Abdominal Aortic Aneurysm This Pulsatile expansile abdominal mass not only presents risk of rupture,some erode into spine size is critical,5.5cm in males,5-5.2cm in females indicate impending rupture Mortality: Post rupture:80-90% Pre-hospital:50% 30 day post surgical:30-50%

Pulsatile bulges always suggest AAA !

🚨 A patient presents with pulsatile proptosis, orbital bruit, and diplopia. What is the most likely diagnosis ? #MedX

Physics-Informed Operator Learning for Pulsatile Milk Flow in Distal Generations of a Bifurcated Mammary Duct Network ift.tt/XbpMsuG #biorxiv_bioE

Palpable pulsatile midline infrarenal abdominal mass: Aortic aneurysm. Associated with transmural inflammation. Risk factors; tobacco smoking, advanced age and family hx

A pulsatile abdomen means there is transmitted or true pulsation in an abdominal structure,not necessarily that the aorta is aneurysmal. AAA is the most important diagnosis to exclude because rupture can be fatal, but enlarged organs, tumors, cysts, heart failure with congestive hepatomegaly, and other vascular lesions can all produce the same clinical finding

AAA: Pulsatile expansive abdominal mass Large aneurysm not only present risk of rupture, some erode into spine. size is critical, 5.5cm in males 5.0-5.2cm in females indicate impending rupture Mortality post rupture is 80-90% 50% pre-hospital 30-50% post surgery at 30 days,

Visual summary of the classic peripheral signs of AR.😍 Each sign reflects a hyperdynamic circulation due to high stroke volume & low diastolic pressure. Here’s what each sign means: ⚪De Musset’s sign: Head bobbing with each heartbeat ⚪ Corrigan’s sign/pulse: Rapidly rising & collapsing carotid pulse ⚪ Müller’s sign: Uvular pulsation ⚪ Landolfi’s sign: Pupillary constriction/dilation with pulse ⚪ Becker’s sign: Retinal artery pulsation ⚪ Quincke’s sign: Capillary pulsation in the nail bed ⚪ Hill’s sign: Higher leg BP than arm (by >20 mmHg) ⚪ Mayne’s sign: >15 mmHg drop in diastolic BP on arm elevation ⚪ Duroziez’s sign: Femoral bruit with light pressure ⚪ Traube’s sign: Pistol-shot sounds over femoral artery ⚪ Pistol-shot femorals: Loud, sharp systolic-diastolic sounds ⚪ Rosenbach’s sign: Pulsatile liver ⚪ Gerhardt’s sign: Pulsatile spleen ⚪ Water hammer pulse (Corrigan pulse): Bounding radial pulse ⚪ Lighthouse sign: Alternating red/white reflection on forehead ⚪ Hill’s sign: Marked BP difference between lower & upper limbs These signs reflect wide pulse pressure, a key hemodynamic hallmark of AR.

