Abdo vivas Flashcards
signs of chronic liver diseae
clubbing leukonychia palmar erythema D contract jaudnice spider naevi gynaecomastia loss of ax hair caput medusae hepmegaly if not cirrhotic splenomegaly ascites
signs of cause of CLD
black ethnicity - saroidosis more likely
slate grey skin + diabetes = haemochormatosis
track marks - hep C
xanthelasma - PBC
goitre / middle aged female - autoimmune
emphysema - A1AT deficiency
signs of decompensation in lvier disaes
flapping tremor + confusion = enceph
jaundice, ascites
signs of kidney transplant o/e
old AV fistula
Rutherford Morrison scar
smooth mass underlying scar in IF
signs of cause of renal failure + need for kidney transplant
cap glucose moniotring marks = daibets
hearing aid - Alport
collapsed nasal bridge = Gwith PA
buttefly rash SLE
sternotomy - vascular
flank masses - PKD
evidence of poor functioning kidney
uraemia - itching, flap
pale - aneamia
retaining fluid
complications of immunosuppression o/e
tremor (calcineurin x), cushingoid/brusing (Steroids), skin lesions (ca)
signs of cause of hepatomegaly o/e
signs of CLD
raised LNs - malignancy
peripheral oedema / JVP - heart faiure
signs of splenomegaly cause o/e
hand deformity (RA/ Felty’s )
signs of CLD
pallor (leuk,lympho, hameolysis, myeloproflif)
polycystic kidneys o/e
AV fistula HTN pale conjunctiva flank scar bilateral ballotable flnk masses hepmeg
signs of liver transplant o/e
signs of CLD
Mercedes Benz scar
signs of cause for liver transplant
black ethnicity - saroidosis more likely
slate grey skin + diabetes = haemochormatosis
track marks - hep C
xanthelasma - PBC
goitre / middle aged female - autoimmune
emphysema - A1AT deficiency
combined kidney pancreas transplant o/e
LIF sar
RIF scar
smooth mass under LIF scar
signs of diabetic complicaions
visual aids, Charcot joints
toe ulcers
amputations
neuroapthy
previous renal replacemnt therpay
AV fistula
central line scars
peritoneal dialysis scars
polycythaemia rubra vera o/e
dusky cyanosis
HTN
facial plethora
splenomegaly
hereditary spherocytosis o/e
pale conj
mild jaundice
splenomegaly
primary biliary cirrhosis o/e
middle aged female jaundice hyperpigmented excoriations xanthelasma hepatomegaly
top 4 causes of end stage renal failure
- Diabetes 2. HTN 3. GN 4. PKD
PR exam summary
lie left lateral. Check for blood, fistula, fissures, warts, piles, prolapse. Comment on tone, prostate, bowel, faeces. Ind – constipation, retention, masses
hernia examination
examine standing up. Palpate scrotum, inguinal region, compress lump + cough, deep inguinal ring mid ASIS+tubercle -> reduce into deep ring ask to cough, see if reappears. Direct if so, if not indirect. Hand off – hernia projects straight forward if direct and slides obliquely if indirect. Percuss/ausc.
inguinal hernia direct vs indirect
direct = superior to PT, herniates through superficial ring. Indirect = between deep ring + scrotum. Can be contained.
femoral hernia o;e
always inferior and lateral to pubic tubercle. Less common
testicular exmiantino
stand up, examine side on. Inspect all over. Palpate testes, epididymis, spermatic cord. If pain relieved by elevation – epididymitis, if not think of torsion. Absent cremasteric reflex in torsion usually. Check SCL nodes.
hydrocoele
– fluid around testicles. Young – patent proceccus vaginalis. Old may be smaller and secondary to tumour/trauma/inf. US testicle and sac repair.
varicocoele
dilated venous plexus in scrotum ‘bag of worms’ feel. Dull ache. Left sided commoner. Can have surg to clip vein.
epididymal cyst
– separate, fluid-filled sac above epididymis
testicular tumour o/e
hard irregular lump, inseparable from testicle
inguinoscrotal hernia
can’t get above on palpation
epididymitis
pain, swelling at back of T. may be STI or UTI bugs. Systemically unwell. Give abx. Drain any abscess.
testicular torsion
– painful, high-riding testicle with horizontal lie. V painful + swollen. Usually young with trauma/exercise hx. Surgical emergency. Senior + NBM.
abdo scars
Abdo scars – Kocher RUQ (Gallbladder ops), Loin (renal ops), Mercedes Benz / Rooftop (liver transplant, upper GI surgery), midline lap, paramedian (spleen, kidney, adrenal), RIF/LIF (stoma sites), Pfannenstiel (c section, pelvic surgery), Lanz or McBurney (appendix), Rutherford Morrison – longer McB = kidney transplant, bowel surgery) also may see laparoscopic port scars
renal dialysis summary (indications, types, complications)
Renal dialysis – maintains electrolytes and removes plasma waste products. AKI indications = Acidosis Electro abnorm Intoxicants Overload Uraemia, CKD when eGFR <15ml/min. CKD = haemodialysis / peritoneal AKI = haemodialysis / haemo – filtration. Complications – headache, itch, muscle cramps, disequilibrium syndro (cerebral oedema from osmotic chng), low BP, haemolysis + hyperK, sepsis.
