Any Discipline Flashcards
- What is an Abscess?
- Definition
- Collection of pus (neutrophils, necrotic tissue, proteinaceous exudate +/- organisms) walled off by a zone of acute inflammation
- Formation
- Response to pyogenic micro-organisms
- Attract neutrophils
- Resistant to phagocytosis and lysosomal destruction
- Response to localized tissue necrosis
- Organic foreign bodies (wood splinters)
- Response to pyogenic micro-organisms
- Common organisms
- Staph Aureus
- Strep pyogenes,
- E.coli
- Coliforms
- Bacteriodes
- Outcomes
- Eventually ‘point’ to nearby epitherlial surface and discharge contents.
- If remote from surface à progressively enlarges causing tissue destruction.
- Cellulitis
- Systemic sepsis
- “Bacterial showers” or Bacteremia à swinging pyrexia
- If incomplete tx à chronic abscess à sinus or fistula formation.
- Complete tx without drainage à ‘sterile abscess’ or ‘antibioma’
- Organization and repair
- Dead tissue removed by phagocytosis and defect filled by vascular connective tissue – Granulation tissue.
- Clinical presentation
- swinging pyrexia
- redness, cellulitis

- What is cancer Staging?
- Process of determining how much cancer is in the body and where it is located. Describes the severity of an individuals cancer based on the magnitude of the primary tumor and the extent to which it has spread through the body.
- TNM or four stages
- Some cancers have specific staging systems for sites.
- TNM (not for leukaemia, lymphoma or myeloma, brian or spinal tumors) – American Joint Committee on Cancer (AJCC)
- Tumor size
- TX – cannot be evaluated
- T0 no evidence of primary
- Tis – carcinoma in situ
- T1-4 – size and/or extent of primary tumor
- Node involvement 0-3
- NX – cannot be evaluated
- N0 – no regional lymph node involvement
- N1-3 involvement of regional lymph nodes (number and/or extent of spread)
- Metastases 0-1
- M0 – no mets
- M1 – distant mets
- Tumor size
- Note: Grading is different to staging – it is the pathological assessment of a tumour to estimate the level of aggressiveness or level of malignancy based on the cytological differentiation and mitotic activity of the tumour. Grade I to IV in order of increasing anaplasia.
- Staging has proved to be of greater clinical value than grading
- What Modalities are used to stage cancer?
- Physical examinations: size & locations, lymph involvement
- Imaging tests:
- X-rays, CT scans, and MRI scans, Barium studies, USS – size, location, Mets
- Blood tests:
- FBC, LFTs, Tumor Markers
- Endoscopy
- Upper GI, colonoscopy, ERCP
- Pathology Reports:
- size of tumor, growth into other tissues, type of tissue cells and grade of tumor (how closely cancer cells resemble normal tissue).
- Cytology/Histology:
- Body fluids
- FNA
- biopsy
- Immunohistochemistry
- Cytogenic analysis
- Surgical reports:
- size and appearance of tumor, lymph node and organ involvement
- What is the purpose of “staging” a patients cancer?
- Aids in develop a prognosis and treatment plan
- Surgical/radiotherapy/hormone therapy
- Curative vs Palliative
- Allows for evidence-based treatment due to comparison with trial data
- Common language to communicate and collaborate re:patients cancer
- Eligibility for clinical trials
- What is neoplasia? Give examples of benign and malignant neoplasms.
- Uncontrolled growth that persists after the initiating stimulus has been removed.
- Benign
- slow growing, well demarcated, encapsulated, histology closely reminiscent of tissue of origin, localised to site of origin
- adenoma, fibroma, lipoma, osteochondroma,
- malignant
- progressive and rapid growth, poorly defined, irregular outline, non-encapsulated, local invasion and metastasize to parent tissue, anaplastic, pleomorphic.
- carcinoma, sarcoma, teratoma, leukemia, lymphoma
- What is a fistula? Give some examples.
