage IIb (claudication distance <200 m). The classic symptom is muscular cramping pain brought on by exertion and relieved by rest within minutes (not by changing position, which distinguishes it from neurogenic claudication).
2. Underlying pathology: Atherosclerosis Progressive build-up of atherosclerotic plaque in the arterial wall (intimal deposition of lipid, foam cells, fibrous cap) causes stenosis/occlusion of peripheral arteries. The superficial femoral artery in the adductor canal is the most commonly affected segment. Smoking, hypertension, diabetes, and hypercholesterolaemia are the major risk factors.
3. Useful investigations
  • Ankle-Brachial Pressure Index (ABPI): Gold standard non-invasive test; normal 1.0-1.3; claudication typically 0.5-0.9; critical ischaemia <0.5
  • Duplex ultrasound: maps stenoses and occlusions
  • CT Angiography (CTA) or MR Angiography (MRA): pre-intervention planning
  • Bloods: FBC, HbA1c, lipid profile, renal function, coagulation

Case 16 - 70-year-old: Sudden Severe Left Leg Pain, Pale, Cold, Pulseless

1. Diagnosis: Acute Limb Ischaemia (most likely arterial embolism, given sudden onset)
2. Classical signs - The 6 P's
  1. Pain - sudden and severe, at rest
  2. Pallor - white/waxy appearance (later cyanosis)
  3. Pulselessness - absent distal pulses below the level of occlusion
  4. Paraesthesia - pins and needles (early nerve ischaemia)
  5. Paralysis - inability to move the foot/toes (late, urgent sign; indicates irreversible ischaemia if prolonged)
  6. Perishing cold (Poikilothermia) - the limb is cold to touch
  • In aortic embolism, both legs are affected with loss of movement at hips and knees
Embolic causes (most common): atrial fibrillation, mitral stenosis, post-MI mural thrombus. In the lower limb, emboli commonly lodge at the common femoral bifurcation or popliteal trifurcation.
3. Immediate management
  • IV heparin immediately (5,000-10,000 U bolus then infusion) to prevent clot propagation
  • Urgent vascular surgical referral - this is a time-critical emergency (viable <6h, irreversible >6h)
  • Embolectomy: Fogarty balloon catheter embolectomy under local anaesthesia (treatment of choice for embolic occlusion within 6h)
  • Thrombolysis: Intra-arterial catheter-directed thrombolysis (e.g. tPA) for acute-on-chronic thrombosis or when surgery not feasible; requires 12-24h
  • Treat underlying cardiac cause (rate control/anticoagulation for AF)
  • If irreversible ischaemia (paralysis + rigidity + fixed staining): primary amputation

Case 17 - 34-year-old: Dilated Tortuous Medial Leg Veins

1. Diagnosis: Varicose Veins (long/great saphenous system, given medial distribution) Incompetent sapheno-femoral junction with reflux down the long saphenous vein is the most common cause. - Pye's Surgical Handicraft
2. Complications
  • Varicose eczema/lipodermatosclerosis - pigmentation, induration of skin around medial malleolus
  • Varicose (venous) ulceration - chronic ulcer at medial malleolus; the most serious complication
  • Superficial thrombophlebitis - painful, hard, cord-like vein
  • Haemorrhage - from a varix, can be alarming (compression controls it)
  • Ankle oedema
  • Deep vein thrombosis (less common direct complication)
3. Treatment options
  • Conservative: Compression stockings (Class II), lifestyle advice (avoid prolonged standing), leg elevation
  • Endovenous ablation: Endovenous laser ablation (EVLA) or radiofrequency ablation (RFA) - now first-line for truncal reflux; less morbidity than surgery
  • Ultrasound-guided foam sclerotherapy: Injection of sclerosant foam; good for smaller veins and recurrences
  • Surgical (saphenofemoral ligation and stripping): Trendelenburg operation - still used; ligation of sapheno-femoral junction plus stripping of the long saphenous vein
  • Phlebectomy/avulsions: For tributary varicosities alongside any of the above