haemodialysis details (incl access)
AV fistula + either a tunnelled central venous catheter (stays for months) or non tunnelled (10 days)
blood taken from vein, pumped along semi permeable membrane, dialysate fluid pumped in oppo direction on other side. toxins diffuse out over gradient.
conventional - 4hrs, 3x weekly
short daily - 2 hrs /day
noctural - 6-8 hrs nightly 6 days a week
lifestyle modifications needed while on haemodialysis
fluid restrict, salt restrict, potassium restrict, phosphate restrict
peritoneal dialysis details
Peritoneal – Tenckhoff catheter. Continuous ambulatory (replace fluid bags 3-5 x daily or automated overnight over 8-10 hrs. peritoneum acts as the membrane.
haemofiltration why
used for more critically ill patients as less haemodynamic instability caused.
AV fistula o/e
o/e -> location, any inflamm, collapsing as should on arm elevation, any collateral veins, any oedema or ischaemia/Steal syndrome. Normal thrill and easy compression. Occlude vein above + see art pulsation- normal.
can be in wrist, ACF, upper arm basilic vein
venous stenosis of AV fistula
Venous stenosis – high pitched murmur, collateral veins, pulsatile vein w/out manoeuvre.
AV fistula info
AV fistula info – 6 weeks to dilate vein. Distal needle – afferent needle, proximal needle= efferent (both in AV fistula).
AV fistula cautions and complications
). Complications – thrombosis, v stenosis, aneurysm, infection, distal ischaemia (S syndro). Cautions – no bloods / cannula on AVF arm, no BP measure that side, keep clean, check daily
why have an AV fistula over a CVC?
Why AVF over CVC – lower re-circulation a/efferent mingling, less infection, higher flow rate – more efficient filtration, less clotting.
Tenckhoff catheter
catheter placed through abdo wall to access the peritoneum for dialysis.
always check for acute abdo / peritonism o/e.
either replace dialysate manually many times a day or auto repair auto replace overnight!
complications of peritoneal dialysis
peritonitis, infection, constipation, pleural effusion, hernias, weight gain
but at home and can travel
contraindications to peritoneal dialysis
adhesions (i.e. prev surgery), stoma, hernias, IBD
kidney failure o/e basic summ
o/e look for cause, evidence of dialysis + if active/historic, signs of Isupp
indications for renal transplant
Transplant ind – ESRF <15ml/min (diabetes, PKD, HTN, GN).
contraind to renal tansplant
Contraind – cardiac/lung failure, liver disease, cancer, active inflamm.
kidney transplant procedure
Procedure – pre op screen donor/recipient (HLA, x match, inf screen). Screen donor also with ultrasound, surgical bloods, urine tests. Donor kidney (loin scar) anastamosed with external iliac vein/artery
post op renal transplant
Post op Isupp = pred, tacrolimus, myco mofetil.
pred + calcineurin inhibitor + antimetabolie
complications kidney transplant
Complications – rejection (hyperacute – during op, acute – flu prodrome, reducing function + tenderness over many weeks, chronic – reducing func over years).
oppo infections, sepsis, EBV post tansplant lymphoprolif disorder, UTI, graft thrombosis
kidney T prognosis
. Lasts up to 15 years. Prognostic factors for kidney – donor type/age, cold time.
colostomy types
end or loop
end (either AP resection for low rectal tumours – permanent- or Hartmann’s procedure to resect rectosigmoid lesions + reverse once deflamed). Loop – loop of intact bowel brought out with 2 openings. Protects distal bowel i.e. if obstruction, palliative distal tumours, anastamosed lower down (reverse later).
ileostomy types
end or loop
end – subtotal or total colectomy +/- reversal with anoileal join up later. Loop – protects anastomosis lower down or protects anus e.g. IBD/ca.
urostomy
short piece of ileum removed + acts as bladder (after cystectomy).
stoma complications
– early (high output >1L/day dehydrates and loses K+, retraction, ileus, ischaemia), late (parastomal hernia, prolapse, fistulae, malnutrition
stoma care
) stoma care – stoma nurse expert, empty bag 2/3 full + irrigate / single-use bag, stays on in shower, first 2 months loads fluids/little fibre. Eat right to avoid block/diarr/odour
hepatomegaly detailed summary of cause
malignancy (primary or secondary)
congestoin - RHF, BuddChiari hep vein clot
haem - lympohoma, leukaemia, myelofib
inf - EBV, viral hepatitis
anatomical -Riedel’s lobe
other - NAFLD, alcholic, sarcoid, amyloid, i.e.