- abnormal connection of 2 epithelial surfaces, such as two hollow organs or between a hollow organ and the exterior
- They are lined by granulation tissue and colonised by bacteria
- The formation of a fistula requires inflammation and pressure
- Causes:
- Inflammation
- Infection - Abscess formation and spontaneous drainage
- Trauma - Penetrating wounds
- Iatrogenic – Surgical and radiation therapy
- Neoplastic
- Congenital
- Examples:
- Rectovesical fistula – most commonly caused by diverticulitis
- Crohn’s Disease:
- Colocolic fistula
- Gastrocolic fistula
- Enterovesical fistula
- Enterocutaneous fistula
- Anal fistula – due to abscess rupture
- Rectovaginal fistula – pelvic cancer/ treatment
- Tracheo-oesophageal fistula – congenital
- Causes of a non-healing fistula: (FRIEND)
F – Foreign Body
R – Radiation
I – Inflammation/ Infection
E – Epithelialisation
N – Neoplasia
D – Distal Obstruction
treatment
- drain and remove granulation tissue
- nutrition
- What is a stoma?
- Definition
- Opening created between hollow viscus and the skin.
- Either ‘end’ (only one lumen brought to surface) or ‘loop’ – both ends
- Ileostomy - Right iliac fossa
- Colostomy – left iliac fossa
- Dehiscence – separation of the mucocutaneous junction
- Temporary or permanent
- Complications 56%
- What are the potential complications of a srugical procedure?
- complications predisposed to by co-morbid ‘medical disorders’, wheather symptomatic or occult e.g. Ischaemic heart disease, chronic respiratory disease or diabetes mellitus
- complications of anaesthesia
- general complications of operations e.g. haemorrhage or wound infections
- complications of any surgical condition e.g. pulmonary embolism, pneumonia, UTI, pressure sores
- complications of specific disorders and operations e.g. bowel surgery - obstruction, peristalsis, failed anastomes, peritonitis, fistula.
e. g. laparscopic, sub cut emphysema, cardiovascular collapse, haemorrhage,
- What are the risk factors for a superficial wound infection?
Patient related factors
- Advanced age
- Cigarette smoking, Malnutrition, High BMI
- Diabetes, Concurrent infection
- Impaired immune response (Immunosuppression, Prior site irradiation, Peripheral vascular disease)
Surgical factors
- Inadequate sterilization of surgical instruments, Foreign material in surgical kit, Microbial contamination, Surgical drains
- Preoperative shaving, Inadequate skin preparation
- Inappropriate selection of prophylaxis, Prolonged operation
- Poor operating room ventilation, Poor surgical technique
- How do you treat a superficial wound infection?
- Confirm SSI with history and examination
- Samples for gram stain and culture
- Surgical drainage and irrigation with 0.9% Saline
- Fluid absorbing dressing; consider antibiotics
- Mild to moderate
- flucloxacillin or cephalexin
- If gram neg suspected: amoxycillin + clavunate
- Severe (systemic):
- flucloxacillin IV or vancomycin IV
- If MRSA suspected: add vancomycin IV to above
- If gram neg: add gentamycin IV
- If susceptibility testing not available by 72hrs and empirical IV therapy is still required, cease gentamixin regimen, and use pipercillin + tazobactam (Tazacin)
- What are the principles of antibiotic prophylaxis for surgical patients?
* Decide if prophylaxis is appropriate
- Determine the bacterial flora most likely to cause postoperative infection (not every species needs to be covered)
- Choose an antibiotic, nased on the steps above, with the narrowest antibacterial spectrum required.
- Choose the less expensive drug if two drugs are otherwise of equal antibacterial spectrum, efficacy, toxicity and ease of administration
- Administer dose at the right time
- Administer antibiotics for a short period (one dose if surgery of four hours duration or loss)
- Avoid antibiotics likely to be of use in the treatment of serious sepsis
- Do not use antibiotic prophylaxis to overcome poor surgical technique
- Review antibiotic prophylaxis protocols regularly as both cost and hospital antibiotic resistance patterns may change.
- IV bolus on induction of anesthesia
- Oral or rectal need to be given earlier
NPS
- Why do surgical wounds fail?
- Technical issues with close of the incision
- Materials unsuitable to hold the edges and sides of incision together.
- Suture knots slip/beak/unrave/cut through tissue
- Too much/little tension
- Mechanical stress
- Forced tension closure with inadequate tissue mobilization
- Local oedema (infection/inflammation)
- General oedema (CHF)
- External trauma
- Intra-abdominal and/or intra-thoracic pressure – coughing, retching, lifting weights etc
- Disrupted Healing
- Local factors - ischaemia/hypoxia, infection/contamination, inflammatory conditions
- systemic factors - chronic disease/comorbidities (Diabetes, CKD, immunosuppression), medication (corticosteroids, chemotherapy), radiotherapy, smoking, alcoholism, malnutrition, connective tissue disorders
- poor compliance to treatment plan
- What is the difference between the tissue obtained by fine needle aspiration and a core biopsy?
