Capsul surgery Flashcards
A right iliac fossa mass is most likely to rise from the bowel, what are the three most common causes
- Cecal carcinoma
- Crohn’s disease
- appendix abscess
hepatomegaly can also extend down to the right iliac fossa to be aware of this also
What are two organisms that can mimic ileocaecal Crohn’s disease?
Tuberculosis and the Yersinia
The short history of worsening dysphagia to solids and then liquids, combined with weight loss, is highly suggestive of?
oesophageal malignancy
when suspecting oesophageal CA what is the investigation of choice to confirm?
gastroscopy/ upper gastrointestinal endoscopy
Describe this barium swallow
Extensive ulcerating oesophageal carcinoma in the mid-oesophagus
Achalasia classically has a ‘’ appearance on barium swallow
Bird beak
it has a smooth tapering with possible dilation above the lesion
What are common Sites for metastasis of oesophageal malignancy
Liver and lung
What imaging techniques could be used to help establish stage of a newly discovered oesophageal adenocarcinoma
- CT chest abdo pelvis – investigates nodal spread, metastases to lung and liver are most common
- endoscopic ultrasound – useful for T staging and local N staging
- pet scan can also be useful for identifying distal metastases that don’t have any lymph node enlargement
*
are tumours most common in the lower or upper oesophagus?
Lower oesophagus
Barrett’s oesophagus is a consequence of
Gastro-oesophageal reflux disease
Barrett’s oesophagus increases risk of what?
Adenocarcinoma of the oesophagus
Smoking is a particular risk for what forms of GI cancer?
Squamous cell
A patient with a three-day history of epigastric pain and a history of heavy alcohol use should should have what included in the differential diagnosis
- Acute pancreatitis
- perforated duodenal ulcer
- alcoholic gastritis
A serum amylase above 1000, and an elevated serum lipase can indicate what
pancreatitis
Should IV fluids be given to patients with mild pancreatitis?
Early administration of intravenous fluids is of critical importance in all patients with acute pancreatitis, however mild.
Why are blood gases needed for all pancreatitis patients
There used in the severity scoring and therefore guide treatment
A patient presents shortly after discharge for acute pancreatitis complaining of upper abdominal pain and distension what is important common complications of acute pancreatitis
A pancreatic pseudocyst
a common complication of acute pancreatitis. Most consist of a collection of fluid, debris and pancreatic juices. Such cysts usually results from a disruption of pancreatic ducts as a consequence of acute pancreatitis.
Such patients may also develop ascites (so called pancreatic ascites), this diagnosis is made by a very high amylase content in the ascitic fluid.
Calprotectin is a measure of
gastrointestinal inflammation (think of it like CRP for the bowel)
Faecal elastase can be used to measure pancreatic what?
Pancreatic exocrine function
owever it is a fairly blunt instrument to determine pancreatic insufficiency. Clinical judgement is just as good for determining pancreatic exocrine insufficiency
In patients with chronic pancreatitis and pancreatic insufficiency what is important in the treatment
Enzyme replacement therapy is essential and expert dietary advice is needed.
Diabetic input may also be very helpful
Describe the important findings on this image
Dilated loops of small bowel
air within the peritoneum/pneumoperitoneum. (Rigler sign)
What would be the preferred imaging modality to locate a abdominal perforation prior to surgery
CT scan
the free air may be picked up initially on a abdominal radiograph however CT scan will give an idea to the location of perforation.
Ultrasound is not indicated
Perforated diverticulum and perforated duodenal ulcers are common cause for?
Pneumoperitoneum
What are some common causes for pneumoperitoneum?
Perforated duodenal ulcer perforated diverticulum,
perforated viscous in general
recent abdominal surgery especially laparotomy.
(The CO2 used in laparoscopy is normally just within hours of surgery)
Which portion of the duodenum is retroperitoneale?
The distal duodenum/ last third
What is this image diagnostic of, and what sign is it showing?
Sigmoid volvulus showing coffee bean sign.
The dilated loops are converging in the left pelvis signifying sigmoid rather than cecal
In an elderly frail patient presenting with volvulus of the sigmoid colon what would be the less invasive option for treatment?
Sigmoidoscopy and passage of a decompressing flatus tube.
For some patients this may be sufficient, volvulus may be recurrent however and therefore a sigmoid colectomy may be needed
Which volvulus is associated with large bowel malignancy, cecal or sigmoid?
Cecal volvulus has an association with large bow malignancy
What are the criteria to determine acutely severe colitis established by Truelove and wits
(six)
Frequency of stools greater than six
- overtly bloody stool
- fever over 37.5
- tachycardia greater than 90
- anaemia less than 105
- raised ESR greater than 30
Our bloody stools more common in UC or Crohn’s disease
Ulcerative colitis
Colovesical fistula is associated with
diverticulitis, colon cancer, Crohn’s disease, and cancer that involves nearby organs.
What are some of the complications/extraintestinal manifestations of ulcerative colitis
- Colonic carcinoma
- rectal haemorrhage
- large joint arthritis
- primary sclerosing cholangitis
- anterior uveitis
- aphthous ulcers
Skip lesions, deep ulcers, and ileal involvement occur in?
Crohn’s disease
Crohn’s disease involves:
- Skip (blank)
- (blank) ulcers
- (blank) involvement
*
- Skip lesions
- deep ulcers
- ileal involvement
In severe pan colitis from ulcerative colitis how may there be small-bowel involvement?
The ileocecal valve may become damaged and fixed open resulting in backwash ileitis, this is where exudate from the colonic mucosa causes minor inflammation in the very last section of the ileum
How smoking linked to ulcerative colitis
It is somehow protective, often patients have flares or present when they quit smoking
How is smoking associated with Crohn’s disease
In Crohn’s patients who smoke tend to have a severe disease course
What is the most important treatment in a patient presenting with acute severe colitis?
Steroids
IV hydrocortisone hundred milligrams every six hours
A patient being treated with steroids for severe colitis may also have what adjunctive therapy?
- Heparin = these patients are at high risk of thromboembolic events, important to weigh up risk of them haemorrhaging before administering
- Adcal D3 = bone protection due to being on steroids
What is a nice recommended second-line therapy for acute severe colitis?
Infliximab
this is due to patients that are refractory to steroids and there is a contraindication for cyclosporine (as this is the first second-line treatment for acute disease)
Comment on what can be observed in this image and suggest a diagnosis
Pathological dilation of the transverse colon (greater than 6 cm) with marked oedema of the colon walls.
(Thumbprinting)
toxic megacolon usually affects transverse colon and presence with the dilation of greater than 6 cm
what diagnosis is this abdominal radiographs likely indicating
Toxic megacolon is complication of?
Severe colitis, both infectious and inflammatory
What is the most common inflammatory cause of toxic megacolon?
Ulcerative colitis
What is the most common infective cause of toxic megacolon
C diff colitis
ther infectious agents including Salmonella, Shigella, Campylobacter, Yersinia, Entamoeba histolytica, and Cryptosporidium have been associated with toxic megacolon
Is Crohn’s disease or ulcerative colitis more associated with toxic megacolon
UC
Describe the findings of this image
This is a cross-section of the upper abdomen through the liver and spleen, there is a perihepatic and parasplenic haemoperitoneum. The liver borders appear normal whereas the spleen has an irregular outline with contrast medium present in the area indicating active bleeding.
There is also a fractured rib on the left side
What is the most commonly injured solid organ of the abdomen, and by what mechanism is it injured?