@DirectorWray @Keir_Starmer @ArmyParachute @CherieBlairKC I know this challenge was hard with my second book Parahuting the Name of Charity Sequel and I thought about it long and hard a strategy on how to win by my investigative research book. The aeroplane was a bent Air Pilot who I suspected was ex-RAF John Saunders who did spelling errors and would not let me correct the spelling when I know that I was not dsylexic and that Northamptonshire NHS Mental health team and Northamptonshire Police were paranoid because they smoked cannabis and took cocaine themselves and tried to stop me from having a normal private life and quiet enjoyment after Northants government had made significant financial gains and for reasons of their own sexual gratification and theft of any of my rich friends money by armed robberies or an alleged police investigation and then made a film from my stolen private information so it was only armed robbery thieves who Princess Kate had allowed to get rich due to pure jealousy and racial hatred and why I never wanted to ever get married to anyone in the Royal family. I had received targeted pulsatile tinnitus so I cannot work in any noisy environments because I recognised that bent qualified solicitors Russian born citizen previously charged with terrorism at least half a dozens times as a child to his fifties Muiris Lyons (DOB 10.07.1967) and Jon Dunkley of Devon also previously charged with terrorism half a dozen times in the USA who escaped each American Prevention of Terrorism Court trials process (DOB 19.01.1971) of Barnstaple Devon, Robert James Nelson (DOB 18.06.1972) who also escaped each American Prevention of Terrorism Court trial process was previously captured by the FBI of the USA but whom had escaped prison due to stealing my military law conference notes so Robert James Nelson and Mrs Nicole Shehi maiden name Duarte and Yasmin Duarte had committed identity theft of my British Passport when I have never travelled on any aeroplane since 26 January 1997 not because I was scared but due to real bastards of Northants government who tried to stop me from ever getting legally married due to their hellbent desire to steal my life insurance money and each time I had not died they had gone psychotic after they had already spent one million pounds on themselves that each UK thief terrorist suspect had directly intended to steal after my death date according to private medico-legal opinions in London. I remembered when the Home Office had alerted the Met Police in London that Robert James Nelson had ran off with my stolen British Passport in 1990s and he was chased by the Met Police in London who had dragged their heals when they had failed to stop Robert James Nelson from attending a military law conference abroad with my stolen British Passport and that was exactly where Robert James Nelson had learnt military ways how to do things with Queen Bees and dangerous Australian spiders to escape from prison in real life which he had done successfully from numerous NHS mental hospitals in Northants, Birmingham, Southampton, Winchester, the Priory London and the USA mental hospitals and the prisons in both the USA Los Angeles USA April 2001 after Jennifer Symes death so Robert James Nelson had also escaped prison HMP Woodhill in the UK from his mobile phone device smuggled in by his family members and/or friends when the past staff member was my past body balance instructor so I was not murdered by ex-cons who had left prison and Robert James Nelson had previously sexually assaulted such Northampton NHS mental health team staff in the past whilst he was a serving policeman who had abused his position of authority with Mental health nurse Lorraine Duffy who had helped him escape prison due to his illegitimate sons who worked for East Midlands Ambulance Service Northamptonshire NHS, Mrs Nicole Shehi maiden name Duarte and Yasmin Duarte, Ashley Rowley in Northampton who were each on board aeroplane MH370 were both real nasty people via the British Parachute Association with a builder renovation worker skydiver who permanently damaged my ear with a drill inserted directly inside my left ear by targeted acts of terrorism at the APIL International group meeting in London @StewartsLawLLP on 3 December 2014 and Northamptonshire Police and Northamptonshire NHS mental health tried to stop me from getting seduced by Muiris Lyons by cruel acts of terrorism when each idiot of Northants government had no idea who had Aids or HIV positive infections because each member of JuicyFields drugs cartel all had sexual intercourse with more than one person at that time and that was why each of the said organisations had tried to force my suicide death by theft of my two diamond cross Platinum pendant necklaces recently and theft of my one million pounds first book sales money because they were classified as b******" UK by 132 military worldwide who targeted them now whenever they travelled by aeroplane and which they knew never affected me in the slightest. So, if my second book did not get published then I was not bothered because my book sales money just gets stolen by the same UK terrorists suspects and the UK government did no further action that Northamptonshire Police were too arrogant and proud to ever change for their past 1500 murdered victims in the UK because they were a corrupt police force since the early 1970s and the worst ever police authorities in the whole UK with a catalogue of catastrophic errors in each of their police work on a daily basis due to poor education and training at the University of Northampton for their police law lectures. So @DirectorWray needs to acknowledge the fact that if you have ever tried to get any UK government to detain the correct UK terrorist suspects in prison in the UK then you were mistaken and that it was indeed the responsibility of the Australian government to detain the said UK terrorist suspects in their prison in Australia when you had recovered at least twenty years to thirty years significant hard evidence of acts of terrorism against each UK terrorist suspect charged with terrorism on board aeroplane MH370 and each UK terrorist suspect should have been immediately thrown in prison and the main reason why they were not thrown in prison for serious charges of terrorism was direclty due to Princess Kate five years continuous sexual affair and hence her cervical cancer which I do sympathise and understand because I had suffered with cervical cancer issues for the past twenty years with both Muiris Lyons and Mark Lyons when I had noticed that Princess Kate and/or someone who looked exactly like Princess Kate had each tried to kill either Mark Lyons or Muiris Lyons with her Aids infections when I did used to love Princess Kate until I had found out it looked exactly like Princess Kate whom had tried to kill Muiris or Mark Lyons with her own Aids infection but people with Aids do not die instantly as Robert James Nelson and Jon Dunkley of Devon had noticed with their Aids infections whom had lived for over thirty years with it. It was better when every cop had to go to Hendon Police school for their training so they each had the best police lectures and training so Keir Starmer can make that positive difference in police training or better still make it compulsory that all police officers have to do part of their training at @UniversityofLaw because that was where I believe that I had received the best legal training to not collaborate and think for myself and figure things out for myself by doing detective work and problems solving from legal research which was my favourite subject and my favourite temporary job was working for the University of Southampton Library in a nice quiet environment doing significant amounts of research and solving research enquiries from both law students and numerous other students which job I had loved and recommended to my best school friend Georgina so she could live happily ever after and get married and have children. Pure bliss peace and quiet and the University of Southampton Library felt like my second home when I worked there and I had even fallen asleep in the library once because I had felt safe in that library because it was too noisy in my University student house or I had Muiris Lyons whom phoned me at 1am to 4am to chat with me for hours every fortnight on the University of Southampton Nightline helpline service for three years 1994, 1995 and 1996 and you can see from this University photograph how exhausted I had felt but looked genuinely happy at University. I remembered how Robert James Nelson used to eat all my food that I had cooked him so I rarely had any food left to eat for myself. That was why having Robert James Nelson as my boyfriend was the worst experience of my entire life when I used to feel starving to death when luckily my postgraduate friends used to take me out to dinner when I looked so thin when I used to do ballet dancing cllasses and Robert James Nelson stopped me from doing that when he had threatened my parents because it was something that I loved doing and he said that I was stick thin when I was a normal body mass index weight for my height and I was considered in the group of fat ballet damcers size 10 at 52-54kg when other Hampshire Police cops joined in my class so I did not look like the only fat ballet dancer. American Darren Aronofsky had filmed me doing ballet dancing, horse riding and swimming at St Pancras Spa when I had passed all my USA Military fitness training tests in the UK for the FBI of the USA external exams but I would not be able to swim in the deep water if the aeroplane crashed because I had only passed in shallow water and why The Queen Elizabeth II used to think it was really funny how I had passed each USA Military fitness tests like borrowing a horse from a complete stranger when I was being chased by a crime suspect which was after Robert James Nelson had proposed marriage to me in Winchester Cathedral where he insisted on having five children after marriage and refused to compromise which had literally made me run a mile as fast away as possible to Winchester train station. I then borrowed a horse from a complete stranger when there were no taxis at the taxi rank when I had no money left for a taxi back to my house in Highfield Southampton when Knob-Rob had insisted that he would drive me home so I did not have to worry about anything and I had worn high heels and a ball gown from the University of Southampton medics ball in Winchester. It was so difficult riding a horse in high heels and a slim body contour ball gown with a hangover but I had luckily sobered up by the next day when I was never a heavy drinker anyway and I had passed my fitness USA Military training tests with high marks unexpectedly in both Southampton and London UK and I just had the last part residential training part in the USA left to do which I had intended to do after my graduation with my LPC from @UniversityofLaw after I had no luck with Trainee Solicitor job interviews so I could not get easily married to anyone I had ever met in my whole lifetime since my relocation back to my strict parents house in Northampton UK. I felt happy when my dad had moved to a care home because now I actually feel like I have a genuine chance to get happily married and even my dad had said yes for his permission for me to get married to my white male Frenchman best boyfriend Julien Repellin and then my dad changed his mind by the weekend because my dad and my mum both never wanted to share me with any man whatsoever! True story.