- FNA = thin needle and stylet is used to aspirate a small amount of tissue and/or fluid from the area under investigation
- Anaesthetic may or may not be used
- Cytological evaluation
- Sensitivity 95%
- Less expensive
- sampling problems (may miss cancer cells if the needle is not sampling from within the lesion)
- Can’t distinguish between invasive and non-invasive lesions (i.e. DCIS vs invasive carcinoma)
- Fewer complications and less invasive
- Core Biopsy = A larger, hollow needle is used to withdraw small cylinders (cores) of tissue from the area under investigation
- Takes longer than FNA and local anaesthetic is used
- Histological evaluation
- Sensitivity 98%
- yields tissue fragments allowing architectural features of the lesion to be identified (i.e. determine whether DCIS or invasive carcinoma)
- Detect tumour markers
- Better sample to detect hormonal receptors
- Investigation of choice for evaluating microcalcifications
- Please look at these arterial blood gas results:
pH 7.30
PaO2 66mmHg
PaCO2 26mmHg
base excess -6,5
Lactate 9.4
What is a summary description of these results?
Metabolic acidosis with partial respiratory compensation
pH 7.30 Acidotic
Pa02 88mmHg Hypoxic
PaCO2 Hypocapnic
Lactate high- lactic acidosis
base excess negatic - metabolic acidosis
- Please look at these arterial blood gas results: pH 7.30, arterial blood gas results: pH 7.30, Pa O2 66mmHg, Pa CO2 26mmHg, base excess - 6.5, lactate 9.4. What causes a blood gas profile of this sort?
Lactic acidosis with hypoxaemia – imadequate oxygen delivery.
- Hypoventilation
- Diffusion limitation
- Shunt
- V/Q inequality
This pattern suggests severe shock with end organ failure
Compensation has occurred with hyperventilation to remove CO2
Does not yet meet the criteria for respiratory failure.
- Type 1 – Hypoxia (<60 mmHg) and Normo- or Hypocapnia (< 50 mmHg)
- Type 2 – Hypoxia (<60 mmHg) and Hypercapnia (> 50 mmHg)
- What is a deep vein thrombosis?
- Blood clot develops within a deep vein of the leg
- 90% in calf
- Pain, swelling and tenderness in one leg, warmth in the area of the clot
- Why is a DVT important?
- 1 in 10 people with a DVT will develop a PE à lung collapse à RHF
- Or chronic thromboembolic pulmonary hypertension
- Or DVT post-thrombotic syndrome
- Chronic leg swelling and discomfort due to damage to the venous valves
- Skin ulceration if severe
- What are some risk factors for hypercoagulability?
- Hereditary
- Factor V Leiden
- Elevated factor VIII
- Antithrombin III deficiency
- Prothrombin mutation
- Hyperhomocystinemia
- Protein S deficiency
- Protein C deficiency
- Acquired
- Previous DVT
- Trauma and surgery
- Increasing age
- Venous stasis during general or regional anaesthesia
- Malignancy
- Immobility
- Cardiac failure
- High-oestrogen OCP, tx, HRT
- Pregnancy
- Obesity
- dehydration
- How can the risks of a DVT be reduced in a surgical patient?
- General measures
- Early post-op mobilization
- Adequate hydration
- Avoiding pressure on the calves
- Prophylactic measures
- Low-dose subcut heparin
- Oral direct factor XA inhibitors – rivaroxaban
- Calf-compression devices
- Graduated compression ‘anti-embolism’ stockings
- Warfarin anticoagulation
- What is Virchow’s Triad?
- Abnormalities in the vein wall (trauma, inflammation)
- Alterations in blood flow (stasis)
- Changes in blood (hypercoagulability)
- You are the general surgery resident on call. You are asked to review a 70 year old man who is 72 hours post elective, uncomplicated colonic surgery. He has developed an acute confusion having been well and behaving normally since surgery. What are you going to do?
- Phone call
- In what way were they confused? GCS?
- Vital signs?
- what has been tried so far?