The spleen, most usually injured via blunt trauma
What concurrent injuries are splenic injuries most associated with?
Rib fractures = 40%
left renal injury = 25%
diagrammatic rupture = 2%
How are the majority of splenic lacerations managed?
Most are self-limiting and can be managed conservatively. Patient is there unstable and continue to haemorrhage will require splenectopy
Post splenectopy patients are increased risk of several bacterial infections, what precautions need be taken with these patients on discharge/within two weeks of discharge?
- Pneumococcal vaccination
- meningeococcal vaccination
- haemophilus influenza vaccination
these patients also may need to be on long term penicillin prophylaxis (practice varies)
they are also at greater risk of malaria
Achalasia of the oesophagus generally presents how?
Progressive dysphagy over the course of months with possible aspiration.
Swallowing of foods and liquids become difficult simultaneously.
May also be associated with the cramping discomfort and weight loss
What investigations would be indicated first for oesophageal achalasia?
Upper gastroesophageal endoscope
barium swallow
oesophageal manometry
What investigations would be indicated first for oesophageal achalasia?
Upper gastroesophageal endoscope
barium swallow
oesophageal manometry
What is this barium swallow indicative of
Oesophageal achalasia
a tight smooth narrowing of the distal oesophagus can be seen with the dilation above
Oesophageal achalasia is a disease of the functioning of the oesophagus, a definitive diagnosis needs what to be shown on what?
A lack of functioning in the body of the oesophagus and an overactive lower oesophageal sphincter on manometry
Achalasia can be associated with oesophageal and (investigation) is needed to exclude this
Achalasia can be associated with oesophageal malignancy and endoscopy is needed to exclude this
Treatment for oesophageal achalasia can be split into three categories
- initial/patients awaiting definitive treatment
- good surgical candidates
- Poor surgical candidates
- Initial = pharmacotherapy = calcium channel blockers or nitrates prior to mealtime = nifedipine, verapamil, isosorbide dinitrate
- good surgical candidate = balloon dilation, laparoscopic cardiomyotomy, Peroral endoscopic myotomy (POEM)
- Poor surgical candidates = Botox injection + pharmacological therapy
In acute cholecystitis what are the first-line investigations:
- Bloods = full blood count, CRP, LFTs + bilirubin, serum lipase + amylase and possible cultures (blood + bile)
- abdo ultrasound
- CT or MRI
MRCP can be considered but not first-line
What are the labels on this ultrasound of the gallbladder (hint: this patient is presenting with right upper quadrant pain)
- A = liver
- B = thickened wall of gallbladder
- C = gallbladder contents (sludge/bile)
- calculi in gallbladder
In a patient presenting with cholecystitis what is the importance of normal liver function tests and a non-violated biliary tree on ultrasound?
they make a common bile duct stone unlikely, meaning the location of the stone is likely still within the gallbladder
What is the general treatment algorithm for a patient presenting with acute cholecystitis: (in order)
- Analgesia
- fluid resuscitation
- (consider) antibiotics
- laparoscopic cholecystectomy/percutaneous cholecystectomy
in a patient with associated organ dysfunction intensive care admissions comes first
Our gallstones always visible on x-ray?
Only 10 to 20% are radiopaque
What is the rationale for early cholecystectomy in patients presenting with cholecystitis?
Complications are associated with later procedures and it also reduces the readmission burden on the NHS
Why is sickle-cell associated with gallstones?
Any condition that is haemolytic will result in increased bilirubin excretion hence increase pigment stone formation.
A gallstone present in the common bile duct can cause
Ascending cholangitis
A gallstone in the ampullar can cause
Acute pancreatitis
Porcelain bladder is?
A rare complications secondary to chronic inflammation, presents on radiograph with mural calcification. Can be a risk factor for malignant change.
How is a mucocele of the gallbladder created?
If a stone impacts into Hartmann’s pouch this can obstruct the cystic duct orifice resulting in an acute buildup in mucus within the gallbladder producing distension, discomfort and possible empyema of the gallbladder
Anarrhexis chest x-ray is useful in patients presenting with acute peritonitis why
To help look for free intraperitoneal air
In the top picture what can be seen under the right hemidiaphragm
Normal large bowel can be seen interposed between liver and right hemidiaphragm. This is a normal variant and is known as Chilaiditi’s sign, do not confuse this appearance with free intraperitoneal air.
In the bottom picture are there dilated loops of large or small bowel
Small-bowel
In acute pancreatitis amylase levels may be how high
1000 units per millilitre
In amylase level of 380 (normal range 0-150 iU/L) may indicate
An acute pancreatitis that has been ongoing for a few days as levels may drop to a more moderate elevation.
This level of elevation also may be seen in duodenal perforation, mesenteric infarction and acute cholecystitis
The Glasgow-Imrie criteria for the severity of acute pancreatitis is scored once, 48 hours after admission and uses the following parameters:
- Pa02
- White cell count
- serum calcium
- urea
- LDH (lactate dehydrogenase)
- albumin
- glucose
Worsening pancreatitis may be associated with what findings:
hypoxia, hyperglycaemia, reduced serum calcium and albumin, rising white cell count, C-reactive protein and renal failure.
(Blank) and (blank) account for at least half of all cases of acute pancreatitis
Gallstones and alcohol misuse account for at least half of cases of acute pancreatitis
Gallstones and alcohol misuse account for at least half of cases of acute pancreatitis. Other causes include
- Hypertriglyceridaemia
- pancreatic malignancy
- hypocalcaemia
- Post ERCP
- trauma
- infection
- drugs
- autoimmune
- sphincter of Oddi dysfunction
infections that cause acute pancreatitis include
- Mumps
- Mycoplasma
- Epstein-Barr
- HIV-related co-infections
drugs that can cause pancreatitis include
Azathioprine and mercaptopurine
there is limited evidence to suggest frusemide, oestrogen, thiazide diuretics, tetracyclines, valproate. (To name a few)
Mittelschmertz is
one-sided, lower abdominal pain associated with ovulation
Mesenteric adenitis typically follows a
respiratory tract infection
In a child presenting with an apparent appendicitis what investigations/examinations are important rule out the top differentials
Urine test = both UTI and pregnancy
ENT examination = mesenteric adenitis
What abnormality can be seen in this image
Air underneath the right hemidiaphragm
What can be seen in this image
(hint one of the things is non-related to the bowel)
Small-bowel dilation- note the mucosal folds (valvulae conniventes) traversing the bowel lumen
Paget’s Disease of his pelvis – the bone is sclerotic and the trabecular pattern is coarsened.
In small-bowel Ileus post surgery what electrolytes are particularly important to consider?
Replacement of potassium and magnesium, aiming for a K of greater than 4 mmol/L to maximise the chance of peristalsis restarting.
What five things need to be monitored the patient on total parenteral nutrition?
- Line inspection
- regular temp and observations (for hourly)
- blood glucose
- daily electrolytes
- fluid balance
Pabrinex contains a mixture of
B vitamins and vitamin C
Patient who has had small-bowel ileus for several days now needs to be treated with TPN, what may be needs to be given prior to starting this and why?
Pabrinex, as thymine is required to process food and this patient has been in a style state so is likely to have low thymine levels. This could cause Wernick’s encephalopathy and if not treated good progress on to Korsakoff psychosis
classic triad of Wernicke’s =
- Ataxia
- confusion
- ophthalmoplegia
Courvoisier’s law (known as Courvoisier’s sign or Courvoisier–Terrier’s sign, or Courvoisier syndrome) states that
a painless palpably enlarged gallbladder accompanied with mild jaundice is unlikely to be caused by gallstones.