🚨 The Deadly Diagnosis Hidden Behind “Just Back Pain” A 67-year-old man arrives in the ED with: ✅ Sudden severe back pain ✅ Diaphoresis ✅ Nausea ✅ Blood pressure 90/60 mmHg He thinks he “pulled a muscle.” The initial focus is on pain control. Hours later, he deteriorates. The diagnosis? Abdominal Aortic Aneurysm (AAA) rupture. 🧵 Let’s talk about one of the most catastrophic diagnoses in emergency medicine. What Is an AAA? An abdominal aortic aneurysm is a permanent dilation of the abdominal aorta, usually defined as: 📏 Aortic diameter ≥ 3 cm Most occur below the renal arteries. Many remain silent for years. The danger arises when they expand and rupture. Why Does It Matter? Because rupture carries an extremely high mortality rate. Many patients die before reaching the hospital. Among those who arrive alive, every minute matters. Who Is at Risk? Major risk factors include: 🚩 Age > 65 years 🚩 Male sex 🚩 Smoking history 🚩 Hypertension 🚩 Atherosclerotic disease 🚩 Family history of AAA Smoking remains the strongest modifiable risk factor. The Classic Triad Medical students learn: 1️⃣ Hypotension 2️⃣ Abdominal or back pain 3️⃣ Pulsatile abdominal mass But here’s the reality: The complete triad is present in only a minority of patients. Waiting for all three findings can be dangerous. The Presentation Can Be Deceptive Patients may present with: 🔴 Back pain 🔴 Flank pain 🔴 Groin pain 🔴 Syncope 🔴 Collapse 🔴 Unexplained hypotension Some are initially mistaken for: ❌ Renal colic ❌ Musculoskeletal back pain ❌ Sciatica ❌ Gastroenteritis A Clinical Clue Worth Remembering An older patient with: • Sudden severe back pain PLUS • Hypotension Should trigger one immediate question: “Could this be an AAA until proven otherwise?” Bedside Ultrasound Saves Lives One of the most powerful tools in emergency medicine: 🩺 Point-of-care ultrasound (POCUS) In experienced hands, bedside ultrasound can rapidly identify: ✅ Presence of an aneurysm ✅ Aortic diameter ✅ Need for urgent vascular assessment It can often be performed within minutes. The Dangerous Mistake A common cognitive error: The patient looks comfortable after analgesia. The blood pressure transiently improves. Everyone relaxes. But temporary stabilization does not exclude a contained leak or impending rupture. Clinical Pearl Not every ruptured AAA presents dramatically. Some patients experience: ⚠️ A brief syncopal episode ⚠️ Mild hypotension ⚠️ Intermittent pain before suddenly deteriorating. The window for diagnosis may be short. Management Priorities Once rupture is suspected: 🚨 Immediate vascular surgery involvement 🚨 Large-bore IV access 🚨 Blood products as needed 🚨 Rapid imaging if stable 🚨 Preparation for urgent repair Time is a critical determinant of survival. The Lesson Back pain is common. A ruptured abdominal aortic aneurysm is not. But the reason we remember AAA is simple: Missing muscular back pain rarely kills. Missing a ruptured AAA can. When an older patient presents with sudden severe back, abdominal, or flank pain—especially with hypotension—always keep the aorta in mind. Sometimes the most dangerous diagnosis is hiding behind one of the most common complaints. #MedTwitter #FOAMed #EmergencyMedicine #VascularSurgery #POCUS #InternalMedicine #MedicalEducation #MedEd 🚑🩺📚🫀