Case 18 - Unilateral Leg Swelling and Calf Pain After Long Flight

1. Diagnosis: Deep Vein Thrombosis (DVT) - provoked by prolonged immobility (Virchow's triad: stasis, endothelial injury, hypercoagulability)
2. Investigation that confirms it: Duplex (compression) ultrasonography
  • Non-compressibility of the vein is diagnostic of DVT
  • D-dimer (sensitive but not specific): if low clinical probability (low Wells score) + negative D-dimer = DVT excluded; if high probability, proceed to USS regardless
  • CT venography or MRI venography for iliac/pelvic vein DVT
3. Why prompt treatment is important
  • Pulmonary embolism (PE) - the most feared complication; a clot may dislodge and travel to the pulmonary circulation; massive PE causes sudden death; even submassive PE has significant morbidity
  • Post-thrombotic syndrome (PTS) - chronic valvular incompetence causing chronic leg swelling, pain, venous eczema, and ultimately venous ulceration; early anticoagulation reduces incidence
Treatment:
  • Anticoagulation - Direct oral anticoagulants (DOACs) are first-line: rivaroxaban or apixaban (no bridging needed); or low-molecular-weight heparin (LMWH) followed by warfarin
  • Duration: provoked DVT (identifiable reversible cause like flight) = 3 months; unprovoked = minimum 3 months, consider extended therapy
  • Compression stockings to reduce PTS
  • Mobilise (bed rest is no longer recommended)

Case 19 - Chronic Ulcer Over the Medial Malleolus

1. Type: Venous Leg Ulcer (the medial malleolus location is pathognomonic of venous disease)
2. Underlying cause: Chronic venous insufficiency Incompetent deep and/or perforating venous valves cause sustained venous hypertension in the lower leg. This leads to capillary leak, tissue oedema, lipid and haemosiderin deposition, lipodermatosclerosis, and ultimately skin breakdown. Previous DVT, varicose veins, and obesity are common antecedents.
3. Management
  • ABPI must be measured first to exclude arterial disease before applying compression; ABPI >0.8 = safe for compression
  • Compression therapy: Four-layer compression bandaging (or class 3 compression stockings once healed) - the cornerstone of treatment; promotes venous return
  • Wound care: Moist wound dressings (hydrocolloid, alginate); treat surrounding eczema; debridement of slough
  • Treat infection: Antibiotics only if clinical signs of infection (not for colonisation)
  • Correct underlying venous disease: Endovenous ablation of superficial reflux has been shown to improve healing and reduce recurrence (EVRA trial)
  • Leg elevation when resting
  • Pentoxifylline as adjunct to compression
  • Skin grafting for large persistent ulcers

Case 20 - 35-year-old Smoker with Foot Pain, Toe Ulcers, Absent Distal Pulses

1. Diagnosis: Buerger's Disease (Thromboangiitis Obliterans) Classic presentation: young male smoker, absent distal pulses, ischaemic ulcers of toes, with no major cardiovascular risk factors (no diabetes, hypertension, or hypercholesterolaemia).
2. Strongest risk factor: Smoking (tobacco use) Tobacco use is absolutely essential to both the diagnosis and progression of Buerger's disease. The cause is unknown but tobacco exposure drives the inflammatory process in small- and medium-sized limb arteries and veins. - Schwartz's Principles of Surgery
3. Most important treatment: Complete and absolute smoking cessation
  • In patients who stop smoking entirely, disease remission is impressive and amputation is largely avoidable
  • Continued smoking leads to 67% limb loss vs 35% in those who stop
  • Additional measures: vasodilators (nifedipine, prostacyclin infusions for rest pain/ulcers), analgesia, wound care for ulcers; bypass surgery is often not possible due to distal disease pattern and absent conduit; amputation may ultimately be required for gangrene

Case 21 - Abdominal Pain, Guarding, Rigidity, Fever After Perforated Duodenal Ulcer

1. Complication: Generalised Peritonitis (chemical initially, then bacterial)
2. Investigations required
  • Erect chest X-ray or abdominal X-ray: free gas under the diaphragm (pneumoperitoneum)
  • CT abdomen and pelvis with contrast: Confirms free air, defines the perforation site, and identifies any collection
  • FBC, U&E, LFTs, amylase/lipase, coagulation, group and save
  • Blood cultures
  • Lactate (assess perfusion)
  • ECG (exclude MI as cause of abdominal pain)
3. Management
  • Resuscitation: IV fluids, analgesia (IV morphine), NG tube (free drainage), urinary catheter, IV antibiotics (co-amoxiclav + metronidazole or piperacillin-tazobactam), oxygen
  • Surgery (emergency laparotomy or laparoscopy):
    • Graham patch repair (omental patch closure of perforation) - most common
    • Thorough peritoneal lavage with warm saline
    • Drains placed
  • Post-operative: Continue antibiotics, PPIs (high-dose), H. pylori eradication therapy, DVT prophylaxis
  • In selected stable patients with contained perforation: non-operative management (NG suction, antibiotics, PPI, close monitoring) - but most require surgery