A Patient with painless obstructive jaundice on LFTs and clinical examination with steatorrhoea and a right upper quadrant mass should be considered to have
Cholangiocarcinoma or carcinoma of the pancreas until proven otherwise
In a patient with weight loss and painless jaundice, cancer is the most likely diagnosis until proven otherwise. Therefore in a patient being queried for a biliary/pancreatic cancer what are the first investigations?
CT chest abdo pelvis and tumour markers (CA-19, CEA, AFP)
A patient presents with painless jaundice and is confirmed to have a mass in the head of the pancreas with positive CA 19-9 what is the next most appropriate investigation
ERCP-allows the insertion of a stent and tissue sampling by endoscopic brushing
Most pancreatic tumours occur where in the pancreas and from what tissue
Head from exocrine tissue
As diabetes risk factor or a consequence of pancreatic carcinoma
Consequence
The most common complications of ERCP include:
- Pancreatis
- cholangeitis
- haemorrhage
- duodenal perforation
Appropriately label this CT:
(E and D are pathological)
- A = right lobe of the liver
- B = left kidney
- C = hepatic flexure of the colon
- D = para aorta adenopathy
- E = wall of stomach (thickened)
- F = aorta
Note gross thickening of stomach wall in keeping with metastatic infiltration and metastatic para-aortic nodes.
What is the most common type of stomach cancer?
Adenocarcinoma
Risk factors for adenocarcinoma of the stomach include:
- Age
- male sex
- Poor socio-economic status
- H. pylori
- high salt and preserved food diet
- smoking
- atrophic gastritis, pernicious anaemia
- familial risk
- blood group A
- Hypogammaglobulinaemia
What is a Krukenberg tumour
An ovarian mass as a result of a metastatic gastric tumour
this is a rare presentation
Comment on this x-ray
Lung fields are normal, a loop of large bowel can be seen interposed between the liver and the diaphragm.
Remember for assessing chest x-ray
- rotation
- inspiration
- projection
- exposure
- ABCDE
- airway
- breathing
- cardiac
- diaphragm
- Everything else
When assessing chest x-ray what is the systematic approach to use:
First assess the image quality = ripe:
- rotation-look at the clavicles and spinous process
- inspiration-5 to 6 anterior ribs
- projection-AP or PA
- exposure-spine and vertebra should be visible behind the heart
ABCDE approach:
- airway = trachea, carina, bronchi, hilar
- breathing = lungs and pleura
- cardiac = heart size and border
- diaphragm = costophrenic angles
- Everything else = mediastinal contours, bones, soft tissue, valves.
The triad of acute pain fever and jaundice is diagnostic of what
ascending cholangitis
What type of picture do these LFTs paint
Amy
140 28-100 IU/L
Bili
600-21 µM
ALP
18035-104 IU/L
AST
400-32 IU/L
GGT
2 756-42 IU/L
Obstructive picture
What is the initial treatment for ascending cholangitis
intravenous antibiotics and intravenous fluid (often a lot of i.v. fluid is needed for resuscitation). Analgesia may also be required.
Why are abdo CT scans not ideal for assessing for gallstones/stones blocking the biliary tree?
Only 10% are radiopaque, dilation of the biliary vessels might be seen but it is not ideal for assessing the location of the stone
In a patient who is clinically suspected of having ascending cholangitis and who is seen to have a diluted biliary tree on ultrasound but no stone located due to air a in the bowel obstructing the image what are the two best options for the patient?
- Use of MRCP to locate stone
- some clinicians may choose to go straight for ERCP despite there being no confirmed stone
Label this image
- A = gallbladder
- B = cystic duct
- C = intra- hepatic duct
- D = common hepatic duct
- E= common bile duct
- F = gallstone/obstruction
- G = pancreatic duct
- H = duodenum
*
Patient with confirmed ascending cholangitis due to a calculi located in the distal common bile duct-what is the definitive treatment
ERCP is the technique of choice
What is the morbidity risk roughly of ERCP
Around 5%
and there is significant mortality especially in patients with ascending cholangitis
It can be associated with pancreatitis, infection, aspiration pneumonia.
Sphincterotomy can cause duodenal perforation and haemorrhage.
a patient with a long history of right upper quadrant discomfort, nausea, bloating and flatulence what is the most likely differential
chronic cholecystitis
Porcelain gallbladder is rare but permanent, in these patience what is the optimal treatment
Cholecystectomy-there’s an association with gallbladder carcinoma
emphysematous cholecystitis is classified by the finding of what
Distended thick-walled gallbladder with air within the wall
What are the most likely causes of large bowel obstruction:
- 60% = colorectal malignancy
- 20% = diverticular strictures
- 5% = volvulus
igmoid volvulus is more usually seen in frail or older patients. Caecal volvulus is more rare and more commonly seen in younger patients
Duke staging is a classification system for what
Bowel cancer
What sided colonic tumours are more likely to obstruct?
Left-sided
the diameter is smaller and the bow contains more solids
Why are right sided colonic tumours more likely to present with anaemia?
These tumours obstruct later and I generally allowed to grow larger due to late presentation, the larger tumours can lose more blood from their strict surface leading to iron deficiency anaemia.
This can be the presenting complaint
What are the most common sites of metastasis of colorectal cancer
Lymph nodes, liver and lung
What cell types are the majority of colonic carcinomas
Adenocarcinoma
Barium enemas are contraindicated in which group of patients due to risk of peritonitis
Patient who have risk of perforation
Describe this x-ray
Large bowel dilation, in keeping with obstruction. Note the loops descending into the pelvis
In a patient whose clinically obstructed what are the three compulsory initial investigations
Digital rectal
supine abdominal x-ray
chest x-ray
Comment on this series of x-rays
Marked large bowel dilation
air in the rectum
small volume lungs-likely related to diaphragmatic splinting
The presence of rectal air in an obstructed pt has what significance?
Pseudo-obstruction is likely,
makes a left sided obstruction less likely, Rectal air makes a sigmoid stricture unlikely.
Pseudo-obstruction is usually managed how?
conservatively
xclusion of a mechanical obstruction is needed in a proportion of patients, either via CT scan or colonscopy.
Electrolyte imbalance is a causative factor may need correcting, look at K
Symptomatic acute diverticulitis classically presents with what triad:
- Fever
- leukocytosis
- lower left quadrant pain
What is the imaging modality of choice for acute diverticulitis or complicated diverticular disease
CT
Labelled the features in this axial CT
A = fluid contained within abscess
B = air in abscess
C = thickened loop of sigmoidcolon
In a patient with a diverticular abscess with no evidence of peritonitis or perforation outline the general plan of treatment
Conservative management, if unwell and constipated to rehydration + nil by mouth + ABX
follow-up CT to ensure abscesses resolving, if not consider percutaneous drainage
need to rule out underlying carcinoma = colonoscopies when information is resolved
In a patient with pneumaturia or fecaluria what underlying pathology may be responsible
Diverticular disease
common course for fistulas between the sigmoid colon and bladder (small bladder and vagina are also possible fistula locations)
Most diverticular are acquired secondary to
Low fibre diets
there are genetic factors also
What is the general distribution of diverticula disease
Generally focused around the sigmoid colon
however can occur anywhere in the bowel
A colovesical fistula or a enterovesicula fistula can result in what symptoms
air or faecal matter in the urine
What is the most common cause of enterovesicula fistula in elderly women
Diverticular disease (in the UK)
Label this, patient has diverticular disease
- A = bladder
- B = sigmoid colon
- C = gluteus muscle
- D = femoral head
- E = air in the bladder
Pseudomembranous colitis (PMC) is the most likely diagnosis in what group of patients?