alcoholics - splenomegaly more likley as cirrhotic shirnks
splenomegaly detailed causes
infiltration - leukaemia, lymphoma, myeloprolif
increased function - extravascular haemolysis, infection response (malaria, EBV, HIV)
congestion - cirrhosis, splenic vein obstruction
massive splenomeglay causes
CML
myelofibrosis, malaria
hep splenomegaly
hepatosplenomegaly – chronic liver disease with portal HTN, haem (leuk,lympho, MPDs), inf (viral hep, CMV/EBV, malaria), infilt (amyloid, sarcoid)
causeschronic liver disase
chronic liver disease – causes -> alcohol, NAFLD, viral cause, AI, haemochrom
inv cause CLD
viral serology, AI screen, alpha fetoprotein, trans/ferritin, copper/caeruloplas, glucose/lipids, AAT, TTG, LFTs, abdo US/CT, biopsy
manage and monitor CLD
Manage CLD – treat cause, optimise nutrition, stop drinking, 6 monthly FBC/LFT/alb/coag/afeto + USS, OGD every 3 years. Treat complic – varices (band, TIPS), ascites (spiro, low salt, fluid restrict), enceph (lactulose, rifamixin), coag (vit K). elastography grades cirrhosis.
acute CLD complications x 3
decompensation
hepatorenal failure
spontaneous bacterial peritonitis
acute decompensation nCLD
jaundice, ascites, enceph
causes: SBP, sepsis, dehyd/aki, upper gi bleed, constipation, drugs, HCC
treat cause, lactulose enemas, avoid sedaation
hepatorenal failuer
worsening renal function in CLD with no other cause andno response to fluids
fluid balance and weihts, suspend diuretics + nephrotoxics, give human albuin solution and terlipressin
SBP
septic with ascites
dx with asciitc tap
give IV abx, human albumin solution
inguinal lig
ASIS to pubic tubercle
deep inguinal ring location
midpoint of inguinal lig
superficial ring = just above pubic tubercle
borders of inguinal canal
internal oblique roof
external oblique anterior
inguinal lig floor
transversalsis fascia posterior
contents of inguinal canal
male - spermatic cord + ilioinguinal nerve
cord = 3 arteries, 3 nerves, 3 others
females = round ligament of uterus and ilioinuinal nerve
femoral artery position vs deep inguinal ring position
fem artery= midpoint of ASIS and Symphysis
deep ring - midpoint of ASIS and tubercle (slightly lateral to symphisis)
direct vs indirect inguinal hernia
direct - go through superficial ring, can’t be ontrolled by pressuring deep ring
indirect - runs down ing canal, can control with pressure over deep ring
inguinal vs femoral hernia
femoral is inferior and lateral to pubic tubercle
direct inguinal is superior to pubic tubercle
indirect can occur anywhere between deep ring and scrotum
open hernia repair
if irreducible obstructed or strnagled
ddx groin lump
psoas abscess, femoral neurofibroma, ing LNs, fem aneurysm, hydrocoele of cord
summarisse DDx of goitre
goitre 1. Grave’s 2. Multinodular goitre (Dx USS) 3. Physiological (pregnancy / puberty). Diffuse = simple (phsyiol/iodine), AI, infective+painful, iatro nodular = multinodular, toxic multinod (hyperT), solitary nodule (cyst/ca)
complications of large goitre
compression symtoms
trachea - SOB
nerve - dysphonia
oesophageal - dysphagia
SVCO - facial swelling, dizzy, headache, blurred vision, syncope
pre gang Horner’s = ptosis, miosis, anhidroiss
ACTH dependent Cushing’s
Cush disease (tumour secreting ACTH) ectopic ACTH (Lung ca)
ACTH indpendent Cushing’
steroids
adrenal adenoma/ca
adrenal hyperplasia
inv processes Cushing’s syndrome
dex suppression test (not suppressed)
24 hr urinary cortisol
plasma ACTH
if low - CT adrenals
if high - high dose test (ectopic not suppressed)
either CT thorax or MR pituitary after that
management Cushing’s disease
metyrapone/ketoconazole for symptoms
resect tumours
remove adrenals if can’t find source
manage acromegaly
IGF1 screening
no GH suppression during glucose tolerance test
MR pit to visualise
prolactin levels to exclude simult prolactinoma
trans sphenoidal resection
ocretotide
complications of acromegaly
colon cancr (need surveillance), impaired glucose tolerance/DM, cardiomyopathy
dupytren’s table top test
can’t lay hand flat due to flexed fingers (usually ring/little)
Dupytren’s contract assoc and treat
dupytren’s causes – assoc with CLD, FH, anti epileptics, DM, tissue disord
manage with splinting, physio, steroid inj, surgical = partial fasciotomy / fasciectomy.
Carpal Tunnel DDx
thoracic outlet syndrome
pronator teres syndrome
watch and wait splint at night sterod inj NSAIDs surgical release