Case 22 - Rapidly Spreading Forearm Infection with Palpable Crepitus After Puncture Wound

1. Diagnosis: Gas Gangrene (Clostridial Myonecrosis) or Crepitant/Necrotizing Fasciitis with gas-forming organisms Crepitus = subcutaneous gas from gas-producing bacteria. The combination of rapid spread + crepitus after a wound is gas gangrene until proven otherwise.
2. Causative organism: Clostridium perfringens (most common) Other clostridia: C. septicum, C. novyi, C. histolyticum. These are gram-positive anaerobic spore-forming bacilli. They elaborate alpha-toxin (lecithinase) which destroys cell membranes, causing rapid tissue destruction and gas production (CO₂ and H₂). Non-clostridial gas-forming organisms can also cause crepitant cellulitis (e.g. coliforms, anaerobic streptococci - typically less severe).
3. Treatment required - Surgical emergency
  1. Emergency surgical debridement - wide, radical excision of all affected muscle and necrotic tissue; amputation may be life-saving
  2. High-dose IV penicillin G (drug of choice for clostridia) + metronidazole; add broad-spectrum cover if polymicrobial
  3. Hyperbaric oxygen (HBO) as adjunct where available
  4. Aggressive resuscitation - massive fluid shifts, haemolysis
  5. Repeated debridement (re-look at 24-48h)
  6. Wound reconstruction after eradication of infection

Case 23 - Child with Painful, Swollen Neck Mass; Necrotic Lymph Nodes on Ultrasound

1. Diagnosis to consider: Tuberculous Lymphadenitis (Scrofula) Also consider: bacterial lymphadenitis, cat scratch disease (Bartonella henselae), atypical mycobacterial infection, lymphoma (necrotic nodes on USS require exclusion of malignancy)
2. Useful investigations
  • Mantoux test/tuberculin skin test (TST) or IGRA (Interferon-Gamma Release Assay) - for TB
  • Fine needle aspiration cytology (FNAC): Caseating granulomas, AFB staining, TB culture (liquid media - 6-8 weeks); also cytology to exclude lymphoma
  • Core needle biopsy or excision biopsy if FNAC inconclusive
  • Chest X-ray (look for primary TB focus)
  • Culture of aspirate (AFB culture + sensitivity testing for drug resistance)
  • Bloods: FBC, CRP, HIV status
3. Treatment
  • If TB confirmed: Standard anti-TB therapy: 2 months HRZE (isoniazid, rifampicin, pyrazinamide, ethambutol) followed by 4 months HR (isoniazid, rifampicin) - total 6 months
  • Surgical drainage only if abscess fluctuates and threatens to discharge spontaneously ("collar stud" abscess)
  • Excision biopsy if diagnosis uncertain or atypical mycobacteria suspected (which respond poorly to standard TB therapy)

Case 24 - Fever and Tenderness Over Fracture Fixation Plate 8 Months Post-op

1. Diagnosis: Implant/Prosthetic-Related Osteomyelitis (Periprosthetic/Implant Infection) Late infection (after 3 months) is typically caused by haematogenous seeding onto the implant or by low-virulence organisms that were introduced at surgery (delayed presentation).
2. Investigations
  • Bloods: FBC, ESR, CRP (raised), blood cultures
  • X-ray: Periosteal reaction, bone lysis around implant, loosening
  • CT or MRI: To assess extent of bone involvement and soft tissue involvement
  • Nuclear medicine bone scan (Tc-99m) or white cell scan: For extent of infection
  • Bone biopsy with culture (gold standard) - multiple samples from around the implant; long incubation for slow-growing organisms (Propionibacterium/Cutibacterium acnes)
  • Culture and sensitivity including TB and fungi
3. Principles of treatment (DAIR vs implant removal)
  • DAIR (Debridement, Antibiotics, Implant Retention): For early infection or acute haematogenous infection with a stable, well-fixed implant; only if bone still healing
  • Implant removal is usually necessary for late chronic infection:
    1. Remove all hardware
    2. Thorough debridement of all infected and necrotic bone/tissue
    3. Culture-guided prolonged antibiotics (IV then oral, typically 6 weeks - months)
    4. Use of antibiotic-impregnated beads/spacers
    5. Re-implantation once infection cleared (if fixation needed)
  • Refer to specialist orthopaedic infection unit