Patients with Abdo pain, profuse diarrhoea commencing after starting antibiotic treatment
What can be seen here?
(Context: patient presenting with profuse watery diarrhoea)
Thick-walled loops of colon on the right upper quadrant, there is thumb printing and mucosal oedema of colonic loops
What is the most common causative organism for pseudomembranous colitis
Clostridium difficile
In elderly patients with C. difficile who require treatment what is the regimen of choice
vancomycin or metronidazole
Convocations of pseudomembranous colitis include:
- Ileus
- perforation and peritonitis
- toxica megacolon
Which of these five are not a risk factor for the development of gallstones
- obesity
- raised oestrogen levels
- pregnancy
- constipation
- family history
Constipation is not a risk factor/associated with gallstones
What is the benefit of a laparoscopic cholecystectomy versus an open operation
Short stay in hospital + shorter convalescence
Abdominal pain, rigidity, quiet bowel sounds, and guarding are classic features of?
Peritonitis
Generalised peritonitis and clinically unwell patient would trigger suspicion of
Perforated viscous
A lump in the scrotum of a infant that can’t be palpated above and transilluminates is likely to be a?
hydrocele of the spermatic cord
What is the most common causative organism for cholangitis?
E. coli
(followed by Klebsiella)
A patient presenting with severe pancreatitis is at risk of what respiratory complications?
Acute respiratory distress syndrome
Murphy sign on examination =
Inspiration arrest on palpation of the upper right quadrant
How would a inguinal hernia present on examination of the scrotum
A mass that does not transilluminate and cannot be palpated above
What are the two classic features of hernias (non-impinged/not entrapped)
- They have a cough reflex (due to the transmitted pressure from the abdomen)
- they can be reduced/they can be put back into the abdomen (unless they are trapped)
Is this large or small bowel that is dilated
Small-bowel
generally the small-bowel is more central (this differentiation is problematic in terms of the transverse colon, sigmoid as they are fairly mobile)
mall bowel has valvulae conniventes (bands which go all the way round the bowel circumferentially) while large bowel has haustra (lines which do not quite go all the way around).
When can one say a small bowel is obstructed (diameter)
>3cm
When can one say a large bowel is obstructed (diameter)
>5 cm
How can one tell this is dilated small-bowel
- Central location
- valvulae commitantes
- loops of bowel lie alongside each other
What abdominal examination findings could help differentiate between paralytic ileus and small bowel obstruction in a patient presenting with this x-ray
The bowel sounds, obstruction may present with tinkling while Ilheus would present with absent sounds
What type of stoma is this?
Loop ileostomy
Femoral hernias are more common in (male or female)
Female
they are often irreducible and can strangulate
Inguinal hernias are more common in (male or female)
male
80% of inguinal hernias are indirect.
Describe the location of an inguinal hernia
Passes superior and medial to the pubic tubercle following the line of the inguinal canal
Describe the location of a femoral hernia
Lies inferior and lateral to the pubic tubercle
The contents of the spermatic cord and inguinal canal are:
- Three arteries = testicular, cremasteric, vas deferens
- three nerves = genitofemoral nerve, sympathetic nerve, (and ilioinguinal – not actually in cord, but in canal)
- 3 other structures: vas deferens, veins (pampiniform plexus) and lymphatics.
A patient presenting with: pain, distension, absence of bowel movements and increased bowel sounds may have
Obstruction
Comment on this image
Dilated loops of transverse colon
Note also the lack of small bowel loops on the radiograph – this implies a competent ileocaecal valve, which increases the risk of colonic perforation.
Comment on this contrast to enema finding and what is it parapneumonic of
This Apple core appearance is indicative of a carcinoma
Liver enlargement, right upper quadrant pain and sepsis are suggestive of
Pyogenic liver abscess
keep in mind some of the symptoms may also resemble that of:
acute cholecystitis, ascending cholangitis, gallbladder empyema
What can be seen on this cross-section CT
A large separated hypodense mass in the right lobe of the liver
in keeping with a liver abscess
When do pyogenic liver abscesses most commonly occur
After intra-abdominal sepsis
they can occur spontaneously
What are the most common organism isolated from pyogenic abscesses of the liver
E. coli
Klebsiella pneumoniae and Strep milleri are also not uncommonest
enterococcus, Proteus Staphylococcus and anaerobes are recognised
Hepatocellular carcinoma occurs almost exclusively on a background of what?
chronic liver disease
Varicose veins that are present on the medial aspect of the thigh and calf are likely due to valve incompetence which vain?
Long saphenous
In a 60-year-old male patient presenting with severe low back pain where neurological mechanical causes have been excluded what is concerning that this x-ray
There is calcification present in the wall of a aortic aneurysm as can be seen with yellow arrows.
What is the most common demographic to have a AAA
Elderly male
The aorta bifurcates at what level?
L4-this correlates with the level of the umbilicus
At what size of AAA is an elective repair generally regarded as being required
5.5 cm
rate of growth is also used as an indicator
What are the six P’s of acute limb ischaemia
- Pale
- pulseless
- painful
- paralysed
- paraesthesia
- ‘perishing with cold’
While the 6 P’s are signs of acute limb ischaemia, what are some indicators of chronic limb ischaemia
Ulcers and loss of Hair
Lipodermatosclerosis is
The brown discolouration of hard skin with fibrotic subcutaneous tissue seen in chronic venous insufficiency
What are the treatments for acute limb ischaemia
Surgical = embolectomy
pharmaceutical = thrombolysis
IV heparin may be used as a sole treatment or while waiting for transfer to vascular centre
Inability to straight leg raise, and an externally rotated and shortened leg is highly indicative of
A non-impacted neck of femur fracture
In orthopaedics what is the rule of two
two radiological views are always required, usually antero-posterior and lateral i.e. orthogonal to each other. Some fractures may be occult on a single AP view.
What type of neck of femur fracture is this?
Right intracapsular neck of femur fracture
In orthopaedics what is the HB transfusion threshold?
8 g/dL
What is the general HP transfusion threshold
<7 g/dL
In a symptomatic patient what is the transfusion threshold
10 g/dL
The garden classification can be used for
femoral neck fracture
Stage I: Incomplete fracture of the neck (so-called abducted or impacted)
Stage II : Complete without displacement
Stage III: Complete with partial displacement. Fragments are still connected by posterior retinacular attachment and there is malalignment of the femoral trabeculae
Stage IV : This is a complete femoral neck fracture with full displacement, the proximal fragment is free and lies correctly in the acetabulum so that the trabeculae appear normally aligned.
Elderly patients who are active and independently mobile who suffer a intracapsular neck of femur fracture should be treated with
Total hip replacement
Elderly patients who have poor mobility and multiple comorbidities can be treated with what in the event of intracapsular neck of femur fracture
Hemiarthroplasty
quicker operation, with a lower risk of post-operative dislocation, but is associated with more long-term pain and worse mobility.
It’s eponymous
Name that procedure!!!