- Bedside
- if unconscious - ABCDE, call for senior help
- determine if delirious with Confusion Assessment Method
- ask if in pain?
- look for hx or signs of hypoxia, hypotension, sepsis, seizures, intraranial mass lesion
- Physical Examination
- Vitals and GCS – also perform Abbreviated Mental Test Score (AMTS) or Quick Confusion Scale
- HEENT – nuchal rigidity, photophobia, pupil size and symmetry, fundoscopy, otoscopy
- Neuro – focal neurological deficit (esp. cranial nerve or motor deficit)
- CVS – JVP, S3, pitting oedema, new murmur
- Resp – cyanosis, respiratory distress, wheeze, crackles
- Abdo – NG tube output, costovertebral angle tenderness, guarding, rebound tenderness, jaundice, hepatomegaly, asterixis
- GU – Urine output from catheter
- Inv:
- FBC, UEC, BSL, CMP, LFT
- Blood cultures (if sepsis considered)
- Urinalysis and urine MCS
- ECG & CXR
- Consider ABG (if respiratory cause considered
- treat cause
- reorientate patient, close observation, well lit room, clocks visible, have family present
- avoid using sedatives
- last resort use haloperidol, risperidone or olanzapine
- You are the general surgery resident on call. You are asked to review a 70 year old man who is 72 hours post elective, uncomplicated colonic surgery. He has developed a fever of 38.2 degrees C, having had no fever recorded since surgery. What are you going to do?
- phone call
- Vitals, associated symptoms, immunosuppressed?
- bedside
- ABCDE, call superior
- consider sepsis, review chart
-
5W’s of Post-Op Fever
- Wind (24 - 48hours) – i.e. pneumonia
- Predisposed by instrumentation in airway, inadequate pain relief etc.
- Water (3 - 5 days) – i.e. UTI
- Especially if urinary catheter is in place
- Walking (4 - 6 days) – i.e. VTE
- Due to stress response or immobilisation
- Patient should have prevention
- Wound (5 - 7 days) – i.e. SSI
- Also think about intra-abdominal and intra-thoracic
- What did we do? (7+ days) – i.e. iatrogenic causes
- Medication reaction
- Blood transfusion reactions
- Cannula site infection
- Wind (24 - 48hours) – i.e. pneumonia
- physical examination
- Repeat vitals
- General appearance
- Mental status
- HEENT – neck stiffness, photophobia, Kernig’s sign, Brudzinski’s sign, fundoscopy, otoscopy, sinus tenderness, oral inspection
- CVS – pulse volume, skin temperature and colour, murmur
- Resp – crackles, friction rub, bronchial breathing
- Abdo – tenderness, jaundice, costovertebral angle tenderness, ascites, rectal tenderness or mass
- Skin – erythema, tenderness, petechiae or purpura, dehiscence or signs of infection
- investigations
- FBC, UEC, CRP
- Urinalysis and Urine MCS
- CXR and sputum MCS (if present)
- Wound MCS (if purulent discharge)
- Blood cultures x 2
- DVT USS
- management
- treat underlying cause
- Sepsis
- 3 In:
- O2 to keep saturation > 94%
- IV antibiotics (if no focus evident - Flucloxacillin + gentamicin, otherwise treat most likely organisms)
- IV fluids
- 3 Out:
- Blood cultures x 2
- Serum lactate
- Urine output
- Supportive care – analgesia, antiemetics
- Discontinue any fever inducing medications
- Ensure VTE prophylaxis
- 3 In:
If the patient has febrile neutropenia the use piperacillin + tazobactam 4g + 0.5g IV, 6 hourly
- You are the general surgery resident on call. You are asked to review a 70 year old man who is 12 hours post elective, uncomplicated colonic surgery. He has developed an acute episode of hypotension, which has persisted for 10 minutes. What are you going to do?
-
MET call criteria:
- < 100 SBP is yellow – requires clinical review (clinical judgement)
- < 90 SBP is red – requires rapid response (MET call)
- Causes of hypotension:
- Shock – hypovolaemic, cardiogenic, distributive, or obstructive
- Medications (often postural) – antihypertensives, nitrates, sedatives, analgesics
- Autonomic neuropathy – DM, Parkinson’s disease, MSA
- Vasovagal attack
- Constitutional – some patients normally have a low BP
review patient immediately
-
Phone call:
- Vitals, GCS, clammy/pale, dyspnoea/chest pain
- signs of bleeding, or rash?
- medications in last hour? (anaphylaxis)
- Bedside
- ABCDE, repeat vitals, manual BP, GCS
- resus with IV crystalloids
- tx apparent cause
- selective hx (cardio, resp, general)
- ECG, CXR
-
Physical Examination – selective examination (Is there shock? What is the cause of the hypotension? Is the patient bleeding?)
- Vitals (HR, BP, RR, SaO2, Temperature)
- HEENT – dry mouth (hypovolaemia)
- Skin – temperature, colour, sweating, turgor, rash
- CVS – Pulse, capillary refill, JVP, HS
- Resp – Stridor, expansion, percussion (resonance, dullness) and auscultation (wheeze, crackles)
- GIT – tenderness, peritonism, masses (pulsatile?), rectal bleeding (PR exam)
- CNS – orientation, confusion, agitation
- GUT – urine output
- Other – NGT output, wound sites
-
Investigations
- FBC, UEC, LFT, Coagulation studies, Cross match, VBG (?ABG), ? blood cultures
- ECG
- CXR
- Urinalysis (? Urine MCS if abnormal)
- ? USS (AAA, pericardial tamponade, ectopic pregnancy, intraabdominal haemorrhage)
- ? Echo
- ? serum troponin
- ? D-dimer
-
Management:
- Treat any underlying cause identified
- Give IV crystalloids for resuscitation
- Consider giving blood products if the patient is bleeding
- Review the patient regularly
- You are the general surgery resident on call. You are asked to review a 70 year old man who is 24 hours post elective, uncomplicated colonic surgery. His Urine output has dropped from an average of 60mls per hour (>1/2 ml per kg) in the first 24 hours to 20 mls per hour for the last 2. What are you going to do?
- Oliguria is variably defined as < 400mL/day, < 0.5mL/kg/hour, or < 20mL/hour
- Anuria is the complete absence of urine output
- Patients with pain, hyperkalaemia, acidosis, or signs of fluid overload should be seen urgentl
Phone Call:
- Is the patient complaining of abdominal pain?
- vital signs?
- Indwelling urinary catheter? ask the nurse to flush the catheter with 20-30mL of normal saline to dislodge sediment or clots and restore patency
- Also request an ECG
- Let the nurse know that you will come and assess the patient (don’t give phone orders for a fluid challenge)
Bedside:
-
Immediate Management:
- Assess ABCDE
- Review – observation chart, fluid balance chart, medication chart, patient notes
-
History:
- Is the patient thirsty? Does he feel the need to urinate? Does he have a history of renal disease?
- Is he in pain?
- Has he had an haematuria, frothy urine, swollen ankles, rashes or arthralgia?
- Did he have any urinary symptoms before hospital?
-
Physical Examination:
- Vital signs & mental status
- Skin – temperature, colour, sweating, turgor, rash
- HEENT – jaundice (hepatorenal syndrome), dry tongue and mouth
- CVS – Pulse, capillary refill, JVP, HS
- Resp – expansion, percussion (dullness) and auscultation (basal crackles)
- Abdo – bladder size, enlarged kidneys, tenderness, peritonism, intraabdominal haemorrhage, PR exam (bleeding, enlarged prostate)
-
Investigation:
- FBC, UEC, coagulation studies, VBG (? ABG), blood glucose, consider blood cultures
- ECG
- Bedside bladder scan (USS)
- Urinalysis and Urine MCS
- Consider abdominal/ pelvic USS
-
Management:
- If hypovolaemia is suspected than a fluid challenge is appropriate:
- 250 - 500mL of crystalloids IV stat (i.e. under gravity, fast flowing)
- Hartmann’s is the fluid of choice if there are now electrolytes results available
- Continue to closely monitor the urine output and vitals
-
Review the patient yourself in 30 mins:
- A rise in urine output and BP suggests adequate treatment
- If further deterioration or only a short response then call your registrar and potentially involve MET or ICU team
- If hypovolaemia is suspected than a fluid challenge is appropriate:
Major Threats to life:
- Hypotension and shock
- Oliguric acute renal failure
- Sequelae of acute renal failure
- Hyperkalaemia
- Metabolic acidosis
- Acute hypertension
- Pulmonary oedema