Case 25 - Diabetic with Painful Swollen Toe and Purulent Nail Discharge

1. Diagnosis: Paronychia (acute infection of the nail fold/perionychium), possibly with ingrown toenail (onychocryptosis) as the predisposing cause; consider underlying osteomyelitis given the diabetic context.
2. Most common organism: Staphylococcus aureus In diabetics, gram-negative organisms and polymicrobial infections (including anaerobes) are more common than in non-diabetics. MRSA should be considered.
3. Treatment
  • Acute paronychia: Incision and drainage under digital nerve block; remove any ingrown nail spike; pack wound; antibiotics (flucloxacillin or co-amoxiclav)
  • In diabetics: More aggressive approach needed; assess foot vascularity (ABPI); X-ray the toe to exclude osteomyelitis
  • Osteomyelitis: Prolonged antibiotics or surgical debridement/amputation of digit
  • Nail avulsion for recurrent ingrown toenail
  • Optimize diabetic control (HbA1c); aggressive wound care; diabetic podiatry referral
  • Patient education about nail care

Case 26 - Generalized Erythema with Red Streaks Extending from Infected Wound

1. Diagnosis: Lymphangitis
2. Anatomical structure inflamed: The lymphatic vessels (lymphatic channels draining the infected area, running towards regional lymph nodes) The red streaks represent inflamed superficial lymphatic vessels. They typically track from the wound towards the regional lymph node basin (e.g. from hand wound up the medial forearm to the axilla). Regional lymph nodes become tender and enlarged (lymphadenitis). - Andrews' Diseases of the Skin
3. Treatment
  • IV antibiotics promptly - beta-haemolytic streptococci are the most common cause; IV benzylpenicillin is the drug of choice; IV flucloxacillin if staphylococcal superinfection suspected
  • Treat the underlying wound infection (clean, debride, drain if abscess)
  • Rest, elevation of the affected limb
  • Analgesia
  • Monitor for systemic sepsis (can progress rapidly to bacteraemia)
  • Mark the extent of streaking to monitor progression/response

Case 27 - Chronic Anaesthetic Skin Patch and Thickened Peripheral Nerves

1. Diagnosis: Leprosy (Hansen's Disease) The combination of hypopigmented anaesthetic skin patch + thickened peripheral nerves is virtually pathognomonic of leprosy.
2. Causative organism: Mycobacterium leprae An obligate intracellular acid-fast bacillus. It has an extremely long incubation period (2-5 years). It has a predilection for cooler tissues: skin, peripheral nerves (particularly ulnar, common peroneal, great auricular, radial cutaneous, and posterior tibial nerves), and the anterior segment of the eye. Clinical spectrum depends on cell-mediated immunity:
  • Tuberculoid (TT): Strong immunity; few lesions, thickened nerves, AFB negative
  • Lepromatous (LL): Poor immunity; numerous lesions, diffuse infiltration, AFB positive
  • Borderline forms (BT, BB, BL)
3. Principles of treatment (WHO Multi-Drug Therapy - MDT) MDT eliminates the risk of drug resistance and is fully effective:
  • Paucibacillary (PB - 1-5 lesions): Dapsone 100 mg daily + Rifampicin 600 mg monthly - for 6 months
  • Multibacillary (MB - >5 lesions or skin smear positive): Dapsone 100 mg daily + Clofazimine 50 mg daily + Rifampicin 600 mg + Clofazimine 300 mg monthly - for 12 months
  • Treat reactions: Type 1 (reversal) with prednisolone; Type 2 (ENL) with thalidomide or prednisolone
  • Prevent deformity: physiotherapy, nerve decompression surgery, padded footwear, self-care for anaesthetic hands/feet