Austin-Moore hemiarthroplasty
Describe the classic demographic of NoF patients
Elderly women with osteoporosis
in the under 60s category it’s more common in men
Name that anatomy
- A = head of femur
- B = neck of femur
- C = greater trochanter
- D = intetrochanter line
- E = lesser trochanter
- F = femoral shaft
Which bone is fractured
scaphoid
Which nerve is involved in carpal tunnel
Median
Describe the effect of impingement on the median nerve within the hand
Pain/pins and needles of the thumb, index, and the middle half of the ring finger on the palmar side and up to the terminal joint of the index and middle half of the ring finger on dorsal side.
And wasting of the thenar muscle
Tinel’s sign and Phalen’s test =
Tests for carpal tunnel
What is the general treatment approach and escalation for carpal tunnel
- Rest, anti-inflammatory medication
- splinting
- steroid injection
- surgical release of the carpal tunnel
Name that fracture
Extracapsular femoral neck fracture
specifically = a comminuted intra-trochanteric fracture
What is the usual management for an extracapsular neck of femur fracture
fixed with pin and plate and the majority of extra-capsular fractures heal within about 3 months or so following the fixation.
How are femoral fractures best treated
Operative fixation
preferably intra medullary nail
Describe the treatment options for tibial fractures
The majority are managed with operative fixation either external or internal.
In children and young adults if the bone is not overly displaced can be manipulated and treated with plaster mobilisation
Derive the characteristic features of the clawhand deformity
Extension of the fourth and fifth fingers at the metacarpophalangeal joints and flexion at the interpharyngeal joints
Injury to the ulnar nerve distal to the wrist can cause
Clawhand deformity
An injury what location can cause the clawhand deformity
ulnar nerve distal to the wrist
The ulnar nerve comprises elements of which spinal nerves
C8-T1
The anterior draw test assesses which structure
The anterior cruciate ligament
abnormal laxity can occur with ACL damage
The posterior draw test assesses which structure
Posterior cruciate ligament
McMurphy’s test is a rotational test of the knee to assess
Meniscal injury
What is the primary function of the anterior cruciate ligament
Preventing anterior translocation of the tibia at the knee
What is the most common cause of knee joint effusion in everyday clinical practice
Osteoarthritis
characterised by localised loss of cartilage, remodelling of adjacent bone and associated inflammation.
The medial collateral ligament of the knee is mainly ruptured due to
Trauma
its main function is to resist a valgus force. This occurs if the tibia or foot is forced outwards in relation to the knee.
The supraspinatus is responsible for what shoulder movement
The first 15° of abduction
the deltoid is responsible thereafter
Pain on abduction of the shoulder is commonly due to?
tendonitis of the supraspinatus tendon (usually secondary to impingement at the level of the acromion) or osteoarthritis of the acromioclavicular joint.
Simmonds Thompson test is for
The Achilles tendon
squeezing the calf looking for plantarflexion of the foot
What nerve is responsible for wrist drop
Radial nerve
Injury of the radial nerve can occur anywhere along its course what are some features they can present with
Wristdrop
weakness to extension of wrist, fingers and elbow
sensory changes over the dorsum of the hand on the radial side/ web space ( superficial branch of radial nerve
The radial nerve is comprised of parts of which spinal nerves
C5 to T1
What is the most common cause of disruption to radial nerve
Trauma = often fractured humorous
compression can also cause neuropraxia – Saturday night palsy – falling asleep with arm draped over a firm object directly compressing the nerve in the spiral groove
Spot the injury
Fractured left pubic rami
What could be seen in this image
Lytic bone lesions in L1 and L2
Additionally there is degenerative disease throughout the lumbar spine. This most marked at L4/5 where there is loss of intervertebral disc space height and osteophytosis.
In male patients carcinoma of the lung and kidney and myeloma are important causes of lytic bone lesions.
What is the most commonly fractured tarsal bone
The calcaneous
Calcaneous fractures are often associated with what other injuries
- a contralateral calcaneal fracture (10%)
- wedge compression fractures of the spine
these injuries occur due to a compressive force following a fall from height
Spot the injury
Stress fracture on the second metatarsal, this can be seen by the periosteal reaction along the shaft of the second metatarsal
Spot the injury
There is a fracture across the base of the fifth metatarsal
Describe this injury
Fracture of the lateral malleolus, with displacement of the talus
(Think fat)
What sign on this x-ray indicates there may be an occult fracture present
There is a lipohaemarthrosis,
The lateral view of the knee in trauma is usually taken with a horizontal beam with the patient supine, this means the fact floats on top of the fluid. The fact fluid level means that fat has leaked out of the medullary bone cavity indicating a fracture
What two pathologies can be seen here?
A tibial plateau fracture with super patella joint effusion
Comment on the findings of this x-ray
Right-sided hip replacement
left-sided intertrochanteric fracture of the left neck of femur
What are the most common causes of osteolytic bone metastases in adults
Lung, breast, thyroid, kidney and colon cancer.
What are the most common cause of osteoblastic bone metastases?
- Breast CA
- prostate CA
Primary malignancies resulting in mixed bone metastases include:
- Prostate
- breast
- lymphoma
More than the femur fracture
Comment on the findings in this x-ray
Pathological fracture of the left femur from a lytic lesion
lytic lesions present on the left pubic rami
Comment on the findings of this x-ray
Fracture of the posterior aspect of the eighth rib, and a large pneumothorax
What position is more common for dislocation of the humeral head
Anterior
Name them bones
- A = radius
- B = ulna
- C = thumb metacarpal
- D = scaphoid
- E = trapezium
- F = trapezoid
- G = capitate
- H = hemate
- I = Pisiform
- J =Triqueral
- K = lunate
The majority of fractures to the carpal bones involve the
Scaphoid
At what site is the scaphoid normally injured
70% occur through the waist
Name that fracture
Colles fracture
There is a comminuted fracture of the distal radius with dorsal angulation of the distal fragment
Describe the pathology and mechanics of a colles fracture
These are fractures of the distal radius with dorsal angulation, they commonly occur in the elderly and are associated with falls on the outstretched hands.
Describe the position of a Smiths fracture
Sometimes described as a reverse colles, this is a fracture of the distal radius with a palma angulation of the distal fragment
This disc prolapse between L2 and L3 what distribution of symptoms
Upper thigh pain and hip/knee weakness
Disc prolapse between L5 and S1 will cause symptoms were
Lateral leg and outside of the foot
The majority of newly presenting sciatic patients are treated how?
Reassurance and analgesia, with conservative treatment over six weeks 60% of patients improve.
- Anti-inflammatories
- analgesia
- physiotherapy
- muscle relaxants
What percentage of sciatica cases settle within 6 to 8 weeks
Over 60%
What does this radiograph showed
Lytic destruction of the left iliac bone
The commonest source of secondary malignant bone tumours are:
breast, prostate, kidney and lung cancers as well as multiple myeloma and lymphoma.
Which are the commonest sites for bony metastases to occur?
spine, ribs and pelvis followed by the proximal femur and proximal humerus.
What are effective treatments for resolving periprostatic infection?
Deep infection of joint replacements is a rare, but devastating complication treatment include:
- Debridement and implant retention
- remove and replacement in either a one stage a two-stage technique
What are the most common organisms associated with infected hip replacements
Streptococcus and staphylococcus
What does Tinal’s test involve
Tapping the median nerve at the wrist, a positive test provoke symptoms of carpal tunnel
Describe phalen’s test
Hyperflexing the wrist for 1 to 2 minutes to provoke symptoms of carpal tunnel
Which thyroid complications is associated with couple tunnel syndrome
Hypothyroidism
Describe the location of this fracture
Intracapsular right femoral neck
Describe the location/type of this fracture
Displaced intracapsular NoF
Intracapsular neck of femur fractures are managed predominantly via a hemiarthroplasty or total hip replacement what is the rationale for choosing the operation:
Total hip replacement is used for patients who are generally younger/that will benefit from the more intense surgery some criteria to meet are:
- Are able to walk independently out of doors with no more than the use of a stick; and
- Are not cognitively impaired; and
- Are medically fit for anaesthesia and the operation. This
What is the most common cause of portal hypertension
Cirrhosis
Ascites, splenomegaly and caput medusae are all signs of
Portal hypertension
How can portal hypertension results in bright red blood in the rectum on PR exam
Rectal varices
A patient presenting with sudden severe generalised Abdo pain (usually out of proportion to physical signs), vomiting and a single passage of bloody diarrhoea should be suspected for
Mesenteric infarction
Can femoral hernia is being managed conservatively?
Surgical repair is necessary as there is high risk of incarceration and strangulation
Shock occurs when there is insufficient tissue perfusion, it can be divided into the following aetiological groups
- Septic
- haemorrhagic
- neurogenic
- cardiogenic
- anaphylactic
another way to split it = obstructive, cardiogenic, distributive, hypovolaemic
A carotid endarterectomy as a risk of disrupting what nerve
The hyoglossal
he hypoglossal nerve supplies ipsilateral motor component to the tongue and the hyoid depressors.
A thyroidectomy has a risk of disrupting what nerve
The laryngeal nerve
In a lesion to the hypoglossal nerve which way does the tongue deviate
To the same side as the lesion
- Tongue goes t’ side of lesion.*
- Uvula goes Uver way*
Summarise the worrying features of this ECG, suggest a cause and treatment
- 66 bpm, a regular rhythm and no axis deviation
- tented T wave, flattened P abnormal QRS
- 66 bpm, a regular rhythm and no axis deviation
- indicative of hyperkalaemia
- calcium gluconate is the first step in management
- stabilisers the cardiac membrane reduces risk of VF
Summarise the worrying features of this ECG, suggest a cause and treatment
- 66 bpm, a regular rhythm and no axis deviation
- tented T wave, flattened P abnormal QRS
- indicative of hyperkalaemia
- calcium gluconate is the first step in management
Typically patients with small bowel obstruction present early with what symptom vomiting or constipation
These patients present with vomiting early and absolute constipation late
What is the most important finding in this radiograph
Free air in the abdomen/pneumoperitoneum
What is the main finding here
Small-bowel dilation = probable obstruction
Duodenal ulcers are more common in gastric ulcers, what is their association with eating?
Duodenal ulcers are relieved by eating
Gastric ulcers present with epigastric pain that is ——- by eating
Worsened
Boerhaaves syndrome is the
Spontaneous rupturing of the oesophagus can be caused by repeated vomiting and is often associated with alcohol excess
A nine-month-old with a umbilical hernia would be managed how initially
Conservatively over 90% resolve spontaneously
A congenital inguinal hernia should be managed how
Should be surgically repaired soon after diagnosis as there is a risk of incarceration
Comment on the findings of this x-ray
Occipital fracture
What can be seen in this image?
left subdural haemorrhage with overlying subcutaneous haematoma
There is a small amount of subtle intracranial free air indicating there must be a skull fracture not demonstrated on these images.
There is marked mass effect with complete loss of cerebral sulci over both cerebral hemispheres and there is marked midline shift.
Subdural haematomas are usually due to tearing of which structures
Bridging veins from this cerebral cortex and the draining venous sinuses
Extradural haematomas are located outside the dura and most commonly due to tearing of which the vessel
The middle meningeal artery
A CT scan of a subdural haematoma will show
A crescent shaped haematoma over one hemisphere, the blood will tend to extend along the caliciform ligament and over the tentorium cerebelli
A CT scan of an extra dural haematoma will show
A biconvex shape limited by the dural attachments
Overactive bladder syndrome is defined as
- Urinary Urgency, with or without incontinence
- increased daytime frequency and nocturia
- no proven infection or other pathology
Before diagnosing overactive bladder syndrome what are important rule out by history and examination
Hematuria, UTI, neurological disease, gynaecological cause and inappropriate habits such as high fluid intake high caffeine intake
What are the two main class of drugs used to treat urge incontinence
Anticholinergics (oxybutynin) and beta three agonists (mirabegron)
What is the general treatment algorithm for urge incontinence
- Fluid advice
- bladder training
- medications (antimuscarinics/anticholinergics and beta three agonists)
Oxybutynin works by what mechanism
Anticholinergic
side effects include:
reduced lacrimation, reduced salivation, constipation or memory problems
What is the appearance of a seminoma
A solid homogenous cut potato appearance is typical and on microscopy there is generally a mixture of tumour cells and normal lymphocytes
Testicula seminoma typically spreads via lymphatics, what nodes may spread to 1st
Para-aortica notes at level LI
note that the lymphatic supply to the testes follows the testicular artery supply, (testicular lymphatics do not drain into the inguinal nodes)
Incidences of seminoma peak in the
30s to 40s
Incidences of teratoma in men peak in the
20s to 30s
Teratomas generally spread via
The bloodstream (and so were treated with chemotherapy)
When taking bloods for an undifferentiated testicular mass what three tumour markers I look for initially
- AFP (alpha-feto protein
- HCG (human chorionic gonadotropin)
- LDH (lactate dehydrogenase)
When removing a testy due to teratoma what operation is first-line
Radical orchidectomy using an inguinal incision allows for the removal of the testy and spermatic cord
Gynaecomastia can be caused by a testicular tumour secreting
Beta HCG
Alpha-feto protein
AFP is more specific for what type of testicular tumour
Teratoma
AFP is expressed by trophoblastic elements within 50-70% of teratomas. It is not raised in pure seminomas.
Human chorionic gonadotropin
HCG is produced mostly by which type of testicular mass
100% of choriocarcinomas, 40% of teratomas, and 10% of seminomas.
Lactate dehydrogenase (LDH) is useful how when diagnosing a testicular mass?
Less specific diagnosis then both AFP or hCG but a useful indicator of tumour burden and treatment response
Cryptorchidism =
A congenitally undescended testicle
Undescended testes have increased risk of
Testicular cancer
this can occur in the normally descended contralateral testi
Loin discomfort and microscopic haematuria is suggestive of
Malignancy until proven otherwise
What are some classic symptoms of bladder outlet obstruction
- Increase frequency
- urgency
- nocturia
- hesitancy
- Poor fellow
- intermittent flow
- terminal dribbling
Testicular torsion can occur in any age group, but the most common group is
11-30 years
Angiodysplasia most commonly affect which side of the colon
Right-sided
Apart from bleeding, which may be massive, these arteriovenous lesions cause little in the way of symptoms
Angiodysplasia most commonly affect which side of the colon
Right-sided
Apart from bleeding, which may be massive, these arteriovenous lesions cause little in the way of symptoms
What is the most common cause of small bowel obstructions?
Adhesions (e.g. following previous surgeries) first
followed by hernias
Sinewave appearance on ECG is an indication of
Severe hyperkalaemia
Describe the ECG changes of hyperkalaemia
- Peaked or tall tented T wave
- loss of P waves + broad QRS complexes
- sinusoid wave pattern
- ventricular fibrillation
Absent T waves can be caused by which electoral imbalance
Hypokalaemia
While an abdominal x-ray and chest x-ray may help indicate a small bowel obstruction what is the gold standard investigation to give a definitive diagnosis according to nice
CT abdomen
How can one differentiate between a incarcerated and strangulated hernia when presented with a non-reducible femoral hernia
In strangulation the hernial will be tender possibly erythematous, the patient may be systemically unwell. This can include patient vomiting, passing bloody stools and generally having a toxic appearance.
Strangulation happens when the blood supply to the herniated tissue is compromised, leading to ischemia or necrosis.
Abdominal wound dehiscence postsurgery should be managed how initially?
Cover the wound with saline soaked cause, IV antibiotics (analgesia plus fluids if needed)
arrange return to theatres
Neurogenic shock is because most often by
Spinal cord transaction
A decrease in sympathetic tone or an increase in parasympathetic tone resulting in a decrease in peripheral vascular resistance mediated by Mark vasodilation is a pathophysiology of what type of shock
Neurogenic
The dose of IM adrenaline for anaphylaxis is
500mcg or 0.5ml of 1 in 1000 adrenaline
Intravenous non-ionic contrast agents are commonly used for intra-arterial and intravenous injection for the purpose of contrast imaging, what allergy is a contraindication to the use
Iodine
Iodine -containing contrasts should be used in caution in which group of patients
Asthmatic patients, patients with renal impairment and diabetic patients taking metformin
A patient presenting with a testicular lump that cannot be felt separately to the testicle, is fluctuant, transluminal and not tethered to the skin is indicative of
A hydrocele
A hydrocele forms when
a closed off tunica vaginalis fills and becomes distended with serous fluid.
Fluid collects around the front and sides of the testicle (so the testicle cannot be felt separately), and can extend upwards in the spermatic cord.
What are risk factors for renal cell carcinoma
- Smoking
- haemodialysis
- von Hippel Lindau disease
- obesity
- chemical exposure (eg benzene, asbestos, trichloroethylene)
- family history
What is the most sensitive technique for demonstrating a renal calculi and/or hydronephrosis?
unenhanced CT KUB
Ureteric stones that measure what size are unlikely to pass spontaneously
5 mm
Ureteric stones that do not pass spontaneously can be managed how
endoscopic removal or fragmentation by extracorporeal shock-wave lithotripsy (ESWL)
What demographic are more likely to present with renal tract stones
Male patients are four times more likely, 20 to 50 is the most common age group
Calcium oxalate and calcium phosphate stones versus urate and xanthine stones which ones are radiopaque versus radiolucent
Calcium oxalate and calcium phosphate stones are typically radio-opaque, while urate and xanthine stones are typically radiolucent with plain X-ray.
CT KUB is quick and very sensitive at detecting all renal stones (97%) except those caused by antiretroviral drugs.
There are a large number of dietary, genetic and metabolic influences for the development of renal calculi what are some of these:
- Dehydration
- hot climate
- high BMI
- gastric bypass surgery
- hypercalciuria
- hyperuricosuria
- hyperoxaluria and hypocitriuria
- urinary tract abnormalities
This film from an intravenous urogram shows?
The left is ureter dilated from bladder to kidney, with the dilation extending into the pelvis of the kidney.
Outflow obstruction should be suspected
When should you do a KUB radiograph in patients suspected of having a renal tract stone before doing a contrast scan?
always check a control KUB radiograph to look for calculi 90% are radiodense, so visible on plain X-ray
they will be obscured once IV contrast has been injected
Where are the most common points for stones to get stuck within the ureter?
- Pelvic ureteric junction (PUJ)
- where the ureteric crosses the iliac vessel
- intramural ureter/vesicoureteric junction (“VUJ”).
What is the treatment of choice for uninfected obstructed urinary system within 24 hours of admission?
Percutaneous nephrostomy insertion
In the treatment of infected obstructed urinary system e.g. pyonephrosis secondary to a ureteric stone why is stone removal not first-line
Percutaneous nephrostomy insertion is first-line as this minimises risk of rapid deterioration and allows for resuscitation of the patient.
Stone removal should not be attempted while the rotors are inflamed and friable as the pressure involved in the endoscopic approach can rupture the orators or help the bacteria to translocating to the bloodstream.
Definitive stone removal should occur after the infection is cleared
When is PCNL (Percutaneous Nephrolithotomy) be used as a treatment
In the treatment of kidney stones that are within the renal collecting system or renal pelvis.
- First line management of staghorn calculi larger than 3 cm
- or if there has been a failed ESWL or stone extraction via Flexible Uretero-renoscopy for renal stones < 3cm
Describe the findings on this chess radiograph
There is a large air – fluid level beneath the right hemidiaphragm, the right hemidiaphragm is elevated, there is a small basal effusion on the right side suggested by the blunting of the costophrenic angle
This presentation is suggestive of a subphrenic abscess
Identify that dilation
Multiple dilated loops of small bowel
they lie centrally and the mucosal folds can be identified (faintly), these are called valvulae conniventes
When investigating the possibility of a postsurgical anastomosis leak what investigation is indicated
Water-soluble contrast enema.
Barium contrast is contraindicated. Water-soluble contrast should be induced via a Foley catheter to avoid any further trauma
In the pre-operative assessment for an elective hernia repair the patient is found to be mildly anaemic, 115 hb (130) how should the anaesthetist proceed
Postpone breastbone delay surgery until the anaemia has been investigated
Insensible losses can be estimated as approximately
50 ml/hr
0.5 – 1.0 ml/kg/h
Maintenance fluid can be calculated using the 4 2 1 rule
what is this?
4mls/ kg for the first 10kg, 2mls/ kg for next 10kg and 1ml/kg for the remaining weight
Maintenance fluids can be calculated using what rule?
4 2 1 = 4 mL per KG for the first 10 KG, 2 mL per KG for the next 10 KG and then 1 mL per KG for the remaining weight.
Daily sodium requirements =
1 -2 mmol per KG
Daily potassium requirements =
0.5-1 mmol per KG
Daily sodium and potassium requirements =
Sodium = 1 to 2
potassium = 0.5 to 1
Millimole per gram
What are the guidelines for nil by mouth presurgery
Six hours for food and drink containing milk
two hours for clear fluids
In a patient that is high risk of aspiration what technique can be used to reduce this during induction
RSI
rapid sequence induction
Concerning post-operative patients with no cardiovascular disease what is the generally accepted transfusion threshold
less than 80 g/l. Some institutions accept an even lower trigger of 70 g/l.
Early post-operative fever (within 24 hours) is most likely due to?
Systemic inflammatory response due to trauma
if on clinical examination no effective cause is indicated only symptomatic management needed
Why is it important to do your analysis on post-operative patients presenting with fever
UTI’s can be a symptomatic in many post-operative patients
In terms of regional anaesthetics Bier’s block effects where
forearm
Peri-operative patients have both an absolute and a relative hypervolaemia, what is meant by the statement?
Absolute = hypovolaemic due to blood and fluid loss and preoperative starvation
relative = hypovolaemic due to the vasodilatory effects of anaesthesia and the inflammatory response of the surgery
Mean arterial blood pressure (map) is calculated how
Diastolic pressure +1/3 pulse pressure
pulse pressure = systolic pressure - diastolic pressure
Mean arterial pressure is useful in calculating profusion of organs, as a general rule the map above what number is required to sustain adequate perfusion
60
What is the mean arterial pressure of a patient with a blood pressure of
70/40?
Mean arterial blood pressure (MAP) = diastolic pressure + 1/3 (pulse pressure)
Pulse pressure = systolic pressure–diastolic pressure
Therefore, MAP = 40 + 1/3(70–40) = 50mmHg
What is the mean arterial pressure of a patient with a blood pressure of
120/60?
80
map = diastolic pressure + 1/3 (pulse pressure)
pulse pressure = systolic - diastolic
Oliguria is defined as
Urine output less than 0.5 mil per KG per hour or less than 400 mills in 24 hours
The ECG shows ST elevation in II, III and AVF and reciprocal changes in I and aVL suggests
inferior MI.
In regards to warfarin or does the INR have to be pre-operation
Less than 1.2
the dinner suggests stopping five days prior, some patients may need to be bridged on low molecular weight heparin
Bilious vomiting within 24 hours of birth is most commonly caused by
intestinal atresia
Bilious vomiting is classically caused by obstruction beyond the sphincter of Oddi, where the common bile duct enters the duodenum.
In terms of hepatobiliary pathology blockage of which duct is least likely to cause jaundice
Cystic duct
For acute cholecystitis what does nice recommend for treatment
Intravenous antibiotics
early laparoscopic cholecystectomy within one week diagnosis
What is the correct initial management for a pancreatic pseudocyst
Initial conservative management for up to 12 weeks as 50% self resolve
definitive treatment is Treatment is either with endoscopic or surgical cystogastrostomy or aspiration
Varicose veins are dilated, tortuous, superficial veins that occur secondary to ?
Incompetent venous valves, allowing blood flow back
Varicose veins most commonly occur in the leg due to reflux in which vessels?
The great and small saphenous vein
What complications of varicose veins can cause hyperpigmentation
Haemosiderin deposition
What complications of varicose veins can cause hard/tight skin
Lipodermatosclerosis
The majority of varicose vein patients do not require surgery, what are some conservative management steps
- Leg elevation
- weight loss
- regular exercise
- graduated compression stockings
What is the treatment of choice for non-infective biliary colic
Elective laparoscopic cholecystectomy as an outpatient in six months
Patient >= 60 years old with new iron-deficiency anaemia →
urgent colorectal cancer pathway referral
Which drugs can slow the rate of fracture healing
- NSAIDs
- steroids
- immunosuppressive agents
- antineoplastic drugs
smoking also has a large effect
A man presenting with a painless lump on his testicle that is suspicious and ultrasound however has a normal AFP and hcg should be considered for what type of testicular cancer
Seminoma
For a patient that does not meet the two wee criteria however you have concerns of possible colorectal cancer what test can be arranged?
FIT test
What is the first-line imaging investigation for a suspected prostate cancer
Multiparametric MRI
Breast cancer can present as a solid hard irregular mass that may or may not be fixed to the chest wall, what are some other associated skin/nipple changes that are addictive towards breast cancer
- Dimpling
- nipple retraction/inversion
- bloodstained nipple discharge
- rash over nipple/areola (pages disease)
- pain
- axilla nodes
Mammographic features of breast cancer include:
- Ill-defined or spiculated mass
- Parenchymal distortion
- overlying skin thickening
- malignant calcification
- enlarged axillary lymph nodes
Ultrasound features of breast cancer include:
- This ill-defined usually hypoechoic mass
- distal acoustic shadowing
- surrounding Halo (caused by oedema and tumour infiltration)
- abnormal axillary nodes
When imaging (ultrasound + mammography) indicates suspected breast cancer what is the next line investigation
Biopsy
core biopsy or fine needle aspiration cytology
Cholangiocarcinoma has which elevated biomarker
CA 19- 9
Beta-hCG may be used to screen for what CA ?
Testicular and ovarian germ cell tumours
as well as gestational trophoblastic disease
C125 is a tumour marker for
Ovarian cancer
although it is often elevated in liver disease, endometriosis and menstruation
A smooth mobile that appear suddenly over the course of a few days with tenderness is most likely to be?
A breast cyst
Cysts account for around 15% of all discrete breast masses and are more common in population
Perimenopausal
Mammograms are not generally performed on women under the age of?
40
as the breast tissue tends to be relatively radiodense.
The exception to this is if cancer has been diagnosed on clinical examination, breast ultrasound or biopsy
Describe the findings on this mammogram
Multiple smooth rounded opacities
consistent with cysts
What is the first-line treatment for a patient presenting with a complicated breast cyst?
Fine-needle aspiration, often ultrasound guided.
Cystic fluid only needs to be sent to cytology if it’s uniformly bloodstained
Breast cysts aredependent
Hormone
Breast fibroadenomas are described as what on examination
Well circumscribed, smooth, firm and mobile. They are often painless with no regional lymph nodes.
Usual age of presentation is 30 however there is a large variety. No new fibroadenomas should occur after menopause
Describe the findings of this breast ultrasound
A well-defined elliptical solid lesion. Homogenous.
in keeping with a fibroadenoma
Breast triple assessment =
Clinical, imaging and histology/cytology
When may it be appropriate to exercise a fibroadenoma?
If the lump is greater than 2 cm and visible then it may be appropriate to excise.
Why may fibroadenomas increase in size during pregnancy and decrease or disappear during menopause
They are hormone -dependent
What are some drugs that can cause gynaecomastia?
- Digoxin
- spirolactone
- methyldopa
- proton pump inhibitors
- anabolic steroids
A patient presenting with rapid onset of breast warmth, erythema and peau d’orange (skin of an orange), often without a definite mass. Should be suspected of having?
Inflammatory breast cancer
Describe the overall treatment approach for inflammatory breast cancer
- Initially neo adjunctive primary chemotherapy- anthracycline based
- definitive treatment with either radiotherapy, surgery or both
Does prostate cancer always cause urinary symptoms?
Localised prostate cancer is often asymptomatic, this is partly due to the cancer developing in the periphery of the prostate and hence does not cause obstructive symptoms early on.
Male patients presenting with urinary retention and hesitancy, haematuria or haemospermia should always be considered for
Prostate cancer
Digital rectal examination findings that may indicate prostate cancer include
- Asymmetrical
- hard
- nodular enlargement
- loss of median sulcus
Which ethnicity has a high risk of prostate cancer
Afro-Caribbean
A keloid scar is a
Scar with an excessive amount of collagen, typically protruding beyond the boundaries of the original injury.
What are the four classic drug groups that impair wound healing
- Non-steroidal’s
- steroids
- immunosuppressive agents
- antineoplastics
Charcot’s cholangitis triad:
- Fever
- jaundice
- right upper quadrant pain
Anal fissures are divided between acute and chronic at how many weeks
Six
What are some risk factors for anal fissures
- Constipation
- inflammatory bowel disease
- STI’s e.g. HIV syphilis and herpes
What are some risk factors for anal fissures
- Constipation
- inflammatory bowel disease
- STI’s e.g. HIV syphilis and herpes
90% of anal fissures occur where
Posterior midline
alternative locations should be considered for alternative underlying diagnoses
General management approach of anal fissures include
- Soften stools
- lubricant before defaecation
- topical anaesthetics
- analgesia
in chronic cases topical GTN may be used
What class of drugs can be used in patients with an overactive bladder
Antimuscarinics e.g. oxybutynin
A patient >= 60 years of age with unexplained non-visible haematuria and either dysuria or a raised white cell count on a blood test should be?
Referred using the two week pathway to exclude bladder cancer
In males over the age of 35 what is the most common cause of epididymitis
E. coli
Epididymo-orchitis in young males is often caused by
Neisseria gonorrhoea and chlamydia