A patient with pulsatile tinnitus had severe transverse sinus stenosis that created a high-velocity venous jet. Over time, the abnormal flow remodeled the skull and produced a bony defect. Venous sinus stenting restored normal flow and pressure. #PulsatileTinnitus

Carotico-cavernous fistula (CCF) Pulsatile proptosis, orbital bruit, and diplopia form the classic triad of CCF. It results from an abnormal communication between the carotid artery and cavernous sinus, causing venous congestion of the orbit. Patients may also have conjunctival congestion, chemosis, and cranial nerve palsies.

🚨 7 Causes of Acute Abdomen 1️⃣ Appendicitis 🔹 Periumbilical → RIF pain 🔹 Nausea, fever 💎 McBurney tenderness 2️⃣ Cholecystitis 🔹 RUQ pain 🔹 Fever, vomiting 💎 Positive Murphy sign 3️⃣ Pancreatitis 🔹 Severe epigastric pain → back 🔹 Nausea, vomiting 💎 ↑ Lipase/Amylase 4️⃣ Small Bowel Obstruction 🔹 Colicky pain 🔹 Distension, vomiting 🔹 Constipation 💎 Air-fluid levels on X-ray 5️⃣ Perforation 🔹 Sudden severe pain 🔹 Guarding, rigidity 💎 Free air under diaphragm 6️⃣ Abdominal Aortic Aneurysm (AAA) 🔹 Abdominal/back pain 🔹 Pulsatile mass 🔹 Hypotension if ruptured 💎 Think AAA in older smokers 7️⃣ Mesenteric Ischemia 🔹 Severe pain out of proportion 🔹 Nausea, vomiting 💎 AF raised lactate ⸻ 🩺 Acute Abdomen Approach ➊ History Pain site, onset, radiation ➋ Examination Vitals, guarding, rigidity ➌ Investigations FBC, CRP, LFT, Lipase, Lactate US/CT Abdomen ➍ Management IV fluids → Analgesia → Surgical review ⸻ 🚩 Red Flags 🔴 Shock/Hypotension 🔴 Guarding & Rigidity 🔴 Persistent Vomiting 🔴 Fever & Tachycardia 🔴 Abdominal Distension ⸻ 🧠 Mnemonic: ACPSPAM A – Appendicitis C – Cholecystitis P – Pancreatitis S – SBO P – Perforation A – AAA M – Mesenteric Ischemia ⸻ 📚 Master Surgery the High-Yield Way with the MedicoNotes Surgery Book. 🌐 mediconotes.com #Surgery #AcuteAbdomen #MRCS #USMLE #PLAB