Case 28 - Post-op Fever, Tachycardia, Hypotension, Confusion

1. Serious complication suspected: Septic Shock (post-operative source: wound, anastomotic leak, pneumonia, UTI, line infection) Also consider: massive PE (sudden hypotension), MI, haemorrhage, adrenal crisis, anaphylaxis - but until proven otherwise, treat as septic shock.
2. Urgent investigations
  • Blood cultures (2 sets from different sites, before antibiotics if <45 minutes possible)
  • FBC (leukocytosis or leukopenia), CRP, procalcitonin
  • Lactate (serial lactate; >4 = poor prognosis)
  • U&E, creatinine, LFTs (organ function)
  • Coagulation screen (DIC)
  • ABG (metabolic acidosis, respiratory failure)
  • Urine culture (catheter urine)
  • CXR, ECG
  • Wound inspection
  • CT abdomen if anastomotic leak/abdominal source suspected
3. Key management principles
  • Resuscitation (SEPSIS-6 within 1 hour): O₂, blood cultures, IV broad-spectrum antibiotics, IV fluids 30 mL/kg, lactate, urine output
  • Source control: Identify and surgically/radiologically drain the focus (re-laparotomy if anastomotic leak)
  • Vasopressors (noradrenaline) if hypotension persists after fluids; target MAP ≥65 mmHg
  • ICU transfer for invasive monitoring, ventilation if needed
  • Corticosteroids for refractory septic shock (hydrocortisone 200 mg/day)
  • Glycaemic control (target 6-10 mmol/L)

Case 29 - Swelling Near Parotid Gland, Fever, Purulent Discharge from Stensen's Duct

1. Diagnosis: Acute Suppurative (Bacterial) Parotitis
2. Predisposing factors
  • Dehydration (most common - reduces salivary flow allowing retrograde bacterial ascent)
  • Advanced age
  • Post-operative state (fluid restriction, NPO)
  • Poor oral hygiene
  • Sialolithiasis (parotid duct stones) obstructing flow
  • Medications reducing salivary flow: anticholinergics, diuretics, antidepressants
  • Immunosuppression, malnutrition, head/neck radiotherapy
3. Treatment
  • Rehydration (IV fluids if dehydrated) - essential to restore salivary flow
  • IV antibiotics: S. aureus is the most common organism; flucloxacillin or co-amoxiclav IV; if MRSA risk, add vancomycin
  • Sialagogues: Stimulate salivary flow (lemon juice, chewing gum)
  • Oral hygiene: Regular mouth washes
  • Massage of the parotid gland
  • Drainage: If abscess forms, incision and drainage (with care to protect facial nerve branches); approach via modified Blair incision
  • Identify and treat any ductal calculus (lithotripsy or Stensen's duct sialolithotomy)
  • Warm compresses

Case 30 - Leg Redness/Swelling + DVT on Duplex Ultrasound

1. Diagnosis: Deep Vein Thrombosis (DVT)
2. Most feared complication: Pulmonary Embolism (PE) A proximal DVT (iliac, femoral, or popliteal vein) can dislodge and travel through the right heart into the pulmonary circulation. Massive PE causes acute right heart failure and sudden death. Even submassive PE carries significant mortality and morbidity. Additional long-term complications include post-thrombotic syndrome and chronic thromboembolic pulmonary hypertension (CTEPH).
3. Treatment
  • Anticoagulation - first-line:
    • DOACs (preferred): Rivaroxaban (15 mg BD for 21 days, then 20 mg OD) or apixaban (10 mg BD for 7 days, then 5 mg BD) - convenient, no INR monitoring
    • LMWH (e.g. enoxaparin) + warfarin (overlap until INR 2-3 for 2 consecutive days) - if DOAC not suitable
    • LMWH alone: preferred in active cancer-associated thrombosis
  • Duration:
    • Provoked (transient risk factor): 3 months
    • Unprovoked: minimum 3 months; consider indefinite if high recurrence risk
    • Active cancer: extended (LMWH or DOAC for at least 6 months)
  • Compression stockings: Grade II below-knee, to reduce post-thrombotic syndrome
  • Mobilisation encouraged (bed rest not recommended)
  • Catheter-directed thrombolysis or surgical thrombectomy: Reserved for massive iliofemoral DVT with threatened limb (phlegmasia cerulea dolens)
  • Investigate for thrombophilia if unprovoked, young, or recurrent
Sources: Bailey and Love's Short Practice of Surgery 28th Ed., Textbook of Family Medicine 9e, Andrews' Diseases of the Skin, Schwartz's Principles of Surgery 11th Ed., Tintinalli's Emergency Medicine, Robbins & Kumar Basic Pathology, Roberts & Hedges' Clinical Procedures in Emergency Medicine, S Das Manual of Clinical Surgery, Pye's Surgical Handicraft 22nd Ed.
